COMBINED “PERIPROSTATIC AND PERIAPICAL” LOCAL ANESTHESIA IS NOT SUPERIOR TO “PERIPROSTATIC” ANESTHESIA ALONE IN REDUCING PAIN DURING Tru-Cut PROSTATE BIOPSY IBRAHIM CEVIK, OZDAL DILLIOGLUGIL, AMNON ZISMAN, AND ATIF AKDAS ABSTRACT Objectives. To evaluate, in a prospective study, the benefit of adding local periapical prostatic anesthesia to routine periprostatic infiltration to the prostate-seminal vesicle junction in a randomized fashion. Trans- rectal ultrasound-guided biopsy is the reference standard in the diagnosis of prostate cancer. Although well tolerated by most patients, it can be associated with discomfort. Methods. A total of 120 consecutive evaluable patients with an elevated total prostate-specific antigen (tPSA) level, increased tPSA velocity, and/or abnormal digital rectal examination findings were enrolled. The patients were randomized into two groups. Group 1 received periprostatic infiltration of 6 mL 1% lidocaine. Group 2 received periprostatic and apical infiltration: 4 mL 1% lidocaine at the prostate-seminal vesicle junction and 2-mL infiltration at the prostatic apex 15 minutes before transrectal ultrasound-guided biopsy. Pain was assessed using a 10-point modified visual analog scale. Results. The mean patient age was 63.7  1.2 years and 64.2  1.1 years, the mean tPSA level was 12.1  1.5 ng/mL and 13.6  2.7 ng/mL, the mean biopsy duration was 6.2  2.5 minutes and 6.1  2.2 minutes, and the mean visual analog scale pain score was 1.26  0.1 and 1.23  0.1 for groups 1 and 2, respectively. No statistically significant difference was observed with respect to age, tPSA level, mean biopsy duration, or pain score between the two groups. Conclusions. Periprostatic lidocaine infiltration provides local anesthesia that results in improved visual analog scale pain scores. Additional apical infiltration did not improve patient discomfort further. However, comparative evidence has indicated that increasing the time elapsed between the anesthetic infiltration and the biopsy procedure may further improve pain control. UROLOGY 68: 1215–1219, 2006. © 2006 Elsevier Inc. T ransrectal ultrasound (TRUS)-guided biopsy is an essential step in the diagnosis of prostate cancer. TRUS-guided Tru-Cut biopsy has become the reference standard because of its effectiveness in cancer diagnosis, as well as a low rate of associ- ated side effects. When performed without anes- thesia, it is well tolerated by most patients but can cause a wide range of pain perceptions from mild discomfort to severe pain, as shown by different studies. 1,2 This can be easily explained by varying pain thresholds and varying rectoanal abnormali- ties. A number of studies have reported on the ben- efit of local anesthesia. Although the techniques that do not involve injectable anesthetics are in- effective in diminishing discomfort, 3 peripros- tatic infiltration with local anesthesia reduces pain effectively. 4 In this prospective study, we evaluated the ben- efit of adding periapical 1% lidocaine infiltration in addition to routine periprostatic lidocaine infiltra- tion to the prostate-seminal vesicle junction. MATERIAL AND METHODS Prostate biopsy was indicated in patients with an elevated total prostate-specific antigen (tPSA), increased tPSA velocity, From the Department of Urology, Urotip Diagnosis Center, Istan- bul, Turkey; Department of Urology, Kocaeli University School of Medicine, Kocaeli, Turkey; and Department of Urology, Assaf Harofeh’ Medical Center, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel Reprint requests: Ibrahım Cevık, M.D., Department of Urol- ogy, Urotip Diagnosis Center, Bagdat cad. No. 448/1 Suadiye, Istanbul, Turkey. E-mail: cevik@rancomp.com Submitted: February 25, 2006, accepted (with revisions): Au- gust 11, 2006 ADULT UROLOGY © 2006 ELSEVIER INC. 0090-4295/06/$32.00 ALL RIGHTS RESERVED doi:10.1016/j.urology.2006.08.1055 1215