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sedation/ brachy logistics

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BobbyHeenan

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We are looking into our work flow/policies on cervix brachy and other procedures and I wanted to get some input.

For first cervix brachy I prefer full OR/full sedation and often suture in a Smitt sleeve and use ultrasound guidance for. For subsequent implants (assuming tandem/ovoid or tandem/cylinder), what type of sedation are you all using? Do you have a CRNA there to help administer sedation? Do you have a procedure room where you do brachy?

For spaceOAR similar question - do you do it with oral sedation or do you go to a procedure room with IV sedation? Do you administer it or does a CRNA do it?
 

evilbooyaa

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During residency, we used to do every case in the OR with MAC/LMA/GETA based on Anesthesia's preference. No smit sleeve. Every case with US guidance.

There was an eventual plan to have anesthesia come down for cases 2-5 if deemed to be an easy insertion on case 1 in the OR. No plans for smit sleeve, although I know they are popular nationwide. Brachy attending was not enthusiastic for Rad Onc running sedation. No real procedure room for brachy like JHU or other places, but could do it in room with HDR.

SpaceOAR - procedure room with IV sedation, done by anesthesiology.

Just my experience. YMMV.
 
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BobbyHeenan

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During residency, we used to do every case in the OR with MAC/LMA/GETA based on Anesthesia's preference. No smit sleeve. Every case with US guidance.

There was an eventual plan to have anesthesia come down for cases 2-5 if deemed to be an easy insertion on case 1 in the OR. No plans for smit sleeve, although I know they are popular nationwide. Brachy attending was not enthusiastic for Rad Onc running sedation. No real procedure room for brachy like JHU or other places, but could do it in room with HDR.

SpaceOAR - procedure room with IV sedation, done by anesthesiology.

Just my experience. YMMV.

Excellent input, thank you. Good to hear residency programs were doing OR stuff.

Where I trained the rad oncs were doing their own sedation for procedures but I don't think we have the space/set up/training for that but didn't want to be completely out of the loop.

I do every case with US guidance. I would continue that practice I think regardless of going to the OR or an in office procedure room.

For smitt sleeve if going to the OR every time I don't love it, so I wouldn't use it. But if plans for lighter sedation not in the OR they can be helpful.
 

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We are looking into our work flow/policies on cervix brachy and other procedures and I wanted to get some input.

For first cervix brachy I prefer full OR/full sedation and often suture in a Smitt sleeve and use ultrasound guidance for. For subsequent implants (assuming tandem/ovoid or tandem/cylinder), what type of sedation are you all using? Do you have a CRNA there to help administer sedation? Do you have a procedure room where you do brachy?

For spaceOAR similar question - do you do it with oral sedation or do you go to a procedure room with IV sedation? Do you administer it or does a CRNA do it?
I've done spaceoar with PO narcotic/benzo prior to procedure, outpatient in the office with local. Many urologists do it that way, there's a few YouTube videos on it actually.

I think reimbursement on it is actually worse outside the office fyi
 

Radonc90

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- Spinal anesthesia, especially in the Covid era, is better I think. The problem is how to find an anesthesiologist who is good at spinal.
- I do not use any sleeve at all.
 

bachiraki

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Currently working in a community hospital with Gyn heavy program..

CRNA helps with sedation/anesthesia under the supervision of anesthesiologist. Mostly it would be MAC/LMA. I do all implants in the OR as good MAC helps with pelvic muscle relaxation and better vaginal packing. I do smit sleeve when ever possible under ultrasound guidance so that I dont have to use ultrasound in subsequent fractions. I don't have procedure room, I do all implants in the OR.
 
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RadOncLazers

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Cervical cases typically done in the brachytherapy suite in our department. Anesthesia will provide MAC for most patients. I also have used oral medications without anesthesia support and results are fine. Never use a sleeve - just do the implants.
 

ramsesthenice

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Thanks, all!

I direct a high volume Brachy center and have tried just about every way of doing things. We have a Brachy suite and keep everything down here. I most frequently use general but that’s because I typically use a hybrid IC/IS system for volume optimization and don’t use needles without it. Being a state hospital, we get a lot of advanced/recurrent tumors and less bread and butter cervical cases.

When I do though, it really depends on what imaging I’m using. If they have organ confined disease there is no reason to put them through an MRI. I’ll implant under conscious sedation and grab a quick non-con CT for planning. This could absolutely be done by rad onc nursing but in our state the required recovery period after CS is profane. To keep admin happy I have anesthesia oversee it so they also recover the patient (this saves me almost .5 nursing FTE given patient numbers).

If they have parametrial or bulky disease that I think a simple T&O will suffice for I will almost always get an MRI under general for fraction 1. If it helps, I do it for all fractions. If I’m on the fence, I’ll sometimes get a CT and MR on fraction 1 to see if I can get away with a CT.

Never use sleeves anymore. I don’t feel like I get as good of placements with them as they often restrict the entry angle.

I do use abdominal US for simple T&Os. they really are helpful in terms of getting it not just in the uterus but situated ant/post and lateral the way you want. Typically use endorectal US for needles (even with the hybrid).

A general comment I have is that I think people overestimate the risks of MAC/general anesthesia and underestimate the risks of suboptimal brachytherapy. If you do a lot of implants and are efficient and have support staff who is comfortable with the procedure and efficient physics support, anything to keep them reasonably still is enough and I agree with using the minimum necessary. But people need to be honest with their comfort and skill level in deciding what really is the safest option. Anesthesia has a small risk of catastrophic complications and Brachy has a significant risk of moderate complications. What’s the bigger source of morbidity, airplanes or cars???
 
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BobbyHeenan

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I direct a high volume Brachy center and have tried just about every way of doing things. We have a Brachy suite and keep everything down here. I most frequently use general but that’s because I typically use a hybrid IC/IS system for volume optimization and don’t use needles without it. Being a state hospital, we get a lot of advanced/recurrent tumors and less bread and butter cervical cases.

When I do though, it really depends on what imaging I’m using. If they have organ confined disease there is no reason to put them through an MRI. I’ll implant under conscious sedation and grab a quick non-con CT for planning. This could absolutely be done by rad onc nursing but in our state the required recovery period after CS is profane. To keep admin happy I have anesthesia oversee it so they also recover the patient (this saves me almost .5 nursing FTE given patient numbers).

If they have parametrial or bulky disease that I think a simple T&O will suffice for I will almost always get an MRI under general for fraction 1. If it helps, I do it for all fractions. If I’m on the fence, I’ll sometimes get a CT and MR on fraction 1 to see if I can get away with a CT.

Never use sleeves anymore. I don’t feel like I get as good of placements with them as they often restrict the entry angle.

I do use abdominal US for simple T&Os. they really are helpful in terms of getting it not just in the uterus but situated ant/post and lateral the way you want. Typically use endorectal US for needles (even with the hybrid).

A general comment I have is that I think people overestimate the risks of MAC/general anesthesia and underestimate the risks of suboptimal brachytherapy. If you do a lot of implants and are efficient and have support staff who is comfortable with the procedure and efficient physics support, anything to keep them reasonably still is enough and I agree with using the minimum necessary. But people need to be honest with their comfort and skill level in deciding what really is the safest option. Anesthesia has a small risk of catastrophic complications and Brachy has a significant risk of moderate complications. What’s the bigger source of morbidity, airplanes or cars???

Awesome, this is great feedback.

I have a busy brachy gyn practice but refer out for interstitial. I too feel that implant quality could suffer if no adequate anesthesia. I feel I'm pretty good, and have had excellent training at a gyn brachy heavy program (though I'm now like 7 years out into practice), but my professors were wizards with the implants and their skills with minimal sedation were fine...I'm not them and know my limitations.
 

evilbooyaa

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@ramsesthenice interesting on TRUS for needle placements, especially for hybrid cases. Do you feel like it really helps a lot? Any concerns about displacing the rectum towards where the needles go? How's visualization of the cervix/uterus/parametria with a TRUS? I've only used TRUS for prostate brachy cases.

Even our full Syeds in intact patients were with abd US guidance, with adjustment of needles at CT sim (advancing posterior ones with CT guidance).

I loved MRI every fx even in organ confined disease. Let you delineate normal parametria vs tumor better than CT could - shrunk volumes considerably (making OAR doses look much prettier).
 

ramsesthenice

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@ramsesthenice interesting on TRUS for needle placements, especially for hybrid cases. Do you feel like it really helps a lot? Any concerns about displacing the rectum towards where the needles go? How's visualization of the cervix/uterus/parametria with a TRUS? I've only used TRUS for prostate brachy cases.

Even our full Syeds in intact patients were with abd US guidance, with adjustment of needles at CT sim (advancing posterior ones with CT guidance).

I loved MRI every fx even in organ confined disease. Let you delineate normal parametria vs tumor better than CT could - shrunk volumes considerably (making OAR doses look much prettier).

It depends on where the disease is. In most cases I think TRUS is better, especially for posterior or low tumors. Our unit will do both and I usually take a peak with abdominal but unless people are nice and small (which in our state is a rarity) I usually end up going to TRUS because the visualization is usually a good bit better (especially for posterior disease).

By organ confined I disease I mean not involving the parametria or vagina. You are completely right, the only thing you will see well on CT is the cervix. If you have to cover anything more than that the MRI will be better. Even for cervical only disease, if people have significant shrinkage during EBRT it can be really hard to find the cervical-vesicular or cervical-retctal interface and MRI may still be useful for normal tissue delineation. Usually a good idea to get an MRI for fraction 1 even if you think you won't need it to make sure.
 

evilbooyaa

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I guess what I mean in regards to last paragraph is that my HR-CTV even for a cervix confined (like IB2 with good response to EBRT let's say) is smaller with MRI guidance than it would be if I was doing just CT planning. I have seen getting just one MRI at time of first implant to be sufficient in that scenario, so seems like we're in agreement there.
 

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I run a busy (close to 200 insertions/year) cervical program and efficiency is everything for me. So I have a very skilled surgeon suture Smit sleeves and then I insert T&R/T&O/hybrid implants in the office. A brief anesthesia is needed for maybe 15% patients (think a heroin addict). After much arguing, anesthesia now sends me a NP with a vent, so long I give them 3 days notice.
 
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ramsesthenice

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I run a busy (close to 200 insertions/year) cervical program and efficiency is everything for me. So I have a very skilled surgeon suture Smit sleeves and then I insert T&R/T&O/hybrid implants in the office. A brief anesthesia is needed for maybe 15% patients (think a heroin addict). After much arguing, anesthesia now sends me a NP with a vent, so long I give them 3 days notice.

Logistics is everything. If I had it completely my way, the interstitial patients would be under during insertion and imaging and then woken up for planning and delivery and I would do BID with a single plan/day (with verification orthogonals of course). Would then bring anesthesia back for brief propofol sedation for removal. This is by far the most efficient workflow. However, you lose about 30% of your revenue in this model (less plans) and I was unable to pull anyone from nursing to monitor them between fractions. As you can imagine, a proposal that slashes revenue and requires hiring new staff is DOA.

For really complex cases (basically any requiring perineal needles), I do an insertion, stitch the apparatus in place, treat, and then admit O/N to GYN ONC with a PCA and do a second fraction the following morning. This buys me 2 treatments with a single insertion. Repeat the process the following week. Lose a bit of revenue but no one could deny it is in the patients best interest to do so (risks of bleeding etc) and I easily got buy in from all levels.

Id say we have a similar volume but since it’s split between 2.5 providers and we have the space to do things with our previous model (ie pre-me), I am having to incrementally chip away at things. our admin is over all very supportive and collaborative, but radical changes to workflow and billing are very difficult to digest.
 
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RadRadRad

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I’ve done t and o in the office where I prescribe moderate sedation and I’ve used general/Mac. My preference is by far the latter. Typically do general with smit for first fraction and Mac for 2-5. I think this is way better for the patient and the doctor. Most patients just won’t totally relax there pelvic muscles under moderate sedation making implant more challenging and time consuming. I bet I get in and out of the procedure 2-3 times faster with general/Mac than with me prescribing moderate sedation.
 
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evilbooyaa

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Anyone doing their own IV sedation? Wasn't trained on it and would be anxious of starting out with that. How mandatory is anesthesia buy-in?
 

BobbyHeenan

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Anyone doing their own IV sedation? Wasn't trained on it and would be anxious of starting out with that. How mandatory is anesthesia buy-in?

We did that in residency but I'm not doing it now. We just gave IV morphine and ativan but man, some of those implants were traumatic - for me and the patients :) but in different ways.

I definitely think sub optimal packing with some of them done that way, though now I really like the paddle retractors often over packing. Probably sacrilegious to the purists, but my rectal doses with those paddles has been fantastic.
 
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seper

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Logistics is everything. If I had it completely my way, the interstitial patients would be under during insertion and imaging and then woken up for planning and delivery and I would do BID with a single plan/day (with verification orthogonals of course). Would then bring anesthesia back for brief propofol sedation for removal. This is by far the most efficient workflow. However, you lose about 30% of your revenue in this model (less plans) and I was unable to pull anyone from nursing to monitor them between fractions. As you can imagine, a proposal that slashes revenue and requires hiring new staff is DOA.

For really complex cases (basically any requiring perineal needles), I do an insertion, stitch the apparatus in place, treat, and then admit O/N to GYN ONC with a PCA and do a second fraction the following morning. This buys me 2 treatments with a single insertion. Repeat the process the following week. Lose a bit of revenue but no one could deny it is in the patients best interest to do so (risks of bleeding etc) and I easily got buy in from all levels.

Id say we have a similar volume but since it’s split between 2.5 providers and we have the space to do things with our previous model (ie pre-me), I am having to incrementally chip away at things. our admin is over all very supportive and collaborative, but radical changes to workflow and billing are very difficult to digest.

Isn’t the most cost effective way is to avoid main OR and inpatient admissions altogether?
 
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ramsesthenice

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Isn’t the most cost effective way is to avoid main OR and inpatient admissions altogether?

Yes. And everyone knows big hospital systems love to talk about cost effectiveness until its their own bottom line. I really don't want to derail this thread delving into these intricacies but suffice it to say when each department has their own bottom line there is going to be a lot of shuffling by each to minimize costs/maximize revenue and it usually doesn't do anything to help with cost effectiveness.
 
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RadRadRad

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We did that in residency but I'm not doing it now. We just gave IV morphine and ativan but man, some of those implants were traumatic - for me and the patients :) but in different ways.

I definitely think sub optimal packing with some of them done that way, though now I really like the paddle retractors often over packing. Probably sacrilegious to the purists, but my rectal doses with those paddles has been fantastic.

Used to use fentanyl and versed. Always felt it hard to find the sweet spot of optimal sedation and analgesia. And agree that most patients do not tolerate same degree of packing.
also, years ago someone publishedthe incidence of ptsd after t and o. I recall it approached 50%. Probably better to have more sedation/amnesia
 
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abish

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70 applications a month.
Admitted a day prior. Enema. Laxatives. Lorazepam.

Inj Pethedine + Inj Phenargan + Syp Morphine. Works ~90% of times - Patients don't feel pain, most are sedated. (No anesthesiologist backup)
-
USG guided measurement and tandem application. FSD Ovoids go in and lock and pack and CT and HRCTV, 8Gyx3.
-
Patients go home in next 4 hours.
 
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seper

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My hospital's CMO axed meperdine due to alleged AE's.
I used it a lot.
 

Radonc90

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For those of you who do interstitial (Syed, Venezia etc.), and since the pt will be admitted as an inpt for a few days (2-4 days),
what is your prefernece re pain control:
1- iv, po opioid?
2- epidural catheter by anesthesia?

PS: personally I prefer epidural for a few days, I wonder how everyone addresses pain control for interstitial HDR...
 

seper

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For those of you who do interstitial (Syed, Venezia etc.), and since the pt will be admitted as an inpt for a few days (2-4 days),
what is your prefernece re pain control:
1- iv, po opioid?
2- epidural catheter by anesthesia?

PS: personally I prefer epidural for a few days, I wonder how everyone addresses pain control for interstitial HDR...
For interstitial admits x 3 days, ideally, you should ask for morphine PCA and epidural catheter.
If it’s an intact cervix case, and you have a Venezia device, consider 3-4 separate insertions instead of keeping the device in. Much better tolerated.
 

ramsesthenice

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For interstitial admits x 3 days, ideally, you should ask for morphine PCA and epidural catheter.
If it’s an intact cervix case, and you have a Venezia device, consider 3-4 separate insertions instead of keeping the device in. Much better tolerated.
This is exactly what I do. If it’s a really complicate insertion and I am going to leave in and admit them I do a PCA. Otherwise just pull it all out and send them home. Don’t need any narcotics. It’s less invasive than a prostate insertion and I don’t even give pain meds for those.
 
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Radonc90

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Wait,

For interstitial (Syed, Venezia), you insert the tandem + needles, do 1 HDR Tx, then pull it out and repeat it later like the way we do for intracavitary?

In other words, bring the pt back and keep doing interstitial x more times (x = 5 to 9)?

Maybe I am doing it wrong but ABS compendium (See Table 8 and Table 9 in the link below) recommends anywhere between 5 to 9 fractions (usually b.i.d., 6h apart). If interstitial is done on Monday, pt is usually d/c'd home on Thurs AM, Thurs PM or even Friday, depending on the # fractions...

 
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seper

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Wait,

For interstitial (Syed, Venezia), you insert the tandem + needles, do 1 HDR Tx, then pull it out and repeat it later like the way we do for intracavitary?

In other words, bring the pt back and keep doing interstitial x3-4 times?

Maybe I am doing it wrong but ABS compendium (See Table 8 and Table 9) recommends anywhere between 5 to 9 fractions (usually b.i.d., 6h apart). If inetrstitial is done on Monday, pt is usually d/c'd home on Thurs AM, Thurs PM or even Friday, depending on the # fractions...
Right. “Interstitial” is not always horrible. If you have a well placed cervical sleeve, and only need 2-3 short needles next to the tandem, it’s not much of a procedure
 

Radonc90

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Oh,

Got it.

My interstitial cases are usually way more complex, usually 10 to 20 needles,
nasty tumor...
 

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Smit sleeve is placed under general anesthesia. Insertions are done in an exam room with PO morphine and ativan only. No packing. It's awful and something I have protested pretty strongly about. Anybody else do this?
 

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Smit sleeve is placed under general anesthesia. Insertions are done in an exam room with PO morphine and ativan only. No packing. It's awful and something I have protested pretty strongly about. Anybody else do this?
We do the same thing, including with hybrid applicators. I would prefer if it was done under anesthesia. We do use alatus packing though.
 
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ramsesthenice

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We do the same thing, including with hybrid applicators. I would prefer if it was done under anesthesia. We do use atalus packing though.
I use general for hybrids. It isn’t 100% necessary but I do think you get better implants when they are really still and it’s a better experience for the patient.

As to more complicated insertions, my practice has changed. I rarely admit people for consecutive treatments for a few reasons. First, even with precautions I’ve seen a couple DVTs in the last year. Second, it’s miserable for patients. Third, I’m going lower and slower because most of these cases have distal involvement and I’m getting tired of having to send people for hyperbaric to manage their necrosis several months later. I don’t want to jinx myself but I’ve not had any significant complications related to the insertion it’s self and I no longer feel that admitting for consecutive treatments offers much if any of an advantage for the patient.

I would like to do BID but where I am there are staffing challenges related to the fact we are considered a satellite clinic by the hospital and anesthesia (even though we are in the main hospital) that make it impractical.
 

Radonc90

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@ramsesthenice,

Re complex interstitial, I wonder what your current practice is, OK, let's say complex Syed with tandem + 20 needles in there...
1. How many fractions after the O.R. procedure?
Is it 1 or 2, then remove and d/c home?

2. How many fractions in total and how many days apart?
Is it one week between complex insertions?

Certainly, this is a nice thought bc radiobiologically, is similar to Tandem & Rings (or Tandem & Ovoids) scheduling system.

The pro: pt does not have to stay overnight.
The cons: multiple anesthesia and multiple insertions.
 

ramsesthenice

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@ramsesthenice,

Re complex interstitial, I wonder what your current practice is, OK, let's say complex Syed with tandem + 20 needles in there...
1. How many fractions after the O.R. procedure?
Is it 1 or 2, then remove and d/c home?

2. How many fractions in total and how many days apart?
Is it one week between complex insertions?

Certainly, this is a nice thought bc radiobiologically, is similar to Tandem & Rings (or Tandem & Ovoids) scheduling system.

The pro: pt does not have to stay overnight.
The cons: multiple anesthesia and multiple insertions.
The issue really has to do with where the lesion is. If there is distal vaginal involvement (distal half) I will do multiple insertions and fractionate since this is where necrosis is most problematic. If it’s a huge pelvic tumor without vaginal involvement, I’ll do the insertion in the afternoon, admit, repeat the next morning (with no sedation, just pain meds) give propofol to take everything out, and then do it again the next week. 700x4. Works pretty well. Again, can be BID but there are BS logistical reasons I can’t do it at my institution.
 

evilbooyaa

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For those of you who do interstitial (Syed, Venezia etc.), and since the pt will be admitted as an inpt for a few days (2-4 days),
what is your prefernece re pain control:
1- iv, po opioid?
2- epidural catheter by anesthesia?

PS: personally I prefer epidural for a few days, I wonder how everyone addresses pain control for interstitial HDR...

This is for full interstitials, NOT hybrid. Hybrid to me is with like <= 5 needles. Interstitial are the 10-20 needle monsters. I think people may have gotten confused based on your wording- Syed is a template used for interstitial, MUPIT is another option.
Venezia is generally used as a hybrid applicator - while it can theoretically do a full interstitial, I'd be very interested to hear if anyone is actually doing that.

Anyways,

Institution #1
Epidural catheter in pre-op with basal rate adjustable by Anesthesia team only
General anesthesia
Dilaudid PCA Rx by RO MD
First fraction evening #1, fractions 2-5 BID on morning/afternoon days #2 and 3, remove after day 3, d/c night day 3 or (more likely) AM Day 4.

Or

Institution #2
Same as above, but Epidural catheter has PCA capabilities with mix of anesthetic and narcotic, thus allowing patient to push button to micro-bolus epidural dosing as necessary.

5Gy x 5 for interstitial dosing for cervical or recurrent endometrial cancer after 45Gy EBRT.

Smit sleeve is placed under general anesthesia. Insertions are done in an exam room with PO morphine and ativan only. No packing. It's awful and something I have protested pretty strongly about. Anybody else do this?

First portion of bolded sounds horrible to me to put patients through. I would not want to do Gyn brachy if that was the support I had access to. Fortunate, I suppose, that I haven't had to and don't really plan to. Second portion will likely lead to very suboptimal implant unless it's say a T&R with rectal retractor or some other system I'm not aware of.
 

Radonc90

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So, for those who perform complex interstitial (let's say 10-20 needles +/- tandem depending on intact cervix or not)...

- Who here does 1 procedure as @evilbooyaa said above? Let's say O.R. procedure is Mon AM, 5 b.i.d. fractions, discharge Wed PM or Thurs AM (overnight observation)...

- Who here does 2-3 O.R. separate procedures (let's say 2 fractions each in 2 separate procedures) à la Vienna style:
 

ramsesthenice

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So, for those who perform complex interstitial (let's say 10-20 needles +/- tandem depending on intact cervix or not)...

- Who here does 1 procedure as @evilbooyaa said above? Let's say O.R. procedure is Mon AM, 5 b.i.d. fractions, discharge Wed PM or Thurs AM (overnight observation)...

- Who here does 2-3 O.R. separate procedures (let's say 2 fractions each in 2 separate procedures) à la Vienna style:
I think I already made it clear I prefer option 2. There is a potential, and I stress potential, advantage to doing multiple insertions and that is it does spread out the hottest doses to normal structure interfaces. If the anatomy is favorable it’s probably a wash but in some cases even with the best implant dose to some normal structure is going to be high and feathering it a bit might be helpful. D2cc might be high but if it’s not the same 2ccs every fraction that might help.

At the end of the day there are a lot of reasonable options and unfortunately realities of staffing and logistics may end up dictating how you approach these at a given institution more than you might like.
 

evilbooyaa

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So, for those who perform complex interstitial (let's say 10-20 needles +/- tandem depending on intact cervix or not)...

- Who here does 1 procedure as @evilbooyaa said above? Let's say O.R. procedure is Mon AM, 5 b.i.d. fractions, discharge Wed PM or Thurs AM (overnight observation)...

- Who here does 2-3 O.R. separate procedures (let's say 2 fractions each in 2 separate procedures) à la Vienna style:

I'll say the second option is certainly very reasonable. If I was going to do that it would be insertion, 2-3 fractions (depending on whether it was good or not), then following week, re-insert, 2-3 fractions (depending on how many I did first time).

Thing is, interstitials at my institution are like a 10-12 hour ordeal, so I'm not super enthusiastic to take one patient and double my days of pain. And getting OR time can be like pulling teeth sometimes despite the supportive Gyn-Oncs.
 
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