Prostate brachytherapy under local anesthesia; lessons from the first 600 patients

Local anesthesia for prostate brachytherapy was instituted at the Puget Sound Veterans Hospital in 1999, peforming the procedure in our own department without anesthesia personnel in attendance.

The patient is brought into the simulator suite in the radiation oncology department, an i.v. line is started, a cardiac monitor attached, and a urinary catheter is inserted. He is then placed in the lithotomy position, using stirrups attached to the simulator table. A 6-8 cm patch of perineal skin and subcutaneous tissue is anesthetized by local infiltration of 1% lidocaine. The transrectal ultrasound (TRUS) probe is then inserted and positioned to reproduce the planning images. A 3.0 inch 22-gauge spinal needle is used to inject lidocaine up to the prostatic apex, in a pattern around the periphery of the prostate. Once the pelvic floor and prostatic apex are anesthetized, a 7.0-inch, 22-gauge spinal needle is inserted through an 18-gauge 3 inch spinal needle into the peripheral planned needle tracks, monitored by TRUS. As the needles are advanced to the prostatic base, about 1.0 cc of lidocaine solution is injected in the intraprostatic track. A total of 200 to 500 mg of lidocaine is used.

As of December 2000, more than 600 patients have received implants under local anesthesia at Seattle, WA. Patients tolerate brachytherapy under local anesthesia surprisingly well. Post-implant CT-defined target coverage has ranged from 80% to 95%, well within published criteria for technical adequacy. Patients' typical implant pain score is 3, on a scale of 0-10. After a series of patient acceptance quality studies, we have abandoned the routine use of sedation, and relied instead on local lidocaine infiltration alone.

In addition to a high degree of patient satisfaction, performing implants under local anesthesia allows for phenomenal logistical efficiencies and cost advantages.