Do unto others--why I would want anesthesia for my prostate biopsy.

U a dramatic new development occurs in our methods to diagnose prostate cancer, an abnormal blood test (currently prostate-specific antigen measurement) or suspicious finding on palpation of the prostate is followed by transrectal ultrasound-guided prostate biopsies (TRUSB). TRUS equipment has improved. The probes are smaller and provide superb images of the prostate. Approximately 500,000 prostate biopsies are performed in the United States annually. This may be a conservative estimate, because more than 220,000 cases of prostate cancer will be diagnosed in 2003. It is not surprising that TRUSB provokes considerable anxiety for the patient. First and foremost is the patient’s concern that he might have prostate cancer. To add to these concerns, the clinician explains the procedure: a lubricated probe will be placed in the rectum and between 6 and 12 (or more) biopsies will be obtained. Moreover, if the survey performed by Davis et al.1 is representative, more than one third of urologists do not provide any analgesia for this procedure. Some prescribe an oral analgesic or rely on a lidocaine rectal suppository or gel. Only 11% use a periprostatic nerve block (PNB) (survey in 2001). In contrast, when a patient sits in a dentist chair and agrees to have a procedure that may be accompanied by pain, he expects that the dentist will minimize the discomfort associated with the procedure. To emphasize their desire to minimize pain, a topical anesthetic usually precedes the lidocaine injection. Dentists are aware that many of their patients associate dental work with pain. Thus, most do everything they can to minimize patient discomfort. Like most of you, I want to avoid pain and am not bashful about requesting ample anesthesia when I am the “subject.” “Do unto others. . . .” A number of our colleagues have documented that our patients are not only anxious before having a prostate biopsy but many experience moderate to severe pain.2–4 Younger patients and those with smaller prostates indicate more pain. Biopsies from the apex are more painful than those obtained from the base. Like many of you, I totally missed the 1996 article by Nash et al.5 They injected either lidocaine or saline into the nerve bundles adjacent to the prostate. Patients were asked to grade (0 to 5) the pain associated with the biopsies from each side. Patients experienced less pain on the side injected with lidocaine. Although I am certain that these investigators routinely performed a PNB on subsequent patients, few of us adopted their technique for minimizing pain associated with TRUSB. In the fall of 1999, I was performing prostate biopsies and mentioned to Can Obek, a urologic oncology fellow working with me at that time, that there should be a way of minimizing the pain associated with TRUSB. He indicated that a study had been performed in Turkey that suggested the benefit of PNB.6 I was immediately struck by the concept. Up to that point, I had minimized the pain my patients experienced as I performed their TRUSB. I accepted their discomfort as a necessary part of the procedure. Although most men did not vigorously complain, they frequently kept a running count of the number of biopsies and their discomfort increased with the number of biopsies. Some patients became diaphoretic and barely tolerated the procedure. In January 2000, we reported on our first 50 TRUSB procedures using a PNB.7 The benefit was readily apparent. A dramatic reduction occurred in the amount of discomfort associated with TRUSB. In an editorial comment to that article, Jay Gillenwater indicated that he had been using a PNB for more than 2 years, having learned the technique from Haaken Ragde. He indicated that as a result of From the Department of Urology, University of Miami School of Medicine, Miami, Florida Reprint requests: Mark S. Soloway, M.D., Department of Urology, University of Miami School of Medicine, P.O. Box 016960 (M814), 1400 Northwest 10th Avenue, Room 506, Miami, FL 33101 Submitted: May 22, 2003, accepted (with revisions): July 10, 2003 EDITORIAL