Wallner K, Simpson C, Roof J, Arthurs S, Korssjoen T, Sutlief S
Radiation Oncology, Puget Sound Health Care System, Department of Veterans Affairs, Seattle, WA 98108-1597, USA.
Int J Radiat Oncol Biol Phys. 1999 Sep 1;45(2):401-6. doi: 10.1016/s0360-3016(99)00216-3.
To demonstrate the technique and feasibility of prostate brachytherapy performed with local anesthesia only.
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 injection into the subcutaneous tissues, the deeper tissues, including the pelvic floor and prostate apex, are anesthetized by injecting 15 cc lidocaine solution with approximately 8 passes of a 20-gauge 1.0-inch needle. Following subcutaneous and peri-apical lidocaine injections, the patient is brought to the simulator suite and placed in leg stirrups. The transrectal ultrasound (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 needle tracks, monitored by TRUS. When the tips of the needles reach the prostatic base, about 1 cc of lidocaine solution is injected in the intraprostatic track, as the needle is slowly withdrawn, for a total volume of 15 cc.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 in 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 the patient experiences substantial discomfort. The total dose of lidocaine is generally limited to 500 mg (50 ml of 1% solution).
To date, we have implanted approximately 50 patients in our simulator 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 insertion ranged from 35 to 90 minutes. Serum lidocaine levels were below or at the low range of therapeutic. There has been only one instance of acute urinary retention in the patients treated so far, and no unplanned admissions to the hospital or need to reschedule a patient to be implanted under general or spinal anesthesia.
The substitution of local anesthesia has facilitated rapid introduction of a high-volume brachytherapy program at an institution that previously had none, without requiring the allocation of significant operating room time. Although the patients reported here were implanted without conscious sedation, we are starting to try various sedatives and analgesics for patients who we anticipate will have substantial anxiety with the procedure.
演示仅采用局部麻醉进行前列腺近距离放射治疗的技术及可行性。
使用25号5/8英寸针头，通过局部浸润10毫升含肾上腺素的1%利多卡因，对5×5平方厘米的会阴皮肤及皮下组织进行麻醉。在将药物注入皮下组织后，立即使用20号1.0英寸针头约注射8次，注射15毫升利多卡因溶液，对包括盆底和前列腺尖部在内的深层组织进行麻醉。在皮下及根尖周围注射利多卡因后，将患者送至模拟定位室，置于腿架上。经直肠超声（TRUS）探头定位以重现计划图像，在TRUS监测下，将一根3.5英寸或6.0英寸、22号的脊髓穿刺针插入外周计划针道。当针尖端到达前列腺底部时，在缓慢退针过程中，向前列腺内针道注射约1毫升利多卡因溶液，总量为15毫升。使用米克施源器进行植入，每次插入并装载2至4根针组，使患者在任何时刻体内最多仅有约4根针。在植入过程中，如果患者感到明显不适，可向一个或多个针道额外注射1毫升利多卡因溶液。利多卡因的总剂量一般限制在500毫克（50毫升1%溶液）。
迄今为止，我们已在模拟定位室对约50例患者采用局部麻醉进行了植入。患者的心率和舒张压通常有中度变化，与一定程度的不适相符。从首次皮下注射到源插入完成的时间为35至90分钟。血清利多卡因水平低于或处于治疗低范围。在目前治疗的患者中，仅出现过1例急性尿潴留，没有计划外住院情况，也无需将患者重新安排为全身麻醉或脊髓麻醉下进行植入。
局部麻醉的替代使用有助于在一个此前没有该技术的机构迅速开展大容量近距离放射治疗项目，而无需占用大量手术室时间。尽管此处报告的患者在没有清醒镇静的情况下进行了植入，但对于预计会对该操作有严重焦虑的患者，我们正开始尝试使用各种镇静剂和镇痛药。
