ELECTROMOTTVE DRUG ADMINISTRATION OF LIDOCAINE AS AN ALTERNATI\TE A}IESTHESIA FOR TRANSURETHRAL SURGERY MICTIAEL A. S. JEWETT,*,t LUC VALIQUETTE,T HEATHER A. SAMPSON,t JOEL KATZ,t YVES FRADET AND DONALD A. REDELMEIER From tlu Diuisrons of Urology4 Depdrtments of Surgery, Universities of Torcnto, Montrcal and Laval, Montrcal a,nd. l,aval, Quebec, Departnunts of Psychology and Meditinc, Uniuersity of Torontn, Divisinn of Clinical Epi:demiology, Sunnybrmh HeoJth Scietue Centre and Toronto Hospital, Torcnto, Ontario, Canadn ABSTRACT Purpose: A multicenter study was undertaken to evaluate the safety, efficacy and cost of electromotive drug adrninistration of intravesical Iidocaine to produce bladder local ^nesthesia as an alternative to traditional methods of spinal or general anesthesia. Materials and Methods: A total of 94 patients were enrolled in the study who had either a history of bladder tumor that requid cold cup bladder biopsy with firlguration for possible riesurence as a comparison trial, a bladder tumor treated with transurethral resection/fulguration or benign pros- tatic hyperplasidcalcinoma treated with transurethral resection. Pain scores psing aVerbal Rating Scale were recorded for each individual biopsy, fulguration and resection event. Data for direct and indirect oosts wer€ mllect€d using a standadized forn for each patient to capture the details of the pmcedure, including times, drugs and disposables for each patient. Results: There was a significant reduction in pain for patients who received electromotive intra- vesical lidocaine compared to no anesthesia for biopsy (p <0.03). Similarly, electromotive intravesical lidocaine for bladder biopsy and transurethral bladder tumor resection/fulguration was associated with higher patient satisfaction compared to previous treatments (p <0.00002). In contrast, electro- motive intravesical lidocaine was insufrcient for 3 of 6 hansurethral prostatic resections. The cost per patient was about $146 Cdn less with elechomotive intravesical lidocaine than with conventional generaVspinal anesthesia. Conclusions: Electromotive intravesical lidocaine may be a safe, effective and affordable forrn of anesthesia for the ambulatory care of patients requiring transurethral bladder biopsy, resec- tion or fulguration with a poteutial for cost savings. KsY WoRDs: anestbeeia, iontophoresis, prostatic neoplasms, bladder neoplasms Traditional techniques for trangurethral resection use gen- eral and spinal anesthesia that is typically applied in an inpatient environment. Moet of the prooedures are of short duration but, given the conplerity of these forns of anesthe- sia, many are undertaken in the operating room and costs are high. Locoregional anesthetic alternatives include intraure- thral,r intravesical lidocaine,z'3 transuretbral needle blocks to urethra, bladder nech and bladder wall,a and percutaneous periprostatic and pudendal nen'ey'saddle blocks. However, attempts to block pain from the bladder with intravegical lidocaine have not been widely adopted because ofthe short duration of anesthesia and generally poor passive diffirsion acrogs the impermeable urothelium.6 Electromotive drug ad- ministration offers a solutiou to these limitations.6'7 Sigdfi- cant benefits could be achieved by reducing main operating roon time and minimizing the need for inpatient stay. Fur- thermore, current anesthesia techniques have associated risks and side effects, particularly in an elderly population. Locoregional anesthesia for transurethral surgery may be possible with electromotive administration of intravesical lidocaine to enhance drug delivery.c A direct pulsed current across the bladder mucosa moves high concentrations of ion- izcd lidocaine into the bladder wall by several electrokinetic forces. In particular, drug penetration is enhanced by ionto- phoresis (active transport of ionized drug down an electrical gradient of appropriate pslarity), electro-osmosis (ionized or nonionized drug transport accelerated by convective flow of water due to current induced movement ofother ions) and electroporation (increased permeability due to direct electri- cal effects on biological membranes that permit increased transport down concentration Bradients).a-r0 lontophoresis is the predominant electrokinetic force involved in the trans- port oflocal anesthetic drug.tr Electromotive drug adninistration has been studied in animal systems, and used to deliver intravesical local anes- thetic agents for transurethral surgery, Examples include transurethral microwave thermotherapy of benigrr prostatic hyperplasia, hy&ostatic distention of the bladder for inter- stitial cystitis, delivery of mitomycin and &aminolevulinic acid for bladder cancer, and oxybutynin for hyperreflex- ia.6' 12-16 Tlansdermal electromotive application of drugs, in- cluding morphine and dexamethasone as well as many other agents, has also been reported,e MATERIALS AND METHODS A multicenter study of 94 patients was undertaken to assess the safety, efficacy and cost-effectiveness ofelectromo- tive administration ofintravesical lidocaine as an alternative to spinal or general anesthesia. lhree centers and 3 groups of patients participated in the study. Group 1 comprised 45 patients who required cold cup bladder biopsy with (27) or without (18) electromotive intravesical lidocaine as a com- parison trial of electromotively administered lidocaine versus no anesthesia. These 2 consecutive cohorts represented all