Local anesthesia in transrectal ultrasound-guided prostate biopsy: Apical periprostatic nerve block versus endorectal lidocaine gel A randomized controlled trial about 100 patients


Sallami Sataa
Mejri Ramzi
Chelif Mohamed
Ben Salah Imed
Ben Rhouma Sami
Hafsia Ghassen
Nouira Yassine
Horchani Ali


 Background: Intrarectal lidocaine application and apical periprostatic nerve block are a safe technique that significantly reduces pain during transrectal prostate biopsy
Aim:We compare prospectively the effectiveness of intrarectal lidocaine gel versus periprostatic lidocaine injection during transrectal ultrasound -guided prostate biopsy.
Methods: From June 2005 to February 2006, 100 consecutive patients underwent prostatic biopsies. Patients were randomized to receive 10 cc of 2% lidocaine gel in endorectally (Group I), 10 cc of 1% lidocaine solution injected into the prostate apex to induce bilateral periprostatic nerve block (Group II), or intrarectal 10 cc of
ultrasound gel as placebo (Groupe III). Pain was evaluated by a 10- point linear visual analogue pain scale (VAS), and a 5-point digital visual scale (DVS). The side effects of the drugs and complications were also evaluated.
Results: The three groups counted respectively: 33, 33 and 34 patients and were statically comparable as the age, prostate volume, PSA level and the number of biopsies.
The mean pain score on the VAS was respectively 4,1; 4,6 and 3,5 for the three groups.
The DVS score was 2,5; 2,8 and 2,15 (p < 0,001). Pain scores were significantly lower in Group 3 and equivalent between Groups 1 and 2.
There is no difference in complication rate between the three groups.
Conclusion: Compared to intrarectal lidocaine application, apical periprostatic nerve block is a safe technique that significantly reduces pain during transrectal prostate biopsy, with no increase in the complication rate.


Prostate, Cancer, Biopsy, Anaesthesia, Pain, Randomized clinical trial



  1. Coley CM, Barry MJ, Fleming C, Wasson JH, Fahs MC, Oesterling JE. Should Medicare provide reimbursement for prostate-specific antigen testing for early detection of prostate cancer? Part II: early detection strategies. Urology. 1995; 46: 125-41.
  2. Peters JL, Thompson AC, MC Nicholas TA, Hilnes JE, Hanbury DC, Boustead GB. Increased patient satisfaction from transrectal ultrasonography and biopsy under sedation. BJU Int. 2001; 87: 827-30.
  3. Issa MM, Bux S, Chun T, et al. A randomized prospective trial of intrarectal lidocaine for pain control during transrectal prostate biopsy: The Emory University experience. J Urol. 2000; 164: 397-9.
  4. Kaver I, Nicola J, Mabjeesh H, Matzkin H. Randomized prospective study of periprostatic local anesthesia during transrectal ultrasoundguided prostate biopsy. Urology. 2002; 59: 405-8.
  5. LeiboviciI D, Zisman A, Siegel YI, Sella A, Kleinmann J, Lindner A. Local anesthesia for prostate biopsy by periprostatic lidocaine injection: a double-blind placebo controlled study. J Urol. 2002; 167: 563-5.
  6. Pareek G, Aemennakas NA, Fracchia JA. Periprostatic nerve blockade for transrectal ultrasound guided biopsy of the prostate: a randomized, double-blind, placebo controlled study. J Urol. 2001; 166: 894-7.
  7. Von Knobloch R, Weber J, Varga Z, Feiber H, Heidenreich A, Hofmann R. Bilateral fine-needle administered local anaesthetic nerve block for pain control during TRUS guided multi-core prostate biopsy: A prospective randomised trial. Eur Urol. 2002; 41: 508-14.
  8. Seymour H, Perry MJA, LEE-Elliot D, Dundas U, Patel U. Pain after transrectal ultrasonography biopsy: the advantages of periprostatic local anaesthesia. BJU Int. 2001; 88: 540-4.
  9. Taverna G, Maffezzini M, BEenettiI A, Seveso M, GiustiI G, Graziotti P. A single injection of lidocaine as local anesthesia for ultrasound guided needle biopsy of the prostate. J Urol 2002; 168: 222-3.
  10. RodriIguez A, Tazi H, Kyriakou G, Leray E, Lobell B, Guillé F. Blocage nerveux périprostatique au niveau de l'apex contre gel de lidocaïne intrarectal. Prog Urol 2002; 12: 1228-33.
  11. Torp-Pederson S, Lee F, Littrup PJ, et al. Transrectal biopsy of the prostate guided with transrectal ultrasound: Longitudinal and mul tiplanar scanning. Radiology. 1989; 170: 23-7.
  12. Ravery V, Fontaine E, Villers A. Biopsies prostatiques : modalités techniques et conditions de l'examen. Prog Urol. 2000; 10: 1271-6.
  13. Irani J, Fournier F, Bon D, Gremmo E, Dore B, Aubert J. Patient tolerance of transrectal ultrasound-guided biopsy of the prostate. Br J Urol. 1997; 79: 608-10.
  14. Reddy P.K. New technique to anesthetize the prostate for transurethral balloon dilatation. Urol Clin North Am. 1990; 17: 55-6.
  15. Nash PA, Bruce JE, Iindudhara R, Shinohara K. Transrectal Ultrasound guided prostatic nerve blockade eases systematic needle biopsy of the prostate. J Urol. 1996; 155: 607-9.
  16. Soloway MS, Obek C. Periprostatic Local Anestesia before ultrasound guided prostate biopsy. J Urol. 2000; 163: 172-3.
  17. Alavi AS, Soloway M.S, Vaidya A, Lynne CM, Gheiler EL. Local anesthesia for ultrasound guided prostate biopsy: a prospective randomized trial comparing 2 methods. J Urol. 2001; 166: 1343-5.
  18. Vaidya A, Soloway MS. Periprostatic local anesthesia before ultrasound-guided prostate biopsy: an update of the Miami experience. Eur Urol. 2001; 40: 135-8.
  19. Philip J, Mccabe JE, Roy SD, Samsudin A, Campbell IM, Javle P. Site of local anaesthesia in transrectal ultrasonography-guided 12- core prostate biopsy: does it make a difference? BJU Int. 2006; 97: 263-5.
  20. De Maria M, Mogorovich A, GiannariniI G, ManasseroF, Selli C. Lidocaine-prilocaine administration during transrectal ultrasoundguided prostatic biopsy: a randomized, single-blind, placebocontrolled trial. J Endourol. 2006; 20: 525-9.
  21. Fink KG, Gnad A, Meissner P, Gotschl R, Sshmeller NT. Lidocaine suppositories for prostate biopsy. BJU Int. 2005; 96: 1028-30.
  22. Basar H, Basar MM, Ozcan S, Akpinar S, Bazar H, Batislam E. Local anesthesia in transrectal ultrasound-guided prostate biopsy: EMLA cream as a new alternative technique. Scand J Urol Nephrol. 2005; 39: 130-4.
  23. Obec C, Onal B, Ozkhan B, Onder AU, Yalcin V, Solok V. Is periprostatic local anesthesia for transrectal ultrasound guided prostate biopsy associated with increased infectious or hemorrhagic complications? A prospective randomized trial. J Urol. 2002; 168: 558-61.
  24. Buckler MR, Bryant NJ, Brown JA, Tiwari P, Cooperberg PL, Wong AD. Tolerance of local anesthetic for transrectal ultrasound-guided prostate biopsy: our experience and a literature review. Can Assoc Radiol J. 2006; 57: 169-74.
  25. Feltes Ochoa JA, Passas Martinez J, Felip Santamaria N, Romero Otero J, Rodriguez AntolinA, Leiva Galvis O. Local anesthesia significantly improves the tolerance of prostate biopsy. Arch Esp Urol. 2006; 59: 407-14.
  26. Tobias-Machado M, VerrottiI MJ, Aragao AJ, Rodriguez AO, Borrelli M, Wroclawski ER. Prospective randomized controlled trial comparing three different ways of anesthesia in transrectal ultrasound-guided prostate biopsy. Int Braz J Urol. 2006; 32: 172-80.
  27. Song SH, Kim JK, Song K, Ahn H, Kim CS. Effectiveness of local anaesthesia techniques in patients undergoing transrectal ultrasound-guided prostate biopsy: a prospective randomized study. Int J Urol. 2006; 13: 707-10.
  28. Trucchi A, De Nunzio C, Mariani S, Palleschi G, Miano L, Tubaro A. Local anesthesia reduces pain associated with transrectal prostatic biopsy. A prospective randomized study. Urol Int. 2005; 74: 209-13.
  29. Aus G, Damber JE, Hugosson J. Prostate biopsy and anaesthesia: an overview. Scand J Urol Nephrol. 2005; 39: 124-9.
  30. Presti JC. Prostate biopsy: how many cores are enough? Urol Oncol. 2003; 21: 135-40.
  31. Aus G, Hermansson CG, Hugosson J, Pedersen KV. Transrectal ultrasound examination of the prostate: complications and acceptance by patients. Br J Urol. 1993; 71: 457-9.
  32. Crundwell MC, Cooke PW, Wallace DM. Patients' tolerance of transrectal ultrasound-guided prostatic biopsy: an audit of 104 cases. BJU Int. 1999; 83: 792-5.
  33. Collins GN, Lloyd SN, Hehir M, Mckelvie GB. Multiple transrectal ultrasound-guided prostatic biopsies--true morbidity and patient acceptance. Br J Urol. 1993; 71: 460-3.
  34. Rodriguez A, Kyriakou G, Leray E, Lobel B, Guille F. Prospective study comparing two methods of anaesthesia for prostate biopsies: apex periprostatic nerve block versus intrarectal lidocaine gel: review of the literature. Eur Urol. 2003; 44: 195-200.
  35. Stirling BN, Shockley KF, Carothers GG, Maatman TJ. Comparison of local anesthesia techniques during transrectal ultrasound-guided biopsies. Urology. 2002; 60: 89-92.
  36. Lynn NN, Collins GN, Brown SC, O'Reilly PH. Periprostatic nerve block gives better analgesia for prostatic biopsy. BJU Int. 2002; 90: 424-6.
  37. Adamakis I, Mitropoulos D, Haritopuolos K, Alamanis C, Stravodimos K, Giannopoulos A. Pain during transrectal ultrasonography guided prostate biopsy: a randomized prospective trial comparing periprostatic infiltration with lidocaine with the intrarectal instillation of lidocaine-prilocain cream. World J Urol. 2004; 22: 281-4.
  38. Mallick S, Humbert M, Braud F, Fofana M, Blanchet P. Local anesthesia before transrectal ultrasound guided prostate biopsy: comparison of 2 methods in a prospective, randomized clinical trial. J Urol. 2004; 171: 730-3.