GSOR02 Presentation Time: 5:05 PM

Abstract

Purpose

In 2015, we transitioned from performing gynecologic brachytherapy procedures in an operating room in the hospital under general anesthesia, to a departmental procedure room with preference for spinal anesthesia. MRI was in the main hospital and generally obtained with fraction 1 and fused to CT scans for subsequent fractions. We sought to review the feasibility and tolerability of this workflow utilizing spinal anesthesia and extra-departmental MRI.

Materials and Methods

This was an IRB-approved, retrospective review of gynecologic brachytherapy procedures performed in a departmental procedure room at a single center from 4/2015-3/2023. Demographic information and treatment-related data including procedure details, imaging used for treatment planning, type of anesthesia, total time in the department, and highest pain score were obtained. OR procedures that required admission with implant in place were excluded from analysis.

Results

A total of 141 patients undergoing 541 procedures were included. The most common diagnosis was cervical cancer (n = 118) followed by endometrial and vaginal cancer. Most patients (98%) underwent external beam radiation therapy ± chemotherapy prior to brachytherapy. The most common brachytherapy regimen was 28 Gy in 4 fractions, delivered twice weekly, and the average overall treatment time was 52.6 days. Tandem and ring was the most frequently used applicator (n = 89), and 38 patients had hybrid or interstitial implants. Eighty-two percent of patients received spinal anesthesia. For those undergoing general anesthesia, the most common reasons were low platelets (52%) or anticoagulation (32%). There were no complications from spinal anesthesia in this cohort. Sixty-seven percent of patients underwent MRI with applicator in place and 22% had pre-brachytherapy MRI. For fractions performed when only a CT scan was obtained for planning, average total time in the department was 346 minutes (min). Patients who received spinal anesthesia spent a longer time in the department than patients who received general anesthesia (average of 353 min vs. 325 min, p=0.00005). Similar trend was seen on fractions when an MRI was obtained, with average time in the department of 371 min for those under spinal anesthesia vs. 346 min for those under general anesthesia (p=0.04). When comparing fractions when an MRI was obtained vs. CT scan only, the MRI added an average of 20 min to the total time (366 min vs. 346 min). Patients receiving spinal anesthesia had a lower average pain score than those receiving general anesthesia (1.63 vs. 2.34, p=0.02). Overall, only 17% of patients required narcotics for post-procedure pain control regardless of type of anesthesia received, and the majority of these (91%) required only 5-10 mg of oxycodone or equivalent for adequate pain control.

Conclusion

Spinal anesthesia is feasible and offers good pain control for patients undergoing HDR brachytherapy for gynecologic cancers. We demonstrated no complications with frequent spinal anesthesia use. Spinal anesthesia allowed for easier and safer transport to extradepartmental MRI as compared to general anesthesia. While time spent in the department was longer with spinal anesthesia in comparison to general anesthesia, the overall clinical impact was less than 30 minutes and acquisition of MRI added minimal time. This project validates our current workflow structure using spinal anesthesia and allows for future exploration into further time optimization.