|Ahead of print
Anesthesia concerns in prostate brachytherapy: An institutional experience
Vinod Kumar1, Deepti Ahuja1, Nishkarsh Gupta1, Sachidanand J Bharati1, Rakesh Garg1, Seema Mishra1, KP Haresh2, Subhash Gupta3, Sushma Bhatnagar1
1 Department of Onco-Anaesthesia and Palliative medicine, Dr. Bhim Rao Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
2 Department of Onco-Anaesthesia and Palliative medicine, Dr. Bhim Rao Ambedkar Institute Rotary Cancer Hospital, All India Institute of Radiotherapy, New Delhi, India
3 Department of Radiotherapy, Dr. Bhim Rao Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
|Date of Submission||11-Oct-2018|
|Date of Decision||04-Mar-2020|
|Date of Acceptance||09-Mar-2020|
|Date of Web Publication||14-Sep-2020|
Department of Onco-Anaesthesia and Palliative medicine, Dr. Bhim Rao Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi
Source of Support: None, Conflict of Interest: None
Background: Prostate cancer is a common cancer found in men worldwide. Brachytherapy is an established modality used for the treatment of these patients. Although anesthetic management of such patients is challenging but the ideal anesthetic technique has not yet been established. Our study aims to identify the most efficacious anesthetic technique for perioperative management of prostate cancer patients undergoing brachytherapy.
Methods: Retrospective analysis of ten patients who underwent 16 brachytherapy sessions under combined spinal epidural (CSE) anesthesia between April 2016 and December 2016 was done. The data were collected, tabulated using MS Excel, and statistically analyzed with EPI Info 6 and SPSS-16 statistical software (SPSS Inc. Chicago, USA) to draw relative conclusions.
Results: The median peak sensory dermatome level achieved was T6 and the median maximum motor block achieved was grade 2. The mean (± standard deviation (SD)) time to sensory regression to T10 (range T5-T8) dermatome was found to be 118.00 ± 47.110 (range = 0-238) minutes. Despite the presence of co-morbidities, minor intraoperative complications were observed only in two patients. The postoperative numerical rating scale (NRS) was less than 4 in all patients during the first 24 hours. None of our patients complained of nausea, vomiting, pruritus and respiratory depression. The mean (± SD) patient satisfaction score was 44.40 ± 0.871 (range : 1-5) at the end of 24 hours.
Conclusions: CSE anesthesia is a safe and effective technique for anesthetic management of patients undergoing prostate brachytherapy.
Keywords: Anesthesia technique, combined spinal-epidural, prostate brachytherapy
|How to cite this URL:|
Kumar V, Ahuja D, Gupta N, Bharati SJ, Garg R, Mishra S, Haresh K P, Gupta S, Bhatnagar S. Anesthesia concerns in prostate brachytherapy: An institutional experience. Indian J Cancer [Epub ahead of print] [cited 2020 Sep 28]. Available from: http://www.indianjcancer.com/preprintarticle.asp?id=295078
| » Introduction|| |
Prostate cancer is the second most common cancer in men worldwide. According to data provided by Global Cancer Observatory i.e., GLOBOCAN 2018, prostate cancer accounted for 7.1% of new cases and 3.8% of deaths in men worldwide. The different options available for the management of prostate cancer include active surveillance, chemotherapy, radical prostatectomy, intensity-modulated radiotherapy, stereotactic ablative radiotherapy, brachytherapy, radiofrequency ablation, cryotherapy, and particle therapy. Brachytherapy is an important modality for prostate cancer treatment. Furthermore, anesthetic management of such patients is quite challenging. In this article, we are describing our experience of providing anesthesia to these patients.
| » Methods|| |
Records of patients undergoing brachytherapy from April 2016 till December 2016 were analyzed retrospectively. Ten patients who received a total of 16 sessions were included in the analysis. These patients aged between 60–70 years and of the American Society of Anesthesiologists (ASA) physical status I and II were admitted in tertiary care oncology setup. They underwent sessions of high dose radiotherapy (HDR) for carcinoma prostate. All the routine investigations including complete hemogram, blood urea, serum creatinine, serum electrolytes, serum bilirubin, electrocardiogram, and chest X-ray were recorded. All patients received tablet ranitidine hydrochloride 150 mg and tablet alprazolam 0.25 mg orally the night before and with one sip of water 2 hours before the procedure. Preoperative, baseline respiratory rate, pulse rate, blood pressure, oxygen saturation, and electrocardiogram (ECG) of patients were noted. Preloading of patients with 10 mL/kg Ringer lactate solution was done. Patients were put in lateral decubitus position and inj. fentanyl 0.5 μg/kg IV was given for sedation. Under all aseptic precautions, CSE anesthesia was performed in L3-L4 intervertebral space with BD Durasafe™ CSE needle set. Epidural space was identified with a Tuohy needle of 18 gauzes using the loss of resistance technique. Following the successful location of epidural space, the syringe was detached and 26 G Quincke's spinal needle was advanced till the free flow of cerebrospinal fluid (CSF) was visualized, 2.5 mL of 0.5% bupivacaine heavy with 25 μg fentanyl was injected intrathecally. Level of sensory blockade was checked by pinprick and motor blockade by modified Bromage scale (1 = unable to move feet or knees, 2 = able to move feet only, 3 = just able to move knees, and 4 = full flexion of knees and feet). Oxygen was routinely administered via an oxygen mask at the rate of 6 L/minute. Episodes of bradycardia and hypotension were recorded. Bradycardia (defined as heart rate <60 beats per minute) was treated with intravenous inj. atropine 0.6 mg. Hypotension (defined as fall in systolic blood pressure >20% of baseline value) was treated with inj. ephedrine 5 mg and additional fluids. Around 6 mL of 0.25% ropivacaine was given epidurally at sensory regression to T10. Further, inj. morphine 3 mg was given epidurally half an hour before the anticipated completion of the procedure. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), respiratory rate, and oxygen saturation (SpO2) were monitored every 5 minutes for the first 30 minutes and then every 10 minutes till the end of the procedure. Patient's pain was assessed using NRS (numerical rating scale 0–10 where 0 is no pain and 10 is worst imaginable pain), heart rate, blood pressure, respiratory rate, and sedation score using Ramsay sedation scale (1-anxious, completely awake, 2-completely awake, 3-awake, drowsy 4-asleep, responsive to verbal commands, 5-asleep, responsive to tactile stimulus, 6-asleep, not responsive to any stimulus) were assessed every half-hourly for first 2 hours and then at 4, 8, 12, 16, and 24 hours after giving bolus dose of ropivacaine. The patient satisfaction score (5-very satisfied, 4-satisfied, 3-neutral, 2-dissatisfied, 1-very dissatisfied) was assessed at the end of 24 hours.
| » Results|| |
The combined spinal-epidural anesthesia technique was accomplished in all the patients. Further data were collected, tabulated using MS Excel and statistically analyzed with EPI Info version 6 and SPSS-16 statistical software (SPSS Inc. Chicago, USA). The median age of patients was 70 (range = 66-74) years. Other demographic variables including ASA physical status, staging, and comorbidities of all patients are shown in [Table 1]. The time to mean onset of sensory block to T10 dermatome after administration of intrathecal bupivacaine and fentanyl was found to be 2.00 ± 1.086 (range = 1-4) minutes [Table 2]. The median sensory level achieved was T6 (range T5-T8) dermatome level. The mean time taken for achieving the maximum sensory level was found to be 11.00 ± 3.211 (range =7-17) minutes [Table 2]. The median maximum motor block achieved was Grade 2. Further, the meantime to regression to T10 dermatome was found to be 118.00 ± 47.110 (range = 80-238) minutes [Table 2]. The intraoperative monitored variables including HR, SBP, DBP, respiratory rate, and SpO2 were noted. Among all the 16 sessions, intraoperative complications were observed in two patients. One of the patients had hypotension and bradycardia after administration of intrathecal drugs which was managed with inj. atropine 0.6 mg and fluid bolus. Another patient who was a diagnosed case of Type 1 heart block showed occasional ventricular ectopics. The patient was anxious but hemodynamically stable. Inj. midazolam 1 mg was given and oxygen supplementation continued. The mean duration of the procedure was found to be 264.375 ± 19.65 (range = 213-290) minutes [Table 2]. The postoperative NRS was from 2–4 in all patients during the first 24 hours. None of our patients complained of nausea, vomiting, pruritus, and respiratory depression. The mean patient satisfaction score was found to be 4.40 ± 0.871 (range = 1-5) at the end of 24 hours.
| » Discussion|| |
Brachytherapy has emerged as a safe and effective local treatment modality for the management of low and intermediate-risk organ-confined prostate cancer with a low side effect rate. The administration of brachytherapy requires implantation of radiation sources in or near the tumor under transrectal ultrasound (TRUS) guidance. The patient is required to be in a lithotomy position for easy insertion of the TRUS probe and subsequent placement of applicators. The patient then receives HDR in the radiotherapy suite. Nevertheless, to administer safe anesthesia to this group of patients, the anesthesiologists are required to plan according to the unique considerations associated with the procedure. To begin with, the placement of applicators for the administration of intracavitary and interstitial brachytherapy in lithotomy position is extremely painful and hence sensory level of blockade till 10th thoracic spinal level (T10) is required for successful outcomes. Patients will require analgesia, till the applicators are in situ. Moreover, most of these patients are elderly with concurrent comorbidities that put them at higher risk of occurrence of perioperative complications. Furthermore, the duration of the brachytherapy procedure is variable and treatment sessions can take place at multiple locations. The whole treatment session may involve operation theatre for ultrasound-guided insertion of applicator under anesthesia, mobilizing the patient to the radiology suite for computerized tomography (CT)/magnetic resonance imaging (MRI) for confirming the correct placement of applicators, computer-based planning of brachytherapy with the applicator in situ, and finally to the radiotherapy room for administration of brachytherapy. Besides, when the patient receives HDR in a radiotherapy suit, all the operating room staff including an anesthesiologist, radiation oncologist, nursing, and technical staff is away from the patient. The patient is monitored through CCTV and slave monitor outside the operating room. Thus, the ideal anesthetic technique administered should be safe and effective under such dynamic conditions.
Different techniques have been selected from the armamentarium of anesthesiologists to provide adequate anesthesia and analgesia to the patients requiring administration of brachytherapy for carcinoma prostate. Wallner et al. in 1999 demonstrated the technique and feasibility of prostate brachytherapy under local anesthesia only. The technique did not require the allocation of significant operating room time but patients experienced discomfort due to lithotomy position and at the time of needle insertion, which was manifested by moderate changes in heart rate and DBP due to discomfort. The authors also reported the occurrence of seizures and urinary retention, both in one patient each. Later, in 2002, Wallner reported that 600 patients satisfactorily received implant and brachytherapy under local anesthesia. Nevertheless, the author also reported that patients moved under the effect of local anesthesia, which required adjustments in the positioning of the TRUS probe. Few patients also reported the inadequate pain relief achieved with the administration of the local anesthetic.
Saddle block is a low spinal block that anesthetizes the saddle area i.e., perineum, perianal area, medial aspect of legs, and thigh. In 2009, another study done by Clarke et al. favored the use of saddle block with 11.25 mg of 0.75% bupivacaine and 20 μg fentanyl for HDR brachytherapy for carcinoma prostate. But they emphasized the maintenance of 15-degree reverse Trendelenburg position throughout the procedure. Another limitation of the study was that motor strength data was not collected. Thus, both the saddle block and spinal block could not fulfill all considerations required for the procedure. With the administration of the spinal “saddle” block, the T10 spinal sensory level may not be attained. On the other end, a spinal block which requires administration of a high dose of a local anesthetic to achieve adequate sensory level for prolonged duration can be detrimental in elderly patients with comorbidities. Both spinal block and spinal “saddle” block do not provide the option of extending the dermatomal level if required and providing postoperative analgesia. Hence, the shorter duration of anesthesia may not be sufficient for the successful completion of the procedure. Benrath et al. in 2006 published a review on anesthesia for 1622 brachytherapy procedures done over 5 ½ years. In this review, authors have described the use of spinal anesthesia, spinal catheter, and combined spinal-epidural anesthesia (CSEA) for prostate brachytherapy. Hypotension and bradycardia were observed in 10% of patients who received regional anesthesia. This was explained by a higher level of regional anesthesia attained at or above T6, due to the predominant use of spinal catheters. Furthermore, Schenck et al. compared pudendal nerve block (NPB) and CSEA for performing pain-free HDR brachytherapy. The authors have mentioned the duration of the procedure as 80 minutes, for which NPB is satisfactory. However, the duration of the entire procedure is about 6 hours. NPB involves multiple injections, causes patient discomfort and does not provide the option of prolonged duration of analgesia. Moreover, patients who received CSEA reported better subjective well-being scores.
Hence, many different anesthetic techniques including sedation with systemic analgesia, general anesthesia, local anesthesia, and regional anesthesia have been used in patients requiring administration of brachytherapy for carcinoma prostate., Though the techniques are associated with variable success rates, it is still difficult to suggest the ideal anesthetic technique. In our opinion, an ideal anesthetic technique will be the one that can provide adequate analgesia throughout the procedure and provide optimal conditions for performing the procedure. The administration of general anesthesia in elderly patients with comorbidities can be associated with multiple complications in the perioperative period. As the procedure may be performed at multiple locations, the conduct of general anesthesia itself is not always feasible. Furthermore, local anesthesia can be administered safely in elderly patients with comorbidities; however, the quality of analgesia is not satisfactory and the duration of analgesia could not be prolonged if required. As the procedure is performed in the lithotomy position, the patient discomfort due to multiple injections of local anesthetic and the positioning may interfere with the procedure. Recently, pudendal nerve block has also been tried to provide analgesia in these patients; however, it can also cause patient discomfort due to the requirement of multiple injections and positioning. Similarly, saddle block may also cause patient discomfort during positioning and hinder the procedure. The block does not provide the option of extending the dermatomal level if required and providing postoperative analgesia. Considering the administration of spinal anesthesia alone may lead to cardiorespiratory complications in fragile elderly patients due to the higher dose of local anesthetic required. Among all the techniques, CSEA is closest to the ideal technique, as it can fulfill almost all the requirements of the procedure. CSE anesthesia technique offers rapid and reliable onset of sensory and motor blockade attributed to spinal block. The sensory level in the spinal block gets regressed with time and the patient may complain of pain. With the epidural catheter in situ, the dermatome level of analgesia can be extended with local anesthetic drugs administered through the epidural catheter. The intrathecal dose of local anesthetic is low resulting in less cardiorespiratory complications in elderly patients. Spinal anesthesia provides rapid onset whereas epidural anesthesia provides the option of prolonging the duration of analgesia when required. The patient's safety is not an issue, even if the procedure is performed at multiple locations. We have found that CSEA can be safely provided to elderly patients requiring brachytherapy. This technique while being associated with the patient's comfort allows for the successful performance of the procedure.
| » Conclusion|| |
Among all the techniques, CSEA provides patients comfort, analgesia, and favorable conditions for the successful conduct of prostate brachytherapy even in the dynamic conditions. Future randomized controlled trials are required to suggest the most effective and safe drugs that can be used in this specific group of patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018;68:394-424.
Podder T, Song D, Showalter T, Beaulieu L. Advances in radiotherapy for prostate cancer treatment. Prostate Cancer 2016;2016:3079684.
Xie R, Wang L, Bao H. Crystalloid and colloid preload for maintaining cardiac output in elderly patients undergoing total hip replacement under spinal anesthesia. J Biomed Res 2011;25:185-90.
Breen TW, Shapiro T, Glass B, Foster-Payne D, Oriol NE. Epidural anesthesia for labor in an ambulatory patient. Anesth Analg. 1993; 77:919–24.
Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with alphaxalone-alphadolone. Br Med J. 1974 22;2(5920):656-9.
Regmi S, Srinivasan S, Badhe AS, Satyaprakash M, Adinarayanan S, Mohan VK. Comparison of analgesic efficacy of continuous bilateral transversus abdominis plane catheter infusion with that of lumbar epidural for postoperative analgesia in patients undergoing lower abdominal surgeries. Indian J Anaesth. 2019; 63(6): 462–68
] [Full text]
Tselis N, Hoskin P, Baltas D, Strnad V, Zamboglou N, Rödel C, et al.
High dose rate brachytherapy as monotherapy for localised prostate cancer: Review of the current status. Clin Oncol (R Coll Radiol) 2017;29:401-11.
Benrath J, Kozek-Langenecker S, Hupfl M, Lierz P, Gustorff B. Anesthesia for brachytherapy 51/2 yr of experience in 1622 procedures. Br J Anaesth 2006;96:195-200.
Wallner K, Simpson C, Roof J, Arthrus S, Korssjoen T, Sutlief S. Local anesthesia for prostate brachytherapy. Int J RadiatOncol Biol Phys 1999;45:401-6.
Wallner K. Prostate brachytherapy under local anesthesia: Lessons from the first 600 patients. Brachytherapy 2002;1:145-8.
Adriani, J., and Roman-Vega, D. A.: Saddle Block Anesthesia. Am. J. Surg.1946; 71:12-18
Clarke HA, Tarshis J, Lam-McCulloch J, Kay J. Saddle block analgesia for high-dose-rate brachytherapy: A prospective study. Brachytherapy 2009;8:335-8.
Schenck M, Schenck C, Rübben H, Stuschke M, Schneider T, Eisenhardt A, et al.
Pudendal nerve block in HDR-brachytherapy patients: Do we really need general or regional anesthesia? World J Urol 2013;31:417-21.
Yildirim I. Anesthesia techniques in brachytherapy. Turk J Oncol 2019;34(Supp 1):99-101.
Roessler B, Six LM, Gustorff B. Anesthesia for brachytherapy. Curr Opin Anaesthesiol 2008;21:514-8.
Lam ST, Cho PS, Marks RJ 2nd, Narayanan S. Detection and correction of patient movement in prostate brachytherapy seed reconstruction. Phys Med Biol 2005;50:2071-87.
[Table 1], [Table 2]