Editing Prostate Biopsy (section)

=== Anesthesia ===

* '''Approaches[https://pubmed.ncbi.nlm.nih.gov/16439219/]'''
** '''Regional anesthetic'''
***'''Periprostatic nerve block'''
****Nerves can be blocked with either unilateral or bilateral injection, around the apex or base of the gland (in the groove between the gland and seminal vesicles).
****Typically performed using a 7 inch 22-gauge spinal needle, and the biopsy channel of the ultrasound probe
****'''Aspirate the syringe before injecting to ensure that the vascular system has not been entered'''
****'''Method 1[https://pubmed.ncbi.nlm.nih.gov/8558671/][https://pubmed.ncbi.nlm.nih.gov/24725491/]'''
*****'''In the region of the neurovascular bundle at the base of the prostate, just lateral to the junction between the prostate and seminal vesicle'''
****** '''Can be easily identified as a hypoechoic (dark) area on TRUS'''
******See [https://pubmed.ncbi.nlm.nih.gov/8558671/ Figure 2 in link] and [https://www.semanticscholar.org/paper/Pain-during-Transrectal-Ultrasound-Guided-Prostate-Nazir/8c1020245b7d2c8f298441aa0355ffe577cd2fde/figure/3 Figure]
******See [https://www.youtube.com/watch?v=Mo3DO1mFTdU Video]
*****Ultrasound monitoring can confirm separation of the tissue planes caused by injection
*****The injection is performed twice, once either side the midline.
****Method 2 (transrectal)[https://pubmed.ncbi.nlm.nih.gov/16439219/]
*****A position just lateral to the midline, and away form the external sphincter is chosen. The needle is passed through rectal mucosa and local anaesthetic instilled, so that the anaesthetic pools within fascial layers (presumed to the Denonvillers' fascia) and bathes the posterior surface of the gland, from the apex up to the base.
*****The injection is performed twice, once either side of the midline.
****Conflicting evidence if direct infiltration into the prostate (intraprostatic injection) can augment the anesthetic benefit seen with periprostatic injection
***Pudendal nerve block[https://pubmed.ncbi.nlm.nih.gov/31374287/]
****Pudendal nerves are located 2cm lateral to anterior medial edge of anus and 3cm deep to skin
** Topical rectal anesthetic gel
** Variations in probe design
** Glyceryl trinitrate (GTN) paste
** Oral NSAIDs
** Inhaled nitrous oxide
** Intravenous analgesia