Prostate Cancer Radiation Fiducial Marker and SpaceOAR Gel Procedure ABS Virtual Reality (360 VR)

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Prostate Cancer Radiation Fiducial Marker and SpaceOAR Gel Procedure ABS Virtual Reality (360 VR)

#Prostate #Cancer #Radiation #Fiducial #Marker #SpaceOAR #Gel #Procedure #ABS #Virtual #Reality

Hello my name is dr neil tonk i’m an assistant professor of radiation oncology at the parliament school of medicine at the university of pennsylvania what we’ll be doing today is transparential placement of prostate fiducial markers as well as implantation of a rectal space oer hydrogel for intact prostate radiotherapy we will

Walk you through the procedure from start to finish behind me on my tray are two chlorhexidine swabs to clean the skin 20 cc syringe of buffered lidocaine a 23 gauge needle with guard a 22 gauge by 6 inch spinal needle jelly and gauze first we’ll use the cleroxidine swabs on the skin

Immediately anterior to the anus the patient has already started pre-procedure antibiotics the day before and he has completed a self-administered enema the morning of the procedure i’ll take the 23 gauge needle with the guard and attach that to the buffered lidocaine syringe first i’ll create a skin wheel

Approximately one and a half centimeters above the anus at the midline then i will inject around this initial injection in a slight star-shaped pattern to create the skin wheel then as i aspirate i’ll inject deeper up until the length of the needle into the perineum i’ll use an estimated six to eight cc’s

I prefer to do the skin wheel first so that the ultrasound probe is not that the first thing that the patients feel then i’ll take jelly and apply that to the front of the ultrasound probe we use a sterilized bk probe that’s covered in a clean condom cover filled with jelly already the

Ultrasound probe is sterile and we have already wiped down the stepper ultrasound on all surfaces we insert the probe into the anus with a slight downward angle and we’ll be frequently adjusting to make sure that we have the prostate in the correct position before we insert the probe the stepper

Is set so that the probe is halfway up the stepping cradle at the 50 centimeter position i am now adjusting the prostate probe so that the gland is midline on my screen and the gland is midline in the axial position once i lock the cradle in the axial

Position i switch to the sagittal plane and identify the whole gland in addition i scroll left and right to visualize the entire prostate ensure that i can see the entire gland and that there are no air bubbles in the rectum i’ll lock again with my urethra in the midline and centered

At this time you can identify your planes for fiducial marker and hydrogel placement i’ll take the long spinal needle which is a 22 gauge six inch needle to my remaining buffered lidocaine to perform a prostate apex block the needle is primed to remove air i’ll step out of the patient to identify

The needle track the most important skill in transparenteel approaches is knowing exactly where your needle is at all times it is easiest by following the exact line formed by the buttons on the ultrasound along the probe length and then following that into the patient once the needle is in the patient i

Assess the position of the needle frequently and follow it along the ultrasound path into the patient i’ll advance the needle and anesthetize along the needle track aspirating every single time before i inject to ensure that i’m not in a blood vessel i’ll step in as needed to reach the prostate apex

I’m now at the prostate apex i inject anesthetic here always taking care to know exactly the position of the needle tip and length and then roll the ultrasound to the patient’s right and inject more anesthetic and then i’ll roll it again to the patient’s left to inject more anesthetic this allows

For a full prostate apex block which can be performed in the office at this time i’ve injected approximately an additional 10 ccs of buffered lidocaine yielding a total injective amount of about 16 cc’s i’ll keep the remaining lidocaine for a later hydrogel injection our standard positioning for prostate markers for imrt

Sbrt or intact prostate proton radiotherapy is that the left mid-gland right apex and right base or vice versa first i’ll rock the ultrasound to the patient’s right to be right of the midline and again we’ll follow the line of my ultrasound into the prostate gland it’s important to follow the pathway of

The ultrasound probe into the patient i recommend inserting parallel to the probe length following an imaginary line from the buttons down the probe along the length of the ultrasound probe and into the patient you can see my visualized needle entering the prostate gland and i step in a little bit more

At this time a gas bubble has come into the patient’s rectum many gas bubbles will pass around the probe however for large bubbles it may be necessary to remove the probe entirely which may allow you and the patient to expel the gas do not place a marker if

You cannot see your needle tip for this patient we waited until the gas ball will move past and we injected the first marker into the patient now i’m inserting the second prostate marker what i’ll do is i’ll rotate the prostate ultrasound probe just past the midline again on the sagittal view

And insert the second needle we’ll create an imaginary path length along the left prostate gland i’ll adjust the probe to make sure that i can find my expected needle track then we insert straight to the prostate base the marker is deployed the needle is removed using the exact same prostate ultrasound position

I’ll enter the patient’s skin in the perineum and insert the marker along the exact same plane but instead this time just at the prostate apex here the needle has just advanced into the prostate at the apex we’ve deployed the last marker and the needle is removed our markers are done

If you’re only doing fiducial markers then the probe can be removed and the procedure is finished if you’re placing a rectal hydrogel spacer then we will continue on currently i’m adjusting the ultrasound to let some gas escape from the patient’s rectum and then i replace the ultrasound in the ideal position

Adjusting the ultrasound we’re identifying the perfect landing zone we set the ultrasound to be in the midline urethra on the sagittal view and identify the rectal wall as well as the perirectal fat the perirectal fat will be bright on the ultrasound we’ll switch over to the axial view and

Then confirm this on the axial positioning at this time now that the prostate is in the ideal position on the ultrasound we’ve identified our landing stone we’ll start assembling the space oer hydrogel kit this view might be a little bit difficult for you to see but there are several other videos available online

Including dr fagundes and dr montoya’s with close up views of kit assembly first we attach the diluent syringe to the powder vial we push down on the syringe barrel not the plunger until the cap of the vial is depressed and the red line disappears then the entire contents are injected fully by

Depressing the plunger and the valve shaken for about 10 total seconds we put the vial down in the tray so that it does not roll off your table then take the accelerator syringe break the heat seal by retracting the plunger and advance the plunger until all but approximately five cc’s of fluid

Are expelled then draw back one cc of air then take this accelerator syringe and attach it to the y connector and then you’ll place this down on the tray so that it’s hip faces up and no accelerator enters the y connector take the vial and withdraw five cc’s of

The mixture into the syringe and you can discard the remaining once the vial is removed add an additional one cc’s of air into the syringe take the y connector with the tip pointing upwards attach the syringe to the y connector then attach the syringe barrel connector and then attach the syringe plunger connector

You now have a completed space oer system do not prime the system by advancing the plungers forward make sure the one cc of air is in each syringe then i place the assembled system down with the tip pointed up remove the hydro dissection needle from the tray and attach a 10c

10cc saline flush expel any air to prime the needle turning back to the patient remember what position your bevel is in insert the needle always with the bevel down and you will have the bevel down for the rest of the procedure here is the landing pathway for the

Hydrogen dissection you aim to enter anterior to the rectal hump and then angle your needle posteriorly to enter the retroprosthetic fat again always remember to have your bevel pointing down for the remainder of the procedure we advance the needle along the ultrasound length quickly to the prostate apex

Here we are at the prostate apex just above the rectal hump you may feel a slight pop when you traverse the recto urethralis muscle now we advance the needle to the mid gland of the prostate when you enter denon va’s fascia clearly you may find the needle advances

Easily to the mid gland and then over to the base of the prostate we’ll switch the axial view to convert positioning of the needle into non-va’s fascia and then step out of the patient we see the needle tip is posterior to the prostate and anterior the rectal wall this is a suitable position

Switching back to the sagittal view and stepping back into the patient we’ll find our needle position again with the bevel tipped down then we’ll give our first puff of saline if in the right position we’ll see a large pocket open up nicely as we do here you’ll see the sailing dissipate as well

If the sailing does not dissipate you may be in the rectal wall or the posterior prostate and you should reposition your needle we retract the needle some more to hydra dissect to the mid prostate and towards the apex we’ll switch the axial once more to check that we are dissecting correctly

We’ll give another puff of saline and we see that the saline disperses cleanly on both sides of the prostate gland at this time i like to take the remaining lidocaine and inject two ccs into the hydro dissection pocket which anecdotally removes any pressure sensation the patient may feel

During the actual space oer hydrogel injection back in the sagittal plane finally we’ll return to the needle position by stepping back in we’ll prime the y connector by pushing the fluid to the top of the barrels in each syringe take care to keep this pointed up the entire time

Now connect the primed y connector to the hydrodissection needle then we’ll inject the hydrogel the entire contents over about 10 seconds and i tend to count out loud so that the team and the patient hear you can see the pocket open up well we’re done injecting at this point

The needle can be removed then we check in the sagittal and axial planes to confirm appropriate and correct placement here in the axial view there is excellent placement and separation the procedure is finished and the probe is removed the patient is cleaned up and then the patient is discharged when he urinates

Thank you you

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