Subcapsular Orchiectomy Under Local Anaesthesia Nursing Essay

Prostate cancer underwent bilateral subcapsular orchiectomy at our Hospital. In every patient, we performed orchiectomy under spermatic cord block by injection of 8-10 ml anaesthetic mixture (1% lignocaine and 0.25 % bupivacaine hydrochloride) to each spermatic cord and infiltrate at skin incision site. During the operation we monitored blood pressure, pulse rate, and record abnormal symptoms such as abdominal pain, nausea, vomiting and pain score of the procedure was assessed at the end of the operation.

Results:

96 patients underwent operation under local anesthesia, 91 patients tolerate the procedure well, while other 5 patients converted to general anaesthesia due to severe pain. 5patients developed scrotal hematoma, 2 patients developed infections one of them is admitted to control because the need for dressing and debridement

Conclusion:

Day case bilateral subcapsular orchiectomy in patient with advanced prostate adenocarcinoma under local anaesthesia is simple, save and coast effective

Key words: Subcapsular orchiectomy, bupivacaine, lidocaine

Correspondence should be addressed to:-

Dr Awad Kaabneh. Tel +96277414388.

email :- awadkaabneh@yahoo.com

P.O.POX:-Jordan-Mdaba 11710-986

Introduction:

Huggins and Hodges (1941) described the androgen dependent nature of prostate cancer by the observation that surgical castration resulted in prompt relief of pain in patients with bone metastatic prostate cancer, and since that time hormonal manipulation in the treatment of prostate cancer has evolved(1,2, 3).

Prostate cancer is the most frequent visceral malignancy and the second leading cause of death in American men. It has been estimated that approximately 184 500 new cases will be diagnosed and over 39 200 men will die from prostate cancer in the United States in 1998 (3, 4, 5, 6).

The annual Medicare expenditure for prostate cancer is approaching $1.5 billion, of which a large portion is spent on androgen deprivation therapy. Androgen deprivation therapy can be achieved medically using luteinizing hormone releasing hormone (LH-RH) agonist or surgically by bilateral orchiectomy. While the two approaches have similar efficacy, medical therapy is significantly more expensive than surgical therapy (4, 7, 8).

The trend towards day case surgery in many countries is increasing (9); it is an efficient way of using resources and reducing waiting lists. Intrascrotal operations are particularly suitable for day case surgery (2, 3, 7, 9). Regional block techniques have been used for minor urological procedures and one such technique is spermatic cord block (2, 3, 7, 9). This is a simple, cost-effective technique suitable for adults undergoing intrascrotal surgery. It is particularly appropriate when the patient is considered a poor risk for general anaesthesia (9, 10, 11, 12, 13).

We report our successful experience with local anaesthesia for a series of 96 patients undergoing a bilateral Subcapsular orchiectomy in Prince Hussein Urology Center

Materials and Methods:

Of 96 patients from April 2004 - October2008 who were diagnosed prostatic cancer. They were nonlocalized prostatic cancer or physical status not suitable for radical prostatectomy surgery. We excluded patients who were allergic to bupivacaine hydrochloride, or having severe hypertension, recent MI, unstable angina, uncorrected bleeding disorder, paraplegia and neuro- sensory deficit. During the pre-operation we explained to the patient the procedure and provided anesthesia only on the scrotal content and scrotal skin at the incision site; he would feel some pain initially during the injection of anesthetic agent, and he might have some abdominal discomfort during the cord manipulation, and postoperatively he could ambulate immediately .The patient was not allowed to take anything by mouth after midnight before the procedure.

Every patient was given an intravenous line and an anaesthetist was on stand-by to give anesthesia if spermatic cord block did not work. The scrotum is prepared by pre-operative shaving and is cleansed using 10%povidone -iodine solution and draped in sterile fashion .The anaesthetic agent is a mixture of 1%lidocaine and 0.25 % bupivacaine hydrochloride was selected, the patient was in supine position. The pubic tubercle is palpated; the cord was trapped between the index and middle fingers of the surgeon; 1 cm below and medial to the tubercle was the injected point, infiltrate at skin and pass the needle vertically down to the anterior aspect of the pubic bone. In it course the needle, thus passes through the spermatic cord, 8 -10 ml of anesthetic solution is injected through the cord at slightly different angle and the needle entering the blood vessel be aware of. The instilled volume of anaesthetic solution causes visual ballooning of the grasped segment of the spermatic cord; this bulge is then gently squeezed between the thumb and index finger to disperse the anesthetic fluid within the spermatic cord. After the spermatic cord was blocked the skin at the incision site was infiltrated with 3-5 ml anesthetic fluid, 3 -5 minutes before the start of the operation so that drug became effective. Orchiectomy was performed in the midline raphae incision with epididymis - sparing fashion to create a round structure mimic a small testis for cosmetic result. A longitudinal incision is made through the tunica albuginea of the testis along its free border, exposing the seminiferous tubules. The internal contents of the testis are quickly freed from the side walls by gentle squeezing the outside of the capsule. This is the most sensitive part of the procedure but if discomfort is experienced, more anesthetic fluid can be injected directly into the cord. The tubules can be disconnected at the testicular hilum using scissors. Any tissue remaining on the inside of the capsule is removed and meticulous haemostasis is established by diathermy. The capsule is resutured with a continuous layer of 3