With restricted operating room resources and capacity limiting access to timely care, along with complications associated with heavier anesthetics, there is a need to innovate the anesthetic approach for various procedures that may not require the support of an operating room.

Our manuscript, published in the July 2024 issue of the AUA journal Urology Practice^®, highlights and compares the utility of alternative techniques to address these shortcomings in efforts to improve patient access to care.¹ We explore the use of local anesthesia combined with traditional anesthesiologist-administered sedation compared to urologist-directed, nursing-administered sedation for penile plication in the ambulatory surgical setting. With preliminary results presented at the Sexual Medicine Society of North America 2023 conference and the most recent AUA meeting, our data show that plication surgery is well tolerated in both approaches with no differences in intraoperative or postoperative pain. Furthermore, over 93% of patients opted for the same form of sedation for a future procedure, and 100% recommended their approach to others, with no differences between cohorts. Cohorts were similar in outcomes and complications, with rates lower than or comparable to the existing literature. Importantly, when implementing this novel approach of conducting invasive procedures in the outpatient setting, an important consideration is the impact this may have on the existing health care infrastructure, including emergency department utilization, family medicine appointments, and urgent transfer to hospital or hospitalization. However, no instances of any of these were seen in our pilot study.

Alternative anesthetic approaches open the door for invasive surgery to be performed in patients with limited comorbidities in an ambulatory surgical center or clinic setting. This avenue can potentially reduce patient wait times, considering the shortage of anesthesiologists, and reduce health care system costs. The ability to expand the application of this approach to other procedures may free operating room resources on a larger scale for more acute conditions or medically complex patients requiring the resources associated with hospital operating rooms. Our group has successfully investigated alternative anesthetic techniques for a variety of urologic procedures, allowing them to be transitioned into the ambulatory surgical or clinic setting, including other penile and scrotal surgeries, radical orchiectomies, varicocelectomies, ureteroscopy, and more.^2-5 The benefits are vast; however, historically, a significant limitation is thought to be patient tolerability. Our work has demonstrated that these are exceptionally well tolerated in the ambulatory setting, even when avoiding general or spinal anesthesia.

It is important to highlight the local anesthetic technique itself. We employ a dorsal nerve block and penile ring block achieved with a mixture of 1% lidocaine and 0.25% bupivacaine in a 1:1 ratio. The Figure, from our Urology Practice^® manuscript, depicts these. These local anesthetic techniques are crucial for trainees to be well versed in as they may be adequate as the only anesthetic modality employed. While outside of the scope of our pilot study, utilizing local anesthetic alone may be tolerable for select patients. There has been literature describing local anesthesia alone for invasive penile procedures, and our institution has experience with certain patients requesting no sedation who have subjectively tolerated plication surgery well with similar clinical outcomes.⁶ While patient anxiety and comfort remain paramount in anesthetic considerations, demonstrating the effectiveness of this approach as one potential option is essential to highlight the utility of local anesthesia, its effectiveness, and its benefits to the health care system and patient access to care. For our future work, we plan to conduct a larger-scale randomized trial of patients undergoing plication surgery randomized to either receive local anesthesia alone, local anesthesia with adjuncts including self-administered inhaled analgesics (methoxyflurane), and local anesthesia combined with nursing-administered sedation as this wasshown to be efficacious in this pilot study.