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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 1  |  Page : 25-33
Local Versus General Anesthesia in Pediatric Renal Biopsy: Which is Associated With Better Outcome?


Pediatric Nephrology and Hypertension Unit, Obafemi Awolowo University Teaching Hospitals Complex , Ile-Ife, Osun State, Nigeria

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   Abstract 

Percutaneous renal biopsy (PRB) of the native kidneys of 32 Nigerian children with varied renal diseases were studied to evaluate which of the two anesthetic techniques (local or general) was associated with better outcome. The children were randomly assigned into two anesthetic groups of 16 subjects each. PRB was performed with Franklin-modified Vim-Silverman renal biopsy needle. The outcome indices in this study were, number of biopsy attempts, duration of the biopsy procedure, number of successful biopsies, episodes and duration of macrohematuria, if any, renal biopsy related trauma (RBT) and other associated complications. There were 19 boys and 13 girls. Mean ages were similar in both local (LA) (8.7 ± 4.14 years) and general anesthesia (GA) (9.9 ± 3.5 years) groups, P > 0.5. The mean biopsy attempts were 3.1 ± 1.8 and 1.6 ± 1.8 in the LA and GA groups respectively (P < 0.05). Mean biopsy duration was significantly longer in the LA group (21.6 ± 6.3 min) than in the GA group (7.6 ± 5.4 min), P < 0.001. Number of successful biopsies were similar in both groups; 12/16 in LA group and 15/16 in the GA group, P = 0.1446. The overall success rate was 84.4%. Mean episodes and duration of macrohematuria were similar in the two groups (P>0.5). It is concluded that in the anxious, fretful and uncooperative children, GA should be the anesthetic technique of choice for kidney biopsy given the fewer biopsy attempts as well as shorter biopsy duration associated with it.

Keywords: Kidney biopsy, Local anesthesia, General anesthesia, Hematuria.

How to cite this article:
Olowu WA. Local Versus General Anesthesia in Pediatric Renal Biopsy: Which is Associated With Better Outcome?. Saudi J Kidney Dis Transpl 2006;17:25-33

How to cite this URL:
Olowu WA. Local Versus General Anesthesia in Pediatric Renal Biopsy: Which is Associated With Better Outcome?. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2020 Jun 2];17:25-33. Available from: http://www.sjkdt.org/text.asp?2006/17/1/25/32440

   Introduction Top


Percutaneous renal biopsy (PRB) is an invaluable diagnostic and prognostic procedure in clinical nephrology. Histopathologic studies of PRB specimens have significantly improved the understanding of the pathogenetic mechanisms as well as therapeutic inter­ventions of many renal diseases in both children and adults. Persistent proteinuria, recurrent hematuria, the nephrotic syndrome, acute renal failure (ARF) of uncertain etiology, chronic renal failure and rapidly progressive glomerulonephritis are some common indica­tions for PRB in children.[1],[2],[3],[4] Other indications include monitoring of the progression of renal disease, determination of the degree of renal involvement in systemic diseases, moni­toring of renal response to therapeutic inter­vention, suspected renal allograft rejection and nephrotoxicity. [5],[6],[7],[8],[9],[10],[11],[12],[13]

Franklin-modified Vim-Silverman needle, Tru-cut needle, spring-loaded needle device and biopsy gun are different types of renal biopsy needles (RBN) that have been used with similar degrees of success in children. [10], [13],[14],[15] Complications from PRB are generally benign, tolerable and self-limiting. Some of

these include macrohematuria, arterio­venous fistula, renal hematomas and severe anemia. [10],[13]

Local anesthesia (LA) with good sedation is a commonly used anesthetic in PRB procedures in children, with remarkable success. [10],[13],[14],[15],[16] This randomized, controlled prospective study was conducted to determine which of the two anesthetic techniques {LA or general anesthesia (GA)} was associated with better outcome. It was important to know because of the frequent need in our unit, to shift from LA to GA in the anxious, fretful and uncooperative children in order to avoid over sedation and the attendant respiratory depression, serious renal trauma and other severe complications. The seven outcome indices evaluated were number of biopsy attempts, biopsy duration, number of successful biopsies, episodes and duration of macrohematuria, renal biopsy-related trauma and other associated complications.


   Patients and Methods Top


Thirty-two children with varied renal diseases underwent percutaneous biopsy of their native kidneys between June 2001 and May 2003. The sample size (N) was deter­mined from the statistical formula Pt (1­ Pt)Z 2 /δ 2 17 where Pi denotes the prevalence of a disease in a population. In this center, the nephrotic syndrome is the commonest renal disorder, accounting for 2.04% of all pediatric admissions; [18] Pt was therefore taken to be 2.04 %. Z equals 1.96 at 95% confidence interval (CI); δthe difference between estimated and true prevalence of a disease in a population. At 95 % CI, δ was taken to be 5 %. It was a prospective randomized, controlled study. The patients were randomly assigned to the two anesthetic groups; each group having 16 patients. One group was administered local anesthesia (LA) while the other, general anesthesia (GA) for the PRB.

Data collected from each patient included age, gender, weight, height, pre- and post­biopsy vital signs, diagnosis, anesthetic technique, and biopsy duration. Biopsy duration was defined as the period between the first biopsy attempt and the first/last successful or failed attempt; an assistant did the timing. Biopsy was considered success­ful only if a renal tissue specimen containing > 5 glomeruli was obtained. Other data collected included respiratory phase at which biopsy was performed, biopsy-related complications, and renal biopsy trauma (RBT). RBT was defined in terms of hema­turia and classified as mild (no hematuria), moderate (microhematuria only), and severe (macrohematuria). Laboratory data studied included hematocrit, platelet count, pro­thrombin time (PT), partial thromboplastin time (PTT) and bleeding and clotting times.

Indications for PRB in the patients were the nephrotic syndrome (n = 15), persistent non-nephrotic significant proteinuria (n = 5), acute renal failure (n = 5), systemic lupus erythematosus (SLE) (n = 3), mixed connective tissue disease (n = 2) and pre­terminal chronic renal failure (n = 2).

Informed consent from parent/guardian of each patient, and ethical approval were obtained.

Exclusion Criteria included:

(i) Urinary tract infection

(ii) Fever due to a cause other than malaria

(iii) Moribund clinical status

(iv) Severe uncontrolled hypertension

(v) Bilateral contracted kidneys on ultrasound

(vi) Solitary kidney

(vii) Plasma urea >10 mmol/L

(viii) Abnormal hemostatic function namely platelet count < 90,000/Cu mm, PT > 15 sec, PTT > 45 sec,

bleeding time > 5 min and clotting time >10 min.

Prior to PRB, the platelet count, PT, PTT, bleeding time and clotting time in the LA group were 112,000 - 541,000/Cu mm, 12­15 sec, 30-40 sec, 2.6 - 4.5 min and 6-10 min, respectively. The corresponding values in the GA group were 140,000-656,000/Cu mm, 13.9-15 sec, 21.5-45 sec, 1.3-5 min and 4-10 min, respectively.


   Biopsy Preparations Top


All patients were subjected to overnight fasting and until after the procedure. An intravenous infusion of 4.3 % dextrose in 0.18 % saline was routinely started on the morning of the procedure and maintained for at least 24 hours after the procedure. Vital signs were checked before biopsy. Pre-medications were given 30-60 minutes before the PRB. The LA group received intramuscular (i.m.) diazepam (0.3-1.8 mg/ kg/dose), i.m. promethazine (0.3-1.3 mg/kg/ dose) and i.m pentazocine (0.4-0.9 mg/kg/ dose) to achieve mild (defined as purposive response to instructions) to moderate (defined as non-purposive response to instructions) degrees of sedation and analgesia. The GA group, received i.m. diazepam (0.2-0.42 mg/kg/dose) and i.m. atropine (6.1-20.0 µg/kg/dose). Blood was grouped and cross­matched for each patient, prior to the PRB. Resuscitatory equipment and drugs were made available, within the procedure room.


   Biopsy Procedure Top


The PRB was performed using the Franklin-modified Vim-Silverman RBN (manufactured by UNIMED SA CH-1002 Lausanne, Switzerland). Sizes F-S 1.8 x 60 mm and F-S 2.1 x 85 mm biopsy needles were used for children below and above five years of age, respectively. The outer lower pole of the left kidney was routinely biopsied.

The sedated patient was positioned prone on the procedure couch; a firm pillow was placed between the abdomen and the couch to prevent antero-posterior movement of the kidney. The region between the iliac crests and the 12th rib was thoroughly cleansed in the following order: cetrimide solution, methylated spirit (MS), Tinc Benzoin CO (TBC) and MS. The patient was then draped, exposing only the biopsy site (the left renal angle). For the PRB, the GA group received intravenous (i.v.) ketamine (1.0-7.0 mg/kg) in addition to the pre-medication. In the LA group, the biopsy site, already mapped out ultrasonographically on the skin, was infiltrated with at least 5 ml of 1% plain xylocaine from the skin through to deeper tissues for local anesthesia, in addition to the pre-medication.

In both groups, the depth and position of the left kidney was determined by carefully advancing the RBN obturator held tangential to the biopsy site through the skin and the subcutaneous tissue until the kidney was penetrated; characteristically, there is an initial resistance followed by a 'give' and then, the typical up and down swing of the obturator. Close to the skin, the obturator was held between the thumb and index finger and then removed. The distance between the two fingers and the obturator tip indicated the depth of the kidney and therefore, how far the RBN cannula could be advanced into the renal tissue. The RBN obturator was then inserted into the RBN cannula and both were carefully advanced through the path initially created with the obturator until the kidney was again pene­trated. On penetrating the kidney, the obturator only was removed and replaced with the RBN cutting prongs. In older, co­operative patients, biopsy was performed by sharply pushing the cutting prongs into the kidney substance while the patient was holding his breath in inspiration; with the cut done, the cannula was quickly advanced further into the kidney to retain the biopsy specimen within the cutting prongs before both cannula and cutting prongs were simultaneously withdrawn from the patient. However, in the uncooperative, anxious patient and those who received GA, biopsy was done at the end of expiration and in some cases, without regard to the respiratory phase. Firm pressure was applied to the biopsy site for about 3-5 minutes or until bleeding stopped. The site was then dressed with sterile TBC gauze. The renal specimen was placed in formalin and sent to the histopathology laboratory.


   Post PRB Measures Top


Each patient was kept in bed for at least 24 hours; the i.v. infusion was also kept flowing for at least 24 hours. Vital signs were recorded 15, 30 and 60 minutes after biopsy initially and thereafter, they were recorded four-hourly. Samples of urine passed post-biopsy were checked for macro­hematuria and microhematuria, for at least 48 hours. The hematocrit was checked at four, 12 and 24 hours post-biopsy. All post­biopsy complications were noted and managed accordingly.


   Statistical Analysis Top


Statistical means + SD were compared using the Student's t test. Where appropriate, X 2 and Fisher's exact tests were used to compare proportions; values of P < 0.05 were regarded as statistically significant.


   Results Top


There were 19 boys and 13 girls in the study group. Age, gender distribution, height, weight and pre-biopsy pulse rate and blood pressure were similar in both groups [Table - 1].

Mild to moderate sedation was administered in the LA group with i.m. diazepam, i.m. prome­thazine and i.m. pentazocine in a mean dose of 18.8 ± 8.9 (5-40) mg, 14.6 ± 9 (6.25­37.5) mg and 12.5 ± 4.1 (7.5-22.5) mg, respectively. In the GA group, i.m. diazepam and i.m. atropine were given as pre­medication in a mean dose of 9.4 ±1 .7 (5-10) mg and 270 ± 50 (150-300) µg, respectively; GA was induced with 75 ± 3 0.3 (25-150) mg of ketamine, administered i.v.

Pre- and post-renal biopsy vital signs are compared in [Table - 2]. PRB and macro­haematuria data in the two anesthetic groups are compared in [Table - 3]. Failure to obtain > five glomeruli in the biopsy sample was experienced in one GA and four LA patients. Renal biopsy trauma (RBT) was mild (no hematuria) in seven (LA, 2; GA, 5), moderate (microhematuria) in nine (LA, 4; GA, 5) and severe (macrohematuria) in 15 (LA, 10; GA 5) patients. The RBT did not differ significantly between the two groups, P>0.05. [Table - 4] shows the number of renal biopsies performed in relation to the respiratory phases. [Table - 5] is a summary of post-PRB complications in the two groups. Macro­hematuria was the commonest complication and it persisted for seven days in one of the 16 patients in the LA group. All tests including renal ultrasound and urine culture were negative in this patient. He was treated with four i.v. doses of ethamsylate (15 mg/kg/dose, repeated six hourly until hematuria stopped) and maintained orally at the same dosage and frequency for one week. The patient also received three pints of fresh whole blood and two units of fresh frozen plasma. Renal histopathology in this patient showed focal glomerulonephritis (FGN).

Mean pre- and post-PRB hematocrit values in the LA group were 31.4 ± 4.8 (17-42%) and 29 ± 9.1 (17-39%) respectively; the difference was not remarkable, P > 0.2. The hematocrit values in the GA group were 32.7 ± 5.4 (20-40 %) and 30.4 ± 8.6 (17-40 %), respectively. The difference was not statis­tically significant, P > 0.2.

One of 16 patients in the GA group, who had systemic lupus erythematosus with features of nephritis, carditis and pneumonitis died 30 minutes post biopsy, from cardiac arrhythmia due to lupus carditis. None died in the LA group. The overall mortality rate was 3.1 %.


   Discussion Top


Our "lytic cocktail" comprising i.m. dia­zepam, pentazocine and promethazine hydro­chloride compares favorably with the i.m. cocktail of chlorpromazine hydrochloride, promethazine hydrochloride and meperidine (or pethidine) hydrochloride that has been used in children undergoing PRB under LA, by other workers.[13]

While pre- and post-PRB vital signs were similar in the LA group, they were signi­ficantly altered in the GA group. Tachy­cardia and increased blood pressure (BP) are recognized side effects of ketamine.[19] Similarly, atropine sulphate is associated with tachycardia. [19] The significantly higher post-PRB pulse rate and BP observed in the GA group were therefore attributed to these drugs. Increased lung perfusion secondary to the tachycardia and increased BP caused by these drugs, could also have accounted for the significant tachypnea observed in this group.

Our results show that smoother and faster PRB can be performed with GA than with LA; this suggests that in the extremely anxious and uncooperative child, GA may be preferred to LA. This is based on the fact that the number of PRB attempts as well as duration was significantly fewer (P < 0.05) and shorter (P < 0.001), respectively in GA than in the LA group. In some units, GA is the anesthesia of choice for PRB in children.[20],[21],[22]

The outcome of PRB with regard to episodes and duration of macrohematuria, and biopsy success or failure rate was not influenced by anesthetic technique in this study. Similarly, White and Poole found no difference between GA and LA with regard to biopsy failure rate.[16] Operator's experience in PRB and hemostatic status of the patient may therefore be more important than the anesthetic technique employed. Our overall biopsy success rate of 84 % is reasonable and compares favorably with

results from other studies, [10],[13],[14],[16] consi­dering the fact that PRBs were performed in our patients without fluoroscopic or direct ultrasound guidance, as was the case in the other studies. Careful patient selection, especially with respect to ensuring normal BP and hemostatic function tests, as well as tolerable blood urea levels in the patients before biopsy, could have accounted for the similarity in RBT in the two groups.

Majority of the children (62.5 %) in the LA group were biopsied without reference to either of the two respiratory phases; this underlined the difficulty encountered in getting the anxious children to cooperate for the biopsy to be done by holding their breath at full inspiration. Throughout the procedure, since patients in the GA group were unconscious and therefore could not be instructed on anything, majority of the biopsies (81.3 %) were performed at the end of expiration (that is, shortly before commencement of inspiration).

Most complications of PRB are benign and self-limiting. [10],[13] Similar to other studies, [10],[13] macrohematuria was the leading compli­cation in this study. It accounted for 52.6 % and 23.8 % of all complications in LA and GA groups, respectively. These figures are higher than the 2.6-17.5% reported by other workers. [14],[15],[16],[23] This is possibly because our biopsies were not ultrasound or fluoroscopy guided. This handicap made one-time biopsy impossible in many instances. Macrohematuria is usually self-limiting, lasting few hours in a majority of the cases.[13],[14],[15],[16],[23] However, a few cases may become quite severe requiring blood transfusion. [13] Severe macrohematuria requiring blood transfusion and treatment with ethamsylate occurred in one of our 16 LA patients. The patient had focal glomerulonephritis as the primary glomerular lesion. This lesion is often associated with recurrent hematuria [24] and we believe that the histopathologic lesion probably provoked the severe persistent macrohematuria in the patient. Hussain et al [14] found patients with Henoch­Schonlein purpura and mesangial IgA nephropathy to be significantly prone to post-biopsy macrohematuria. Arteriovenous fistula, a commonly reported complication of PRB,[13] was not seen in this study. Vomiting was the second leading compli­cation in this series. However, in another study, hypoxia was the second leading complication.[14] Our complication pattern is quite similar to what has been reported in South African children.[10] Severe blood loss was not a common complication in this study. Although there was a fall in the hematocrit levels post-biopsy in both anesthetic groups, the drop was mild and insignificant. While the overall frequency of severe blood loss requiring blood transfusion was 3.1 % in this series, it was 1.7 % in two different series reviewed by Baluarte and Gruskin,[13] thus emphasizing the rarity of severe anemia after PRB.

Mortality is uncommon after pediatric PRBs.[10],[13] The overall mortality rate in this study was 3.1 %. In our patient who died after PRB, death was attributed to atropine and ketamine, which are probably not compatible with survival in patients with SLE, with associated carditis. Both drugs cause tachycardia and raised BP; these might have aggravated the myocardial dysfunction in lupus carditis. This suggests that atropine and ketamine may be unsafe in SLE patients with carditis.

It is concluded that while majority of outcome indices evaluated were similar in both GA and LA groups, smoother and faster PRB could be achieved with GA than with LA given the significantly fewer biopsy attempts and shorter biopsy duration associated with the former.


   Acknowledgement Top


The assistance rendered by DRs. J.B.E. Elusiyan, S.A. Badejo and O.A. Adenowo in administering the intravenous drugs, timing the procedure and monitoring the patients post biopsy is especially appre­ciated. The paper was presented at the16th Annual Scientific Conference of the Nigerian Association of Nephrology, February, 2004.

 
   References Top

1.Coppo R, Gianoglio B, Porcellini MG, Maringhini S. Frequency of renal diseases and clinical indications for renal biopsy in children (report of the Italian National Registry of Renal Biopsies in Children). Nephrol Dial Transplant 1998;13: 293-7.  Back to cited text no. 1  [PUBMED]  
2.Jovanovic O, Popovic-Rolovic M, Sindjic M, Kostic M, Kruscic D, Peco­Antic A. IgA nephropathy in children with various clinico-histologic features and therapy. Srpi Arhl Celok Lek 1992; 120:336-9.  Back to cited text no. 2    
3.Srivastava RN, Moudgil A, Bagga A, Vasudev AS, Bhuyan UN, Sundraem KR. Crescentic glomerulonephritis in children: a review of 43 cases. Am J Nephrol 1992;12:155-61.  Back to cited text no. 3  [PUBMED]  
4.Suh KS, Kim JO, Kang GH. Thin glomerular basement membrane disease: light microscopic and electron micro­scopic studies. J Korean Med Sci 1997; 12:234-9.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.McCurdy DK, Lehman TJ, Bernstein B, et al. Lupus nephritis: prognostic factors in children. Paediatrics 1992; 89:240-46.  Back to cited text no. 5    
6.Rutledge SL, Geraghty M, Mroczek E, Rosenblatt D, Kohout E. Tubulointer­stitial nephritis in methylmalonic acida­emia. Pediatr Nephrol 1993;7:81-2.  Back to cited text no. 6  [PUBMED]  
7.Bergstein JM, Andreoli SP. Response of type I membranoproliferative glomerulo­nephritis to pulse methyl-prednisolone and alternate-day prednisone therapy. Pediatr Nephrol 1995;9: 268-71.  Back to cited text no. 7  [PUBMED]  
8.Adhikari M, Coovadia HM. Cyclosporin in steroid-resistant nephrotic syndrome. South Afr Med J 1994; 84:753-6.  Back to cited text no. 8    
9.Vats A, Mauer M, Burke BA, Weiss RA, Chavers BM . Delayed acute renal failure in post-transplant period in young children from unexplained aetiology. Pediatr Nephrol 1997; 11:531-6.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]
10.McCulloch M, Sinclair P, Maythem D, et al. Audit of paediatric renal biopsies at Red Cross Children's Hospital, Cape Town. Paediatr Nephrol: Proceedings of the 2nd Congress of the African Paediatric Nephrology Association, Port Harcourt, Nigeria. February 2002. Germany,Springer-verlag 2002;468.  Back to cited text no. 10    
11.Ahmad T, Simmonds M, Mclver AG, McGraw ME. Reversible renal failure in renal transplant patients receiving oral acyclovir prophylaxis. Pediatr Nephrol 1994; 8:489-91.  Back to cited text no. 11    
12.Singh J, Dutta AK, Khare S, et al. Diethylene glycol poisoning in Gurgaon, India, 1998. Bulletin of the World Health Organisation 2001;79:88-95.  Back to cited text no. 12    
13.Baluarte HJ, Gruskin AB. Renal biopsy: indications and techniques. In: Postlethwaite RJ (ed). Clinical paediatric nephrology. Bristol. IOP Publishing Ltd, 1986;465-72.  Back to cited text no. 13    
14.Hussain F, Watson AR, Hayes J, Evans J. Standards for renal biopsies: compa­rison of inpatient and day care procedures. Pediatr Nephrol 2003;18:53-6.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.Bohlin AB, Edstron B, Almgren S, Jaremko G, Jorulf H. Renal biopsy in children: indications, technique and efficacy in 119 consecutive cases. Pediatr Nephrol 1995;9:201-3.  Back to cited text no. 15    
16.White RH, Poole C. Day care renal biopsy. Pediatr Nephrol 1996; 10: 408-11.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]
17.Lwanga SK. Biostatistics for medical students; Nairobi: East African Literature Bureau 1975:109-26.  Back to cited text no. 17    
18.Olowu WA, Ogundipe MO. Appraisal of dietiary salt restriction in children with nephrotic syndrome. Nig J Paediatr: Proceedings of the 28th Scientific Conference of Paediatric Association of Nigeria, held at Ile-Ife, Nigeria. January 1997.Ibadan, Clave­rianum Press 1997;69.  Back to cited text no. 18    
19.Mehta DK. British National Formulary; London: BMJ Books. 2000;561-72.  Back to cited text no. 19    
20.Gauthier BG, Mahadeo RS, Trachtman H. Techniques for percutaneous renal biopsies. Paediatr Nephrol 1993; 7: 457-63.  Back to cited text no. 20    
21.Feneberg R, Schaefer F, Zieger B, Waldherr R, Mehls O, Scharer K. Percutaneous renal biopsy in children: a 27-year experience. Nephron 1998;79: 438-46.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]
22.Kamitasuji H, Yoshioka K, Ito H. Percutaneous renal biopsy in children: survey of paediatric nephrologists in Japan. Paediatr Nephrol 1990; 13: 693-96.  Back to cited text no. 22    
23.Chesney DS, Brouhard BH, Cunningham RJ. Safety and cost effectivenss of pediatric percutaneous renal biopsy. Pediatr Nephrol 1996;10: 493-5.  Back to cited text no. 23  [PUBMED]  [FULLTEXT]
24.Cotran RS. The kidney. In: Cotran RS, Kumar V, Collins T (eds). Pathologic basis of disease. Philadelphia. W.B. Saunders Company, 1999; 931-96.  Back to cited text no. 24    

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Correspondence Address:
Wasiu Adekunle Olowu
Pediatric Nephrology and Hypertension Unit, Obafemi Awolowo University Teaching Hospitals Complex, P.M.B. 5538, Ile-Ife, Osun State
Nigeria
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    Abstract
    Introduction
    Patients and Methods
    Biopsy Preparations
    Biopsy Procedure
    Post PRB Measures
    Statistical Analysis
    Results
    Discussion
    Acknowledgement
    References
    Article Tables
 

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