What is the most effective local anesthesia for transrectal ultrasonography-guided biopsy of the prostate? A systematic review and network meta-analysis of 47 randomized clinical trials

Abstract

We aimed to compare the effectiveness of various local anesthetic methods for controlling prostate biopsy (PBx) related pain using network meta-analysis. Literature searches were performed on PubMed/Medline, Embase, and Cochrane Library up to March 2018. Forty-seven randomized controlled trials, in which the effectiveness of PBx-related pain was investigated using a visual analogue scale after various local anesthetic methods, were included. The local anesthetic methods included intraprostatic local anesthesia (IPLA), intrarectal local anesthesia (IRLA), intravenous sedation (IVS), periprostatic nerve block (PNB), pelvic plexus block (PPB), and spinal anesthesia (SPA). Eight pairwise meta-analyses and network meta-analyses with 21 comparisons were performed. All modalities, except single use of IPLA and IRLA, were more effective than placebo. Our results demonstrate that PNB + IVS (rank 1) and SPA (rank 2) were the most effective methods for pain control. The followings are in order of PPB + IRLA, PNB + IPLA, PPB, PNB + IRLA, IVS, and PNB. In conclusion, the most effective way to alleviate PBx-related pain appears to be PNB + IVS and SPA. However, a potential increase in medical cost and additional risk of morbidities should be considered. In the current outpatient setting, PPB + IRLA, PNB + IPLA, PPB, PNB + IRLA, and PNB methods are potentially more acceptable options.

Figure 1

Preferred Reporting Items for Systematic Reviews and Meta-analysis flowchart RCT: randomized controlled trial.

Figure 2

(A) Forest plots comparing IRLA with placebo, (B) Forest plots comparing PNB with IRLA, (C) Forest plots comparing PNB with Placebo, (D) Forest plots comparing PNB + IPLA with PNB, (E) Forest plots comparing PNB + IRLA with IRLA, (F) Forest plots comparing PNB + IRLA with PNB, (G) Forest plots comparing PPB + IRLA with PNB + IRLA, (H) Forest plots comparing SPA with PNB + IRLA IPLA: intraprostatic local anesthesia, IRLA: intrarectal local anesthesia, PNB: periprostatic nerve block, PPB: pelvic plexus block, SPA: spinal anesthesia.

Figure 3

Network plot of evidence of all trials. The width of the lines is proportional to the number of trials comparing every pair of treatments, and the size of every node is proportional to the number of randomized participants. IPLA: intraprostatic local anesthesia, IRLA: intrarectal local anesthesia, IVS: intravenous sedation, PNB: periprostatic nerve block, PPB: pelvic plexus block, SPA: spinal anesthesia.

Figure 4

Relative effect table of local anesthetic method’s efficacy for pain control related prostate biopsy. Comparisons between treatments should be read from left to right, and the estimate is in the cell in common between the column-defining treatment and the row-defining treatment. For efficacy in local anesthesia, mean differences (MDs) less than 0 favor the column-defining treatment. Bold indicates statistical significance. IPLA: intraprostatic local anesthesia, IRLA: intrarectal local anesthesia, IVS: intravenous sedation, PNB: periprostatic nerve block, PPB: pelvic plexus block, SPA: spinal anesthesia.

Figure 5

Relative effect plot of local anesthetic method’s efficacy for pain control related prostate biopsy IPLA: intraprostatic local anesthesia, IRLA: intrarectal local anesthesia, IVS: intravenous sedation, PNB: periprostatic nerve block, PPB: pelvic plexus block, SPA: spinal anesthesia.

Figure 6

Rank probabilities plot for local anesthesia network of efficacy for pain control related prostate biopsy IPLA: intraprostatic local anesthesia, IRLA: intrarectal local anesthesia, IVS: intravenous sedation, PNB: periprostatic nerve block, PPB: pelvic plexus block, SPA: spinal anesthesia.

Figure 7

Risk of bias graph.

Figure 8

Risk of bias assessment. Green plus: low risk of bias, Yellow question: unclear risk of bias, Red minus: high risk of bias.