An Audit of Analgesia Requirements for High-Dose-Rate Prostate Brachytherapy

Abstract

High-dose-rate (HDR) prostate brachytherapy, as performed at our institution, requires the insertion of multiple transperineal catheters under anaesthesia (hereafter referred to as the 'intraoperative' period), after which the patient is allowed to recover from anaesthesia and the treatment is planned and carried out with afterloading of the radioactive source in several treatment sessions over the course of two days (hereafter the 'postoperative' period). The catheters are kept in position by a template sutured to the perineum. At the time of introduction of this new therapy at our institution, we assumed the catheters themselves, the template and the urinary catheter, along with potential bladder spasm, would cause at least moderate pain.Prior to the commencement of our prostate brachytherapy program, the principal anaesthetist (JAL) consulted colleagues locally and elsewhere who were involved in prostate brachytherapy and found that techniques varied widely, but included spinal/epidural anaesthesia and subsequently epidural analgesia for the duration of the treatment period or general anaesthesia followed by patientcontrolled intravenous opioid analgesia (PCA). Very few published reports regarding HDR prostate brachytherapy discuss analgesic techniques 1-3 . We chose a simple regimen of regular paracetamol with supplementary oral or subcutaneous opioids as required, primarily because the nurses of the relevant ward were not accredited at the time to manage more complex techniques.In order to assess the adequacy of the analgesic regimen, we audited the analgesic, anti-emetic and anti-spasmodic drug usage of our patients undergoing HDR brachytherapy for prostate cancer. SUMMARyWe audited the analgesic, anti-emetic and anti-spasmodic drug usage of patients undergoing high-dose-rate brachytherapy for prostate cancer at the Royal Prince Alfred Hospital. With institutional ethics committee approval, we retrospectively reviewed the records of the first 45 patients undergoing high-dose-rate prostate brachytherapy from January 2003 to July 2005. We collected data regarding the dose of intra-and postoperative analgesics and the anti-emetic and anti-spasmodic drugs administered for the duration of the patients' hospital stay. We converted oral oxycodone doses to parenteral morphine equivalents for the purposes of this study, dividing the oxycodone dose by three.The median age of the patients was 69 (range 55 to 80) years. All had general anaesthesia for the catheter insertion procedure. Twenty-five patients (56%) received intraoperative morphine from 5 to 12 mg (mean 9 mg). Forty-three patients (96%) received regular postoperative paracetamol (1 g qid). Thirty-six patients (80%) required additional postoperative opioid administration with an overall mean (all 45 patients included) of 14.5 mg of parenteral morphine equivalents over the entire postoperative course. Thirty-nine patients received intraoperative hyoscine butylbromide to reduce bladder spasm. Fourteen patients were administered antiemetics.These findings indic...