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AMBULATORY ANESTHESIA

An Evaluation of General and Spinal Anesthesia Techniques for Prostate Brachytherapy in a Day Surgery Setting

Ron Flaishon, MD^*, Perla Ekstein, MD^*, Haim Matzkin, MD, and Avi A. Weinbroum, MD^*

Departments of *Anesthesiology and Critical Care Medicine, Urology, Day Surgery, and Post-Anesthesia Care Units, Tel Aviv Sourasky Medical Center and the Sackler Faculty of Medicine, Tel Aviv University, Israel

Address correspondence and reprint requests to Avi A. Weinbroum, MD, Post-Anesthesia Care Unit, Tel Aviv Sourasky Medical Center 6, Weizmann St., Tel Aviv 64239, Israel. Address e-mail to draviw{at}tasmc.heatlh.gov.il.

	Abstract

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We evaluated four anesthetic techniques for transperineal brachytherapy of the prostate in a day-surgery setting: general anesthesia with either fentanyl and propofol total IV anesthesia (TIVA) or with fentanyl, thiopental, and isoflurane (F-P-I), versus spinal block using 5 mg of 0.5% large-dose spinal hyperbaric bupivacaine (LDS) or 2.5 mg of 0.5% hyperbaric bupivacaine plus fentanyl 25 µg small-dose spinal (SDS). Operating room time was shorter in the general anesthesia groups. TIVA patients voided earlier (103 ± 41 min) than F-P-I patients (131 ± 65 min), SDS (126 ± 55 min), and LDS patients (169 ± 65 min; P < 0.05 TIVA versus all groups and between spinal groups). TIVA patients were discharged earlier (119 ± 42 min) than F-P-I patients (160 ± 69 min) and SDS or LDS patients (132 ± 53 and 186 ± 72 min, respectively; P < 0.05 versus all groups and between the spinal groups). There were no intergroup differences regarding postanesthesia nausea or vomiting, pain score, return to normal function at home, or overall satisfaction. Whereas all four techniques are suitable for this procedure, TIVA provides the earliest voiding and consequently fastest discharge. Between spinal techniques, the SDS technique requires more intraoperative sedation but provides earlier voiding and consequently earlier discharge. TIVA, general anesthesia with isoflurane and fentanyl, and two spinal techniques (5 mg of bupivacaine 0.5% or 2.5 mg of bupivacaine 0.5% plus 25 µg of fentanyl) are suitable techniques for transperineal brachytherapy in the day-surgery setting. TIVA allows for earliest voiding and therefore fastest discharge home. Spinal block with 2.5 mg of bupivacaine plus 25 µg of fentanyl provides earlier voiding and consequently earlier discharge than 5 mg of bupivacaine alone.

	Introduction

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Brachytherapy of the prostate, i.e., implantation of radioactive iodine (I¹²⁵) seeds transperineally (1,2) imposes less morbidity than radical prostatectomy (1,2). Spinal anesthesia for brachytherapy has never been compared with general (GA) or local anesthesia (3,4). We evaluated two GA and two spinal techniques in terms of operating room (OR) time, time to home-readiness, and patient satisfaction, assuming GA would allow for earlier discharge than spinal anesthesia for this procedure.

	Methods

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After obtaining IRB approval, consenting ASA class I-II patients were randomly and prospectively allocated into one of four groups—total IV anesthesia (TIVA), fentanyl-thiopental-isoflurane (F-P-I) anesthesia, large- (LDS) and small-dose (SDS) spinals—using sealed envelopes. Exclusion criteria consisted of diseases or medications affecting the nervous system, chronic use of analgesics, and contraindication to spinal anesthesia.

Oral diazepam 5 mg 1 h before and IV midazolam 1 mg upon OR arrival were administered. All patients were connected to a standard vital signs monitor, and 500 mL of crystalloid solution was infused.

TIVA was induced with fentanyl 100 µg plus propofol 2 mg/kg and maintained with propofol 0.15 mg · kg^–1 · min^–1. F-P-I was induced with fentanyl 100 µg and sodium thiopental 2–4 mg/kg IV and maintained with 60% nitrous oxide (N₂O)-in-oxygen plus 0.8% isoflurane. Fentanyl and propofol were supplemented and isoflurane was adjusted, respectively, based on patient's movement or >20% hemodynamic changes compared with preoperative values. Spinal blocks were performed in the OR in the sitting position at L3-5 levels using a 26-gauge pencil-point needle. Spinal solutions (hyperbaric bupivacaine 0.5% 5 mg [1 mL]; LDS) or 2.5 mg plus fentanyl 25 µg (1 mL; SDS) were prepared by a single investigator (RF) and administered by a blinded physician who made all subsequent interventions. To achieve a "saddle block," patients were kept sitting for 5 min before lithotomy positioning. Pinprick sensory level was evaluated; motor level was not directly tested because our pilot study indicated that our sensory block was as low as S₁ so that no motor block would be detectable. Midazolam was administered to these patients at the discretion of the blinded attending anesthesiologist for patient comfort and to reduce movement.

Vital signs were recorded every 3 min during the anesthetic induction and every 5 min during maintenance. OR time was defined as the time from patient's placement on the table until leaving the OR.

The postanesthesia care unit (PACU) staff, blinded to what spinal or GA drugs had been used, recorded vital signs every 15 min, postoperative nausea and vomiting (PONV) occurrence, drug administration, time to ambulation, voiding, and discharge (defined as physical departure from the medical center). Pain was assessed using visual analog scale (VAS; 0 = least and 10 = worst pain); diclofenac 75 mg IM was available upon request.

Discharge criteria included controlled pain (VAS 3), no PONV, stable ambulation, and spontaneous voiding, the latter being an essential discharge criterion. Institutional regulations mandate monitoring outpatients 90 min after the procedure. Upon discharge, patients were directed to take dipyrone 500 mg once every 6 h as required for pain. All patients were interviewed by telephone on the first postoperative day by a blinded interviewer; functional capacity, pain, and satisfaction were scored (0–10 scale).

Prestudy power table where (mean difference in time for home discharge) = 0.5 h, = 0.05, and power = 0.95 resulted in the need for 15 patients in every group. The demographic, vital signs, and all time data were compared using the one-way analysis of variance (ANOVA). An overall ANOVA was used to compare the groups' data; if indicated by an overall P < 0.05, individual comparisons were made between two groups at a time using unpaired t-test. Analysis of the rate of use of drugs in the OR and in the PACU, PONV, and additional analgesic consumption was performed using the Fisher's exact test. Ratings of pain and home functional capacity were analyzed using the Kruskal-Wallis nonparametric test. Time and satisfaction values are expressed as mean ± sd; VAS values are expressed as median and ranges. Significance was defined as P < 0.05.

	Results

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One-hundred-twenty patients were enrolled in the study. One patient in each spinal group was excluded because of failure to perform the block. One LDS and two SDS patients were converted to GA because of movement interfering with the procedure, although denying pain; no other patient moved. Two TIVA patients were excluded because N₂O was administered. The demographic data of these dropouts were analyzed by the intent-to-treat test.

Patients' age, weight, ASA class, and concomitant diseases were similar among the groups, as were perioperative vital signs (data not shown). The OR time for the two spinal groups was longer than the GA group (Table 1). The sensory level of the LDS group was significantly lower than the SDS group (Table 1). More SDS patients required supplemental midazolam during surgery and analgesics in the PACU compared with LDSs. Less intraoperative fentanyl was required in the F-P-I than the TIVA group (Table 1).

Pain scores in the PACU were lower in the two spinal groups compared with the GA groups. TIVA patients were the first and LDS the last to void and be discharged (Table 1). PONV, home pain, analgesic use, functional capacity, and satisfaction were similar among the groups (Table 1). Two SDS patients complained of time-limited itching. No patient required readmission.

	Discussion

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This study demonstrates that the four anesthesia techniques are suitable for brachytherapy of the prostate. TIVA affords earlier voiding (a discharge criterion), ambulation, and discharge. The procedure time in both spinal groups was 10 minutes longer than that of the GA group, as was previously demonstrated (5), because of the time for block performance only, since seeds are prepared in advance.

Brachytherapy patients have a high risk of urinary retention and are thus kept in the PACU until voiding spontaneously (6). Our results indicate that the anesthetic technique affected the time to voiding. It was shown (7–9) that TIVA is associated with faster discharge than spinal; nevertheless, those procedures and spinal techniques were different from the present ones. It has been demonstrated that the smaller the dose of intrathecal bupivacaine, the shorter the time to voiding and discharge (5,10,11). Our data support this contention as well. The dose-volume used in our SDS group is the smallest ever reported and has not been compared with GA. Other authors did use small bupivacaine doses but in larger volumes and in different techniques and settings (9,10).

Our study has several limitations. More than 40% of the spinal patients required midazolam supplementation or conversion to GA, although none complained of pain; this finding requires further investigation. A possible study bias was caused by the impossibility of blinding GA from spinal anesthesia. In addition, the drugs used in the F-P-I group may be outdated for ambulatory settings in numerous countries; the use of propofol instead of thiopental and other inhaled anesthetics, e.g., sevoflurane, could result in faster recovery and discharge of brachytherapy patients. Finally, the relatively long PACU stay in all patients was caused by institutional monitoring time regulations; this nursing practice is now under review.

In conclusion, based on patient self-rating, the four presented anesthesia techniques effectively and satisfactorily controlled pain during brachytherapy. TIVA enabled the shortest OR time, earliest voiding, and consequently fastest discharge. Between the two spinal techniques, SDS, despite requiring supplemental intraoperative sedation and PACU analgesia more frequently, enabled earlier voiding and discharge and equal overall patient satisfaction. The pivotal discharge time among the groups was the difference in time to voiding.

	Footnotes

 
Presented, in part, at the ASA Meeting in New Orleans, LA, October, 2001.

Accepted for publication June 16, 2005.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Flaishon, R. Articles by Weinbroum, A. A. Search for Related Content PubMed PubMed Citation Articles by Flaishon, R. Articles by Weinbroum, A. A. Related Collections Ambulatory Anesthetic Techniques Regional Anesthesia