Steven N. Gange, MD

	A number of favorable patient and physician factors have led urologists to consider performing procedures in an office setting. The success of procedures conducted in this venue requires that patients have a safe and comfortable experience without impacting the quality of their outcome. Once established in this treatment pattern, the physician stands to gain efficiency, possible revenue enhancement, and overall satisfaction.

	This article will discuss the adjunctive role of verbal anesthesia in easing the urology patient’s in-office procedure experience.

	Many diagnostic and therapeutic urologic procedures can be performed easily and safely in the office, with limited anesthesia administration. In-office procedures offer many benefits to patients and also to physicians. While adult diagnostic flexible cystoscopy, vasectomy, and transrectal ultrasound-guided biopsy are almost uniformly performed in urology offices, other procedures such as neuromodulation, endoscopic injections, transurethral resection of bladder tumor, minimally invasive surgical therapy for BPH, are increasingly performed in the office setting, often under strict local anesthesia. Despite potential advantages, some urologists are hesitant to expand their in-office procedural offerings.

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	Patients appreciate some unique benefits of in-office procedures. The average patient is already comfortable in the office and with the office staff, and may perceive a surgical facility as intimidating. Typically, for procedures performed in the office, there is no required fasting period, no needle sticks for labs or IV placement, and less paperwork. From a financial standpoint, patient co-pays and out-of-pocket costs are typically lower for in-office procedures. Also, since many urologic procedures can be done under strict local anesthesia (without sedation), this allows patients with significant comorbidities to complete an in-office procedure with much lower risk. Finally, as opposed to strict post-anesthetic surgical facility requirements, many patients also enjoy the freedom of driving themselves home without an escort following a straightforward office procedure.

	From the urologist’s standpoint, being away from the office to conduct surgical cases seriously impairs one’s efficiency. Even when a day of OR cases begins and flows as scheduled, turnover time in the hospital or ambulatory surgery center results in excessive downtime, time spent away from tasks accumulating on the office EMR, and potential lost revenue 

What is verbal anesthesia (aka ‘vocal local’)?

	Verbal anesthesia (VA) is the art of conversational distraction associated with measures to ensure a calming environment. It is commonly but haphazardly used by in-office surgeons of many disciplines, and is poorly described in the literature 

 2011; 77:12-6). Generally speaking, well-focused VA draws a patient’s attention away from negative stimuli, thereby reducing pain, anxiety, and stress. In so doing, VA encourages a procedural environment that helps to maintain relaxation, well-being, and comfort, enhancing and expanding the urologist’s in-office procedural armamentarium.

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	Good VA begins with clear preoperative communication. It is important to set patient expectations at the time of scheduling. On the procedure day, an assistant is assigned the role of “verbal anesthetist” for the case and begins to set the tone with calming conversation while rooming the patient. Furthermore, care is taken to ensure that the room temperature is made comfortable (72º-74ºF) and that soothing music is playing 

	Once the patient has disrobed, been properly positioned, prepped, draped (preferably with warm soap), and anesthetized as required, the procedure is undertaken. For many urologic procedures, a surgical blinding screen is advantageous, minimizing anxiety resulting from a patient seeing our large and unfamiliar instruments.

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	As the physician begins to work, the conversation between the verbal anesthetist and the patient is deliberately guided to something entirely unrelated to the procedure (eg, weather, family, hobbies, etc.). Along the way, specific coaching comments from the urologist will occasionally be needed. When such encouragement is offered, very selective phrases are used, such as “You will feel some cold water,” “Breathe slowly and easily,” “Try to wiggle your fingers and toes,” “Here come those noises I told you about,” and “let me know when your bladder feels full.” Stress-inducing phrases are avoided, such as “I’m going to insert the scope now,” “This is going to hurt a little,” “I’m going to fire the gun/device,” or “Hold your breath,” and use of the word “pain,” as it seems intuitive that certain words and phrases actually increase a patient’s anxiety.

Next: "The more the verbal anesthetist can personalize the conversation, the more likely the patient can be effectively distracted throughout the procedure"

	Meanwhile, the more the verbal anesthetist can personalize the conversation, the more likely the patient can be effectively distracted throughout the procedure and the need for physician coaching comments reduced. Everyone in the treatment room strives to maintain a calm and peaceful environment. The aim of this standardized approach is to reduce the likelihood of surprises to the patient during the procedure. It is our experience that a well-informed and artfully distracted patient tolerates outpatient procedures better, with less anxiety and discomfort.

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	While VA is poorly defined and not well studied in the literature, it has become an essential adjunct in achieving patient tolerability among dentists and oral surgeons, dermatologists performing Mohs surgery, plastic and reconstructive surgeons using in-office liposuction and laser techniques, ENTs opening sinuses with balloons, ophthalmologists performing LASIK surgery, and gynecologists conducting hysteroscopy and uterine ablations. Most proceduralists, including urologists, have begun to adopt VA to some limited degree with widespread, albeit anecdotal, success.

	VA is a simple technique of saying the right thing at the right time while avoiding words and phrases that evoke anxiety, thus creating a relaxed procedural environment by focusing a patient’s attention away from anxiety-producing stimuli and onto something more familiar. By employing VA for in-office procedures, almost any office procedure can be accomplished without adding safety concerns associated with adjunctive medications 

; “Step by step guide to-verbal-anesthesia,” LondonVision Clinic 2009 [

]). In the end, we believe that VA can be a helpful addition to the overall experience for patients undergoing local anesthetic urologic procedures.

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Articles

Verbal anesthesia: How it’s used in urologic procedures

This video looks at the prostatic urethral lift (UroLift, NeoTract, Inc.), which provides another tool in the urologist's armamentarium for treating BPH. Here, 

 demonstrate several techniques to help urologists transition from performing this procedure in the OR to an office setting, where it is quicker and easier for the patient. Each video presents a different sedative option for in-office UroLift. Commentary on the videos is provided by Dr. Gange, a urologist in group practice in Salt Lake City, and 

'Y'tube Section Editor James M. Hotaling, MD, MS,

 assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City. Dr. Gange has served as a principal investigator, consultant, and proctor for NeoTract.

This video demonstrates UroLift placement under topical anesthesia in the office setting and also includes comments from several patients who underwent the procedure. 

 Dr. Gange explains the evolution of the UroLift and illustrates the optimal techniques for both local analgesia and implant placement. Specifically, he demonstrates an atraumatic rotation of the device in the bladder and placement along a clear plane 1.5 cm from the bladder neck. He also illustrates his care pathway for managing these patients.

 is a urologist in group practice in Salt Lake City. He has served as a principal investigator, consultant, and proctor for NeoTract.

 is assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City.

In this video, Steven N. Gange, MD, demonstrates UroLift placement under topical anesthesia in the office setting and also includes comments from several patients who underwent the procedure.

Placement of urethral lift (UroLift) under topical anesthesia

 is a resource for urologists and other clinicians who focus on men's health. 'Y'tube covers surgical aspects of a variety of men's health issues with the ultimate goal of accumulating a library of videos to serve as a reference. This installment looks at the prostatic urethral lift (UroLift, NeoTract, Inc.), which provides another tool in the urologist's armamentarium for treating BPH. It can be done in the office and provides a great option for patients who want to preserve sexual function and/or do not want to undergo transurethral resection of the prostate. While the data are early, it appears that it may provide a viable alternative to TURP. Here, Drs. 

 demonstrate several techniques to help urologists transition from performing this procedure in the OR to an office setting, where it is quicker and easier for the patient. Each video presents a different sedative option for in-office UroLift.

	This video demonstrates UroLift placement under topical anesthesia in the office setting and also includes comments from several patients who underwent the procedure.

Dr. Gange explains the evolution of the UroLift and illustrates the optimal techniques for both local analgesia and implant placement. Specifically, he demonstrates an atraumatic rotation of the device in the bladder and placement along a clear plane 1.5 cm from the bladder neck. He also illustrates his care pathway for managing these patients.

UroLift vs. TURP: New gold standard for BPH?

Prostatic urethral lift (UroLift): A minimally invasive approach

This video demonstrates UroLift placement under topical anesthesia in the office setting and also includes comments from several patients who underwent the procedure.

Steven N. Gange, MD

Articles

Verbal anesthesia: How it’s used in urologic procedures

Placement of urethral lift (UroLift) under topical anesthesia

Prostatic urethral lift (UroLift) placement under topical anesthesia