Local anesthesia for prostate brachytherapy

Purpose: To demonstrate the technique and feasibility of prostate brachythe rapy performed with local anesthesia only. Methods and Materials: A 5 by 5 cm patch of perineal skin and subcutaneous tissue is anesthetized by local infiltration of 10 cc of 1% lidocaine with epinephrine, using a 25-gauge 5/8-inch needle. Immediately following inject ion into the subcutaneous tissues, the deeper tissues, including the pelvic floor and prostate apex, are anesthetized by injecting 15 cc lidocaine sol ution with approximately 8 passes of a 20-gauge 1.0-inch needle. Following subcutaneous and peri-apical lidocaine injections, the patient is brought t o the simulator suite and placed in leg stirrups. The transrectal ultrasoun d (TRUS) probe is positioned to reproduce the planning images and a 3.5- or 6.0-inch, 22-gauge spinal needle is inserted into the peripheral planned n eedle tracks, monitored by TRUS. When the tips of the needles reach the pro static base, about 1 cc of lidocaine solution is injected in the intraprost atic track, as the needle is slowly withdrawn, for a total volume of 15 cc. The implants are done with a Mick Applicator, inserting and loading groups of two to four needles, so that a maximum of only about four needles are i n the patient at any one time. During the implant procedure, an additional 1 cc of lidocaine solution is injected into one or more needle tracks if th e patient experiences substantial discomfort. The total dose of lidocaine i s generally limited to 500 mg (50 ml of 1% solution). Results: To date, we have implanted approximately 50 patients in our simula tor suite,using local anesthesia. Patients' heart rate and diastolic blood pressure usually showed moderate changes, consistent with some discomfort. The time from first subcutaneous injection and completion of the source ins ertion ranged from 35 to 90 minutes. Serum lidocaine levels were below or a t the low range of therapeutic. There has been only one instance of acute u rinary retention in the patients treated so far, and no unplanned admission s to the hospital or need to reschedule a patient to be implanted under gen eral or spinal anesthesia. Conclusions: The substitution of local anesthesia has facilitated rapid int roduction of a high-volume brachytherapy program at an institution that pre viously had none, without requiring the allocation of significant operating room time. Although the patients reported here were implanted without cons cious sedation, we are starting to try various sedatives and analgesics for patients who we anticipate will have substantial anxiety with the procedur e. (C) 1999 Elsevier Science Inc.