Many investigators believe that a younger patient age predisposes

Many investigators believe that a younger patient age predisposes to increased pain perception. In the European Prostate Cancer Detection Study, Djavan et al. [9] found significantly increased pain perception during prostate biopsy in patients younger than 60years when using no anesthesia. However, when patients received local anesthesia, Kaver et al. [10] found no difference in pain perception among patient groups younger than 60, 60–70, and older than 70years. In other studies, patients younger than 60years reported significantly greater VAS scores [5,11]. However, this statistically significant difference did not translate into a meaningful clinical difference, because the mean VAS for all age groups was less than 2 in the locally anesthetized patients. The explanation may be that younger patients experience prostate biopsy as a more painful experience unless locally anesthetized.
In our study, the difference in the mean VAS score in patients younger than 65years was statistically significant.


Conflict of interest

Prostate cancer (PC) is common, with an estimated 218,890 new diagnoses and 27,050 deaths in the USA in 2007 [1]. PC is usually diagnosed by means of transrectal ultrasound-guided biopsy and the type of treatment chosen is based on prognostic parameters such as the patient\’s age, serum PSA levels, Gleason score (GS), tumor volume, the presence of perineural invasion (PNI) and tumor stage [2–5].
PNI is defined as infiltration of cancer RGDfK in the epineurium and perineurium, or even the endoneurium. The involvement of peripheral nerves has been overlooked for a long time but is now receiving more attention as a potentially important component of the cancer microenvironment [6]. One reason for the prognostic importance of PNI is the possibility of metastatic spread of cancer cells along nerves. Although the effect of PNI on long-term outcome in patients with PC has been challenged by some authors [7,8], its importance in making treatment decisions cannot be overlooked [9].
PNI is associated with higher grade and stage in radical prostatectomy (RP) specimens [10] and it may have prognostic value after RP or external beam radiotherapy (RT) for localized and low risk PC [2,3]. D\’Amico et al. considered PNI an independent prognostic factor for PC recurrence [2]. Resection of the neurovascular bundle on the side of biopsy detected PNI may decrease the positive surgical margin rate and improve outcome for low risk patients [2]. Therefore, until it is proven that PNI has no prognostic significance, the decision to perform nerve-sparing surgery should be made with care.
Because biopsy samples may not be representative of the real extent of PNI [2,9], pathologists should carefully examine Pbx and RP specimens, and urologists should not rely on the results of Pbx samples alone to determine the presence of PNI.

Subjects and methods
A total of 208 patients were diagnosed with PC by means of transrectal ultrasound guided sextant Pbx at two University Hospitals between 2005 and 2010. The exclusion criteria were [1] patients diagnosed with PC after a simple prostatectomy or transurethral resection of the prostate (TURP), [2] patients with transitional cell carcinoma (TCC) of the bladder invading the prostate, [3] if the pathology reports of both Pbx and retropubic RP were not available and [4] patients diagnosed at other centers whose Pbx was not reviewed by our hospital\’s pathologist.
Statistical analysis was performed using the t-test and logistic regression analysis (univariate and multivariate). A p-value <0.05 was accepted as statistically significant.
There were 113 patients who had undergone Pbx but not RP, 66 showed evidence of PNI (group 1) while 47 had no PNI in the Pbx (group 2) (Table 1). The mean patient age was not statistically different between the two groups. There were statistically significant differences in mean serum PSA (p=0.04) and mean biopsy GS (p=0.01) between the groups (Table 1). On uni- and multivariate analysis there were no significant associations between patient age, smoking history or serum PSA and PNI. Univariate analysis showed a significant association between high Pbx GS and PNI (Table 2). Multivariate analysis confirmed this association (p=0.034 for all GS, p=0.03 for Pbx GS=7, and p=0.01 for Pbx GS>7).