Techniques for Local Anesthesia in Transperineal and Transrectal Prostate Biopsy: An Image-based Step-by-Step Guide With Dedication to Anatomy

Prostate biopsy is the cornerstone in the diagnostic pathway of prostate cancer. It's normally performed using local or general anesthesia. The prostate's high sensitivity to mechanical stimuli and irritation is due to its complex nerve supply, mainly from the pelvic plexus. It originates from the sacral plexus, with both parasympathetic and sympathetic nerves having a role in prostatic innervation. As the procedure involves needle penetration into sensitive tissues, it is essential to ensure effective peribioptic pain management, as patients may experience considerable discomfort during the process. Local anesthesia has proven to be one of the safest, most reliable, and most effective approaches to managing this pain, as it provides targeted relief with minimal side effects. This report describes in detail the current anesthesia techniques applied during both transrectal and transperineal prostate biopsy procedures, delving into their mechanisms of action, as well as reviewing recent research findings on their efficacy. We describe an image-based step-by-step technique with dedication to pelvic anatomy for a comprehensive understanding of how local anesthesia can be administered and therefore enhance the overall experience of patients undergoing prostate biopsy.