Experience At Prince Hussein Urology Center

Published Date: 02 Nov 2017

Abstract

Aim:

To report our experience in performing bilateral

subcapsular orchiectomy under local

anaesthesia as day case procedure in

metastatic prostate cancer patients

Material and Methods:

Between January 2004 and December 2008, 96

patients with advanced 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:

Bilateral subcapsular orchiectomy in patient

with advanced prostate adenocarcinoma under

local anaesthesia is simple, cost effective

operation which can be done as a day care

procedure.

Key words: Subcapsular orchiectomy,

bupivacaine, lidocaine.

Introduction:

Huggins and Hodges 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 then

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

Mohanned Al-Nasser, Awad Al-ka`abneh

Calicut Medical Journal 2010;8(1):e2

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techniques have been used for minor urological

procedures and one such technique is spermatic

cord block (2, 3, 7, 9). This is a simple, costeffective

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 cases of nonlocalized prostatic cancer or

the physical status was not suitable for radical

prostatectomy. 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-operative period we explained the

procedure and provided anesthesia only on the

scrotal content and scrotal skin at the incision

site; The patient 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\0 vicryl. The procedure is repeated on other

side through the same skin incision and the

wound closed using 3\0 vicryl to the tunica

vaginalis and covering layers, and 4\0

subcuticular dexon to the scrotal skin. The

procedure is completed by local dressing, a

large gauze pressure pad and a scrotal support

to prevent haematoma formation. During the

operation, the patient was monitored and blood

pressure, pulse rate and abnormal symptom

were recorded; when surgery finished the

patient’s pain score of the procedure (including

pain of anaesthetic injection) was assessed

immediately by using visual analog pain scale (0

= no pain, 5 = moderate pain and 10 = worst

possible pain) . At 1-week follow-up, the

patient’s symptom and wound were evaluated

again.

Mohanned Al-Nasser, Awad Al-ka`abneh

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Discussion:

An LHRH agonist is the preferred first option to

treat patients with advanced prostatic cancer.

However, clinical studies have suggested that

an orchiectomy is superior to an LHRH agonist

in that it more rapidly achieves castrate levels of

testosterone, avoids the testosterone flare, is

less expensive, and has superior therapeutic

compliance (1, 8, 10, 14).

If there were a castration procedure that did not

adversely affect life satisfaction and the male

image, this option might become more

frequently recommended and chosen. Several

attempts have been made to achieve this goal.

In 1942, Riba pioneered the subcapsular

orchiectomy, a procedure that involved the

removal of the testicular parenchyma and the

simple closure of the tunica albuginea (10, 13,

16, 17, 19).

No difference was observed between patients

who underwent a bilateral total orchiectomy and

a subcapsular orchiectomy in preoperative and

postoperative testosterone or luteinizing

hormone levels( 5,17,19).Most importantly,

serum PSA and 3-year survivals for patients

undergoing a bilateral total orchiectomy and a

subcapsular orchiectomy were determined to be

similar (3,10).

The technique of spermatic cord block is based

on the anatomy :( 2, 3, 4, 18) .as the cord

emerges from the external ring, it passes over

the pubic tubercle and the shifted medially to the

scrotum. In this region it is closely associated

with the ilioinguinal nerve and the genital branch

of genitofemoral nerve, which supply the testis

and its covering, the epididymis and the vas

deferens but not the scrotal skin. The scrotal

skin receives sensory supply from the pudendal

nerve and the perineal branch of the posterior

cutaneous nerve of the thigh; therefore it needs

to be infiltrated with the anesthetic agent

separately from spermatic cord block (5, 9, 11,

12). Good result of spermatic cord block

facilitates a successful orchiectomy. No

complication related to anesthesia was detected

in the series. The advantage of spermatic cord

block is its short time of recover, low cost and

may be performed in patient who has high risk of

anesthesia (7, 11, 14, 18). 10 patients numbered

their visual analog pain scale 10. Five had

underlying anxiety disorder, while the other 5,

one had severe pain that needed to be

converted to general anesthesia which might

have caused by his obesity (BW 86.5 kg, HT

165 cm, BMI 31.77 kg/m2; mean BW = 62.55 kg;

patients who had success operation whose BW

was in the range of (45 – 68 kg). Other 4

patients have huge inguinal hernias that also

make procedure more difficult .Obesity made it

difficult to palpate the cord and inject anesthetic

agent to the correct point, so the spermatic cord

block did not work well.

Three patients had bradycardia (pulse rate =

50|min. 49|min.54/ min) which might due to his

vagovagal reflex when the cord was under

traction; however they developed no other

symptom or hypotension.

Intrascrotal procedures can be performed easily

with spermatic cord block rather than general

anaesthesia. This offers advantages to both the

patient and the treating hospital. For the patients

the length of time spent in the recovery room,

the chances of intraoperative anesthetic

complications and the need for postoperative

analgesia are all reduced. For the hospital the

obvious advantages in terms of bed occupancy

and cost saving may be realized (5, 9, 11, 12)

We evaluated the cost-effectiveness of

androgen suppression strategies for men with

advanced prostate cancer. Our principal finding

is that the effectiveness of orchiectomy is much

less expensive.

The subcapsular technique bypasses the need

for prosthesis thus contributing to a lower cost

when compared to total orchiectomy.

Result:

Of the 96 patients age 65 – 83 yr (mean =71.11

yr), operative time 20 – 55 min (mean 36.00

min), amount of anesthetic mixture 10 – 30 ml

(mean = 20 ml) orchiectomy under spermatic

cord block were successful in 91\ 96 (94.79 %).

Five patients failed because they had so severe

pain that needed to be converted to general

anesthesia. Three patients had bradycardia

(pulse rate = 50|min. 49|min.54/ min), 2 patients

had tachycardia (pulse rate = 124/min, 102/min).

None of patients had hypotension, nausea or

vomiting. No complication related to the

anesthesia nor the procedure was seen. Most of

Mohanned Al-Nasser, Awad Al-ka`abneh

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the patients felt little pain especially when

monopolar electrocautery was used to cut the

tissue or stop bleeding. Post-operatively, all of

the patients ambulated immediately; 86 patients

(89.47 %) rated their visual analog pain scale

between 0 – 6; 10 patients (10.42%) numbered

their visual analog pain 10 (5 of them converted

from local to general anesthesia). When classify

to mild (pain score 0-3/10), moderate (pain

score 4-6/10), and severe pain (pain score 7-

10/10). 59 patients (61. 46 %) were in mild pain

group, 27 patients (28.13 %) had moderate pain

and severe pain in 10 patients (10.42 %) table-1.

At 1-week follow-up, 2 patients suffer from

surgical wound infection , one is admitted to

hospital for dressing and debridement, the other

treated as outpatient with wound dressing and

oral antibiotic treatment; 5 patients had scrotal

hematoma which improved with time and

conservative treatment.

Conclusion:

Bilateral subcapsular orchiectomy can be safely

done under local anaesthesia. It is a simple and

coast effective procedure for treatment of

advanced prostatic cancer.

The patient needs to be explained about the

procedure and warned about the symptoms

that may be experienced during the operation.

Spermatic cord block is not suitable in patient

with anxiety or obesity.

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