A reappraisal of local anesthesia for prostate brachytherapy

Faced with rapidly increasing patient numbers, the authors adopted and modified a technique to perform prostate implants under local anesthesia in a radiation oncology facility. Our reasons for assembling the current report detailing 20 consecutive, unselected patients are to show how patients tolerate brachytherapy without the use of sedatives, to provide more technical detail regarding the procedure's practical aspects, and to summarize the time needed to complete its components.

No pre-operative medication is given. The patient is placed in the lithotomy position, using stirrups mounted on the end of the simulator table. A 5-cm x 5-cm patch of perineal skin and subcutaneous tissue is anesthetized by local infiltration of 3-5 cm3 of 0.5% lidocaine, using a 25-gauge 1.5-inch needle. Immediately following injection into the subcutaneous tissues, the deeper tissues, of the pelvic floor are anesthetized by injecting 5 cm3 lidocaine solution with approximately 16 passes of a 25-gauge 1.5-inch needle entering perpendicular to the skin surface. The transrectal ultrasound (TRUS) probe of a Siemens SONOLINE Prima ultrasound machine (6.0 MHz) and a Winston-Barzell stepper unit is next positioned to reproduce the planning images and a 3.5-inch, 22-gauge spinal needle is inserted into the peripheral and a few central tracks. About 0.5 cm3 of lidocaine solution is injected into each intraprostatic track, as the needle is slowly advanced. Finally, a 7-inch 22-gauge spinal needle inserted through the skin via a 3.5-inch 18-gauge needle, is used to anesthetize to the base of the prostate under TRUS and fluoroscopic guidance. Seed placement is done with a Mick Applicator, inserting and loading one needle at a time. The number of seeds placed ranged from 60 to 118 (average: 87) and the number of needles used ranged from 14 to 20 (average: 18). For the purpose of this study, prior to walking to the simulator suite, patients were asked to rate the pain they experienced with their prostate biopsy on a scale of 0-10 (no pain to pain at its worst). They were asked to rate their pain at the time of the catheter insertion, the lidocaine infiltration of the perineum and prostate and again at the completion of the seed insertion.

The amount of lidocaine administered ranged from 250 to 450 mg, with a median of 300 mg. There were no untoward effects of lidocaine. Average pain scores for patients' biopsy, catheter insertion, lidocaine infiltration and seed insertion were 3.3, 3.0, 4.0 and 2.7, respectively. Patients' total time in the simulator room, including taking post-implant dosimetric films, remove the intravenous line and catheter, and to clean the perineum, ranged from 77 to 135 min, with a median of 105 min. The median post-implant CT-defined target coverage by the prescription isodose was 94%, with a range of 80-100%.

Performing prostate brachytherapy under local anesthesia, as reported here, is simple, efficient and well tolerated.