Local Anesthesia During Interstitial Laser Coagulation of the Prostate

ILC in the Treatment of BPH

ILC IN THE TREATMENT OF BPH Local Anesthesia During Interstitial Laser Coagulation of the Prostate Kalish R. Kedia, MD Cleveland Urology Associates, Middleburg Heights, OH With the emergence of minimally invasive therapies for the management of symptoms of benign prostatic hyperplasia (BPH), as well as the reality of a changing medical economic environment, there is a need for a reliable local anesthesia protocol. The protocol described here for prostate anesthetic block is a safe, economical, and effective way to perform interstitial laser coagulation and other minor endoscopic urologic procedures in the office setting. Most patients experience little discomfort and recover quickly, with prompt return to normal activities. Urologists should be aware of and comfortable with these techniques. [Rev Urol. 2005;7(suppl 9):S23–S28] © 2005 MedReviews, LLC Key words: Benign prostatic hyperplasia • Minimally invasive therapies • Interstitial laser coagulation • Local anesthesia • Office-based procedures enign prostatic hyperplasia (BPH) affects 60% of men age 60 and older and the symptoms of this condition can have a profound effect on a patient’s health and quality of life. For decades, doctors were able to offer only a few treatment options: watchful waiting, transurethral resection of prostate (TURP), or open prostatectomy. Even today, TURP is considered the “gold standard” treatment for affective prostatic hyperplasia. However, recent developments in medical therapy and the emergence of minimally invasive therapies (MIT), including thermal therapies that use laser, microwave, ultrasound, or radio frequency (RF) energy, have dramatically changed the options available for treatment of B VOL. 7 SUPPL. 9 2005 REVIEWS IN UROLOGY S23 Local Anesthesia continued obstructive BPH. Many minimally invasive approaches to treating BPH use thermal energy to destroy the obstructing prostatic tissue. TURP is the standard against which all other new technologies for treating bladder outflow obstruction secondary to BPH are compared. Although TURP provides excellent relief of symptoms in about 85% of patients who undergo one, its morbidity and cost have stimulated the extensive development of less invasive methods for treating BPH. The most common complications associated with TURP are bleeding, incontinence, urethral stricture, bladder neck contracture, sexual dysfunction and water intoxication. One of the most dramatic developments in the management of BPH over the last few years has been the advent of medical therapy. Currently,
-blockers as a class are used in 80% of patients receiving initial management of BPH. Inhibitors of 5
reductase (such as finasteride) reduce the size of the prostate. This hormonal manipulation is another approach in the treatment of BPH. Finally, the use of
1-blockade, combined with hormonal manipulation (5
-reductase inhibition), offers a theoretical benefit of reducing the dynamic as well as the static components of bladder outlet obstruction secondary to BPH. The ideal medical agent for treatment of BPH should improve quality of life by relieving symptoms, have minimal side effects, be cost effective, and, eventually, cause a regression of the disease process. Currently available agents do not meet many of these criteria. One of the questions regarding medical treatment is its durability. Will the medical therapy eventually fail, requiring patients to seek surgical or other treatments? One could speculate whether the initial beneficial effect of
-blockers on the dynamic component of the patient’s obstruction would eventually be S24 VOL. 7 SUPPL. 9 2005 overcome by the continuing prostatic growth, producing an ever-increasing static component of obstruction. Long-term trials are needed to resolve this question and to establish the durability and definitive cost effectiveness of all varieties of medical therapy. Patient Algorithm for BPH Any patients with clinical BPH, as determined by subjective parameters, such as symptoms and bother score, and by objective parameters, such as prostate size, peak flow rate, postvoid residual urine volume, and pressure flow studies, are suitable candidates for medical therapy, MIT, or surgical therapy. Minimally invasive interventions fall between medical therapy and surgery on the patient treatment algorithm. If the patient chooses medical therapy first, and the treatment then fails, his choices are MIT or surgery. If the patient chooses MIT first, then the therapy fails, his choices are repeat MIT, medical therapy, or surgery. Among the minimally invasive interventions for BPH, interstitial laser coagulation (ILC), microwave thermotherapy, and transurethral needle ablation (TUNA), are among the most widely used currently. High-intensity focused ultrasound (HIFU), water-induced thermotherapy, and stents are less commonly in use. ILC using the Indigo® Optima Laser System (Ethicon Endo-Surgery, Inc., Cincinnati, OH) has become a popular MIT in recent years because of the simplicity of the procedure, effectiveness, moderate upfront cost to acquire the equipment, adequate reimbursement, and the fact that the procedure can be performed in the office setting using local anesthesia. Patient Selection for ILC Suitable candidates for ILC include any patient with clinical BPH, Americal Urological Association (AUA) REVIEWS IN UROLOGY symptom score greater than 13, flow rate less than 15 mL/sec, and postvoid residual urine greater than 50 mL. Small, enlarged prostates can be treated with ILC, but I personally avoid performing ILC with larger glands (greater than 85 cm3). The median lobe may also be treated with ILC. Patients in Urinary Retention. Patients with acute urinary retention may benefit from ILC, however, they also may require simultaneous medical therapy and prolonged catheter drainage. Patients with chronic urinary retention with decompensated bladder are not suitable candidates for ILC. Anticoagulants. Patients taking anticoagulants should be taken off the medication before the ILC procedure, if possible. However, if the patient cannot be taken off the anticoagulant for some reason, ILC may still be performed with a modification in the technique: towards the end of the procedure, the laser fiber is withdrawn slightly into the urethra, so that the entry site into the urethral mucosa is treated to seal the puncture. Prostate-Specific Antigen and Prostate Cancer. Prostate-specific antigen (PSA) level should be assessed to rule out the possibility of prostate cancer. However, after establishing the diagnosis of prostate cancer, ILC may be performed if the patient has clinical symptoms of BPH. Brachytherapy. ILC is contraindicated with brachytherapy because there will be problems (blackbodies) with the laser fiber during the procedure. Medical Therapy. Patients who fail, are unable to tolerate, or are unwilling to take medical therapy are candidates for ILC. TURP. Patients who are unwilling to have an invasive procedure due to personal preference or who may not be a candidate due to medications (because of significant comorbidities) Local Anesthesia are candidates for ILC. Patients who previously have undergone TURP, but have now developed recurrent voiding symptoms and have obstructive tissue producing outlet obstruction may benefit from ILC, as well. Every attempt should be made to ensure that the patient’s voiding symptoms are not due to other pathologies, such as urethral stricture, neurogenic bladder, bladder stones, or bladder cancer. When a patient presents in my office with clinical symptoms of BPH, I discuss with the patient and his family all the available treatment options, including the risks, complications, and benefits of each treatment modality. I have also prepared an informational pamphlet that I provide to all my patients. Many of my patients choose ILC, and they prefer to have the procedure performed using local anesthesia in my office. I allow sufficient time to discuss the procedure with the patient and answer all of his concerns. In my opinion, ILC is a safe and effective procedure with minimal side effects and can be performed easily using local anesthesia in the office. Patients choosing ILC are able to avoid the high costs of hospital-based or surgery center-based procedures. I prefer ILC to all other minimally invasive interventions because of the simplicity of the procedure, which can be performed using cystoscopic equipment that is available in the offices of most urologists and requires no other expensive equipment. The procedure can be performed in about 20 minutes or less. The Indigo® laser generator is compact, portable, and very easy to operate. The generator has a fully automated delivery program, which continuously adjusts the power wattage to achieve and maintain an efficient intraprostatic temperature of 85°C. The generator also receives feed- back from a temperature sensor (at the tip of the diffuser tip laser fiber), which monitors intraprostatic temperatures during treatment. The generator has a built-in safety feature that turns off the laser if there is a problem. Interstitial placement of the fiber results in a large preservation of the urethral mucosa, thereby reducing the incidence of postoperative irritative voiding symptoms. Although the fiber placement into the adenoma is simple, the technique does requires some skill. However, the technique can be learned easily in a very short period of time over a few cases. Preparation of the Office for ILC and Instruments There are no special room requirements for ILC procedures. A room with an electric-powered cysto table should be chosen. We use biohazard bags to collect irrigation fluid during the procedure and the fluid is later disposed of in the sink. Equipment The equipment needed to perform the ILC procedure includes: Indigo® Optima Laser System generator, diffuser tip fiber, 19 or 20 French cystoscope, 30° lens, cystotubing with double-intake tubing, 3000 mL sterile water for irrigation, pressure infusion bag, 20 French Foley catheter, catheter plug, 3.5-inch long 22-gauge spinal needle, 2% lidocaine jelly, 1% lidocaine solution, and 10-cc syringes. ILC as an In-Office Procedure The last decade has seen a sharp increase in medical costs and a steady decline in reimbursement to urologists for most procedures performed in the hospital setting (professional fee, Part B). Today, there is an increasing trend for many urologic procedures to be performed in the office setting. Not only is local anes- thesia safer, but patients prefer the convenience of having procedures performed in the office setting with local anesthesia. With the emergence of minimally invasive procedures for the treatment of BPH that can be performed in the office, there is a greater need for an effective protocol for local anesthesia.1,2 There have been many reports in the literature describing local anesthetic blocks for outpatient prostate surgery.3-8 Endoscopic transurethral,5 retropubic,9 perineal,3,10 ultrasound-guided,8 or finger-guided transrectal local prostatic blocks have been described; however, no one technique has been uniformly advocated by urologists. There is also a great deal of discussion and controversy in the literature regarding whether local anesthesia should be used alone or in combination with oral sedative agents, pain medications, or intravenous sedation. With the emergence of minimally invasive procedures for the treatment of benign prostatic hyperplasia (BPH), there is now a greater need for an effective local anesthesia protocol. Herein, I describe a protocol for local anesthesia for minimally invasive techniques in the office setting. This protocol has been used in more than 400 patients undergoing ILC of the prostate in the office setting with the Indigo® Optima Laser System. Protocol for Local Anesthesia for ILC All patients underwent complete history and physical examination, including assessment of American Urological Association symptom score and postvoid residual urine volume, flexible cystourethroscopy, uroflow study, prostate-specific antigen assay, and in selected patients, transrectal ultrasonography. Patients were selected for ILC on the basis of preoperative evaluation. VOL. 7 SUPPL. 9 2005 REVIEWS IN UROLOGY S25 Local Anesthesia continued Patients were instructed to bring a family member with them to the office and to have their usual meals beforehand. No oral, intramuscular, or intravenous sedation, narcotics, or analgesia were used. Patients were given fluoroquinolone for antibiotic prophylaxis. The patients were placed in the supine position, and the external genitalia were thoroughly cleaned the neurovascular bundles posterolaterally as they course between the rectum and prostate. The spinal needle was directed into this region with a gloved finger inserted into the rectum. Because of the precise injection site, only 10 mL of 2% lidocaine solution was needed for adequate anesthesia. Lidocaine solution was injected just into the rectal mucosa, moving from left to right all along the base of the prostate. Because of the precise injection site, only 10 mL of 2% lidocaine solution was needed for adequate anesthesia. with povidone–iodine solution. A red rubber catheter was used to drain the bladder completely, and then 60 mL of 2% chilled lidocaine solution was instilled into the bladder. The urethra was then anesthetized with 20 mL of chilled 2% lidocaine gel, and a penile clamp was used to keep the gel in the urethra. Abelladonna and opium (B&O) suppository (60 mg) was inserted into the rectum, and the patients were instructed to wait in the waiting room for 20 to 30 minutes. The patients were brought back to the office cystoscopy suite and were placed in the dorsal lithotomy position. After digital rectal examination, prostate anesthetic block was performed with a 22-gauge spinal needle (length, 3.5 in) attached to a 10-mL Luer Lock syringe containing 10 mL of 2% lidocaine solution. The needle was guided with the help of a gloved index finger toward the base of the prostate, near the prostate–seminal vesicle junction. Prostate anesthesia was achieved by blocking the prostatic sensory branches of the neurovascular bundle, which originates in the inferior hypogastric plexus, located at the tip of seminal vesicles. These branches exit S26 VOL. 7 SUPPL. 9 2005 Urethroscopy was then performed with a 19- or 20-Fr cystoscope with a 30° lens. A Storz flexible transurethral needle was used to inject 1% lidocaine solution into the apex of the prostate. With the tip of the cystoscope at the level of the verumontanum, the cystoscope was rotated 90° toward the lobe; the transurethral needle was inserted into the lateral lobe of the prostate, and 5 mL of 1% lidocaine solution was very slowly injected. Similarly, the other lobe of the prostate was also injected with 5 mL of 1% lidocaine solution. If the median lobe was present and needed treatment with ILC, 5 mL of local anesthetic was injected into the median lobe as well. tion bag to facilitate adequate flow of irrigation fluid for visualization. The laser fiber was then inserted into the lateral lobes of the prostate, preferably at the same site where the transurethral needle was inserted, thus avoiding multiple puncture sites in the prostatic urethra and minimizing bleeding. After completion of ILC, a Foley catheter was inserted, attached to a plug. Patients were then given soft drinks and fruit juices and were sent home with the family member. Home-care instructions were given. Patients were sent home with the following prescriptions: (1) fluoroquinolone for 10 days, (2) phenazopyridine hydrochloride 200 mg po tid for 10 days, and (3) oxybutynin chloride 10 mg po qd for 10 days. Pain was determined with a linear pain scale, and a global questionnaire was used to assess tolerability. Pain was assessed during the administration of local anesthesia and during the actual laser procedure. The global questionnaire has a single question to rate the patient’s overall level of comfort during treatment, scored as 1 (very satisfactory), 2 (satisfactory), 3 (unsatisfactory), or 4 (very unsatisfactory). Results All ILC procedures performed under local anesthesia in the office setting were successfully completed and well Patients were very comfortable during the procedure and were comfortable at home, requiring no narcotics for pain management. Care was taken not to use too much irrigation fluid during the injection of local anesthetic, as well as during ILC, to avoid frequent drainage of the bladder. Because the cystoscope was never inserted fully into the bladder and kept in the urethra, a pressure cuff was placed around the irrigation solu- REVIEWS IN UROLOGY tolerated. No patients reported a linear pain scale score greater than 3 during the procedure. Overall, patient satisfaction was high. Patients were very comfortable during the procedure and were comfortable at home, requiring no narcotics for pain management. On the global questionnaire, 80% of Local Anesthesia patients reported a score of 1 (very satisfied), and 20% reported a score of 2 (satisfied). There were no intraoperative or postoperative complications attributed to the local anesthesia. During the procedure, a few patients had symptoms of intravascular injection of lidocaine. They had slurred speech, became diaphoretic, and had ringing in their ears and lack of sensation in their tongue. These symptoms were transient, and by the time the ILC procedure was completed the patients felt fine and required no additional attention or treatment. Discussion With the emergence of minimally invasive therapies for the management of symptoms of BPH, as well as the reality of a changing medical economic environment, reimbursement issues, and the malpractice crisis, there is a need for a reliable, safe, effective, and simple local anesthesia protocol. Not only can we perform any of the minimally invasive treatments for BPH in the office setting, we can also perform internal urethrotomy for urethral stricture, transurethral incision of the prostate, transurethral resection of the bladder neck for bladder neck contracture, and bladder biopsies and fulguration for minor bladder lesions with little modification of the local anesthesia protocol described here. Although spinal, epidural, and general anesthetics are effective, they require the presence of anesthesiologists, anesthesia monitoring, and resuscitation equipment, oxygen, and other anesthetic gases and medications. These facilities are not available in the typical urologist’s office; thus procedures with these types of anesthetic can only be performed in a hospital or outpatient surgery center. In addition, many elderly patients who are candidates for BPH therapy have significant comorbidities that make them unsuitable, high-risk candidates for general anesthesia. Consequently, the use of safe, effective local anesthesia for minimally invasive procedures in an office setting is most desirable. A trend has recently developed, whereby the anesthesiologist brings all monitoring equipment and portable gases to the urologist’s office, and procedures are performed under local anesthesia supplemented by intravenous sedation (monitored anesthesia care). Not only will this increase the cost of the procedure to the patients, but urologists will also need extra room and space to serve as a recovery room, additional personnel to monitor the patient, and monitoring equipment. The use of local infiltrating anesthesia is not new. Several techniques for a variety of urologic procedures have been described. Dr. Muta M. Issa and colleagues2 have elegantly described the use of a perineal approach for a prostate block. Their technique is based on the neuroanatomy of the prostate. The autonomic nerves that innervate the prostate originate from the inferior hypogastric plexus. These nerves then run along the posterolateral aspect of the prostate, starting at the seminal vesicle and passing along the urethra at the 3 o’clock and 9 o’clock positions. With the perineal approach, one can directly infiltrate these nerves. The average volume of anesthetic used was 45.6 mL (range, 30–70 mL) (equal amounts of 1% lidocaine with epinephrine and .25% bupivacaine with epinephrine) when the procedure was done without intravenous sedation and 23 mL (1% lidocaine solution with epinephrine) when used along with intravenous sedation. In the retropubic approach,9 one needs to inject 300 mg to 800 mg of lidocaine per patient—10 times more than with the perineal approach. During the transurethral approach the Figure 1. Transrectal prostate anesthetic block. Photograph courtesy of Kalish R. Kedia, MD. injected local anesthetic does not easily permeate to the prostatic nerves and might actually distort the prostatic anatomy. A transrectal approach has also been described without or with ultrasound guidance.8 The combination approach that I have been using in my clinical practice has been very effective, with minimal side effects (Figure 1). When we use local anesthetic around the prostate, we need to inject the least amount of anesthetic agent. There is a real possibility of injecting into the vascular bed. Also, because we do not have any cardiac monitoring in the office setting, we do not use any local anesthetic with epinephrine. I have used a similar local anesthesia protocol for several other urologic procedures in the office setting, with few modifications. Bladder Biopsies and Fulguration for Minor Bladder Lesions Catheterize and empty the bladder. Instill 60 mL of 2% chilled lidocaine solution into the bladder. Instill 20 mL of 2% chilled lidocaine jelly into the urethra and clamp for 20 minutes. Insert a B&O suppository (60 mg) into the rectum. Bladder Neck Contractures Catheterize and empty the bladder. Instill 60 mL of 2% chilled lidocaine VOL. 7 SUPPL. 9 2005 REVIEWS IN UROLOGY S27 Local Anesthesia continued solution into the bladder. Instill 20 mL of 2% chilled lidocaine jelly into the urethra and clamp for 20 minutes. Insert a B&O suppository (60 mg) into the rectum. Transurethrally inject 3 to 5 mL of 1% lidocaine solution into the bladder neck. Urethral Stricture Instill 20 mL of 2% chilled lidocaine jelly into the urethra and clamp for 20 minutes. Inject 3 to 5 mL of 1% lidocaine solution into the urethra near the stricture after a guidewire has been placed in the bladder. the office setting with the patient under local anesthesia. Most patients have little discomfort and recover quickly, with prompt return to normal activities. This protocol for prostate anesthetic block seems to be a safe, economical, and effective way to perform many urologic procedures in the office setting. Urologists should be aware of and comfortable with these techniques. ILC and other minor endoscopic urologic procedures are well tolerated in 4. 5. 6. 7. References 1. 2. Summary 3. Lazarov SJ. Office based surgery and anesthesia: where are we now? World J Urol. 1998;16:384385. Issa MM, Perez-Brayfield M, Petros JA, et al. A prospective study of transperineal prostatic block for transurethral needle ablation for benign prostatic hyperplasia: the Emory 8. 9. 10. University experience. J Urol. 1999;162:16361639. Issa MM, Ritenour C, Greenberger M, et al. The prostatic anesthetic block for outpatient prostate surgery. World J Urol. 1998;16:378-383. Leach GE, Sirls L, Ganabathi K, et al. Outpatient visual laser assisted prostatectomy under local anesthesia. Urology. 1994;43:149-153. Orandi A. Urological endoscopic surgery under local anesthesia: a cost reducing idea. J Urol. 1984;132:1146-1147. Birch BR, Anson KM, Miller RA. Sedoanalgesia in urology: a safe, cost effective alternative to general anesthesia: a review of 1020 cases. Br J Urol. 1990;66:342-350. Salameh R, Baum N. Transrectal biopsy under local anesthesia. Urology. 1987;29:79. Jones JS, Oder M, Zippe CD. Saturation prostate biopsy with periprostatic block can be performed in office. J Urol. 2002;168:2108-2110. Tabet BG, Levine S. Nerve block in prostate surgery. J Urol. 1996;156:1659-1661. Moffat NA. Transurethral prostatic resections under local anesthesia. J Urol. 1977;118: 607-608. Main Points • Today, there is an increasing trend for many urologic procedures to be performed in the office setting; local anesthesia is safer, and patients prefer the convenience of having procedures performed in the office setting with local anesthesia. • The author describes a protocol for local anesthesia for minimally invasive techniques in the office setting; this protocol was used in more than 400 patients undergoing interstitial laser coagulation (ILC) of the prostate. • All ILC procedures performed under local anesthesia in the office setting were successfully completed and well tolerated. Patients were very comfortable during the procedure and were comfortable at home, requiring no narcotics for pain management; there were no intraoperative or postoperative complications attributed to the local anesthesia. • In addition to ILC, this local anesthesia protocol can be used with little modification to perform internal urethrotomy for urethral stricture, transurethral incision of the prostate, transurethral resection of the bladder neck for bladder neck contracture, and bladder biopsies and fulguration for minor bladder lesions. S28 VOL. 7 SUPPL. 9 2005 REVIEWS IN UROLOGY