Anesthetic considerations for urologic surgeries

A Systematic Review of Loco-Sedative Anesthesia for Urologic Surgery

OBJECTIVE

To perform a systematic review of the characteristics and outcomes of conscious sedation and local anesthesia for various urologic procedures. Urologic care has much to gain from the routine integration of ambulatory surgery via loco-sedative anesthetic techniques for both surgeon and patient.

METHODS

A comprehensive systematic literature search was conducted on PubMed, and Scopus databases following PRISMA criteria from June to August 2021. Articles were included if they were English, prospective, randomized, or nonrandomized controlled trials that used local anesthetic or conscious sedation for urologic interventions in adult patients. Additionally, included studies provided primary data on the use loco-sedative anesthesia and the efficacy and complications. All studies included were further reviewed to assess the biases and conflicts of interests.

RESULTS

Thirty-two studies with 6897 patients were included in the review. Mean patient age was 46.4years. The most common anesthetic and analgesic relief was the use of local anesthetic with 1% lidocaine. The majority used lidocaine as an injection, whereas the second most common route of administration was a topical cream. However, there was significant heterogeneity in the type of local or conscious sedation method and whether a combination was used. 44.4% of the studies used the visual analog scale as their primary endpoint. All the studies reported an 83%-100% successful procedure rate without note of significant sedation-related complications.

CONCLUSION

Given the high efficacy rates, loco-sedative anesthesia is a promising technique for urologic interventions and should be further investigated to determine whether it may become be the standard of care.

Effect of esketamine on the ED50 of propofol for successful insertion of ureteroscope in elderly male patients: a randomized controlled trial

BACKGROUND

Propofol is effective and used as a kind of routine anesthetics in procedure sedative anesthesia (PSA) for ureteroscopy. However, respiratory depression and unconscious physical activity always occur during propofol-based PSA, especially in elderly patients. Esketamine has sedative and analgesic effects but without risk of cardiorespiratory depression. The purpose of this study is to investigate whether esketamine can reduce the propofol median effective dose (ED50) for successful ureteroscope insertion in elderly male patients.

MATERIALS AND METHODS

49 elderly male patients undergoing elective rigid ureteroscopy were randomly divided into two groups: SK Group (0.25 mg/kg esketamine+propofol) and SF Group (0.1 µg/kg sufentanil+propofol). Patients in both two groups received propofol with initial bolus dose of 1.5 mg/kg after sufentanil or esketamine was administered intravenously. The effective dose of propofol was assessed by a modified Dixon's up-and-down method and then was adjusted with 0.1 mg/kg according to the previous patient response. Patients' response to ureteroscope insertion was classified as "movement" or "no movement". The primary outcome was the ED50 of propofol for successful ureteroscope insertion with esketamine or sufentanil. The secondary outcomes were the induction time, adverse events such as hemodynamic changes, hypoxemia and body movement were also measured.

RESULT

49 patients were enrolled and completed this study. The ED50 of propofol for successful ureteroscope insertion in SK Group was 1.356 ± 0.11 mg/kg, which was decreased compared with that in SF Group, 1.442 ± 0.08 mg/kg (P = 0.003). The induction time in SK Group was significantly shorter than in SF Group (P = 0.001). In SK Group, more stable hemodynamic variables were observed than in SF Group. The incidence of AEs between the two groups was not significantly different.

CONCLUSION

The ED50 of propofol with esketamine administration for ureteroscope insertion in elderly male patients is 1.356 ± 0.11 mg/kg, significantly decreased in comparsion with sufentanil.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, No: ChiCTR2300077170. Registered on 1 November 2023. Prospective registration. http://www.chictr.org.cn .

Anesthesia Preferences and Outcomes in Saudi Arabian Healthcare: A Cross-Sectional Study

BACKGROUND

Anesthesia choice is critical in ensuring optimal surgical outcomes and patient satisfaction. We aimed to investigate anesthesia preferences, trends, and outcomes in elective surgeries within Saudi Arabian healthcare settings.

METHODS

A cross-sectional survey-based study was conducted among anesthesia residents and attending anesthesiologists across Saudi Arabia. Participants provided demographic information and responded to questions regarding anesthesia preferences, trends, and outcomes. Descriptive statistics were used to summarize the data, and logistic regression analysis was employed to identify factors associated with anesthesia preference.

RESULTS

The survey was completed by 572 healthcare professionals in Saudi Arabia. Among participants, 51.7% (n=296) preferred general anesthesia, while 48.3% (n=276) favored regional anesthesia for elective surgeries. Factors influencing anesthesia choice included patient preference, surgical complexity, and resource availability. Over half of the respondents reported an increase in regional anesthesia preference over the past five years, although some perceived inadequate training in this area. Common barriers to regional anesthesia adoption included equipment availability, patient reluctance, and limited training opportunities. Postoperative recovery was perceived as quicker with regional anesthesia by 52.3% (n=299) of participants, with postoperative nausea and vomiting being the most common complication associated with general anesthesia. Multivariable logistic regression analysis revealed that participants above 50 years had lower odds of preferring regional anesthesia, while those perceiving training adequacy in regional anesthesia as adequate had higher odds of preferring it (OR=0.64, 95% CI: 0.41-0.98, p=0.041; OR=1.58, 95% CI: 1.21-2.05, p=0.001, respectively).

CONCLUSION

This study provides insights into anesthesia practice patterns in Saudi Arabian healthcare settings. Individualized anesthesia care, ongoing training in regional anesthesia, and evidence-based decision-making are essential to optimize perioperative outcomes and patient satisfaction.

Impact of Nonselective and Selective α-1 Adrenergic Blockers on the Sedative Efficacy of Dexmedetomidine in Urologic Surgery: A Prospective, Observational Study

BACKGROUND This study aimed to compare the impact of a-1 adrenergic blockers - nonselective (alfuzosin, doxazosin, and terazosin) and selective (silodosin and tamsulosin) - on the sedative effects of the alpha-2 adrenergic agonist dexmedetomidine (DMT) in patients undergoing urologic surgery. The primary outcome was the sedative effect of DMT as determined by the bispectral index (BIS) and Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale scores. MATERIAL AND METHODS One hundred eighteen patients undergoing elective urologic surgery with spinal anesthesia were recruited. Patients were assigned based on their medication status to group N (no medication; n=33), group NS (nonselective alpha-1 blocker; n=27), or group S (selective alpha-1 blocker; n=58). Mean blood pressure (MBP), heart rate (HR), oxygen saturation (SpO₂), BIS, and MOAA/S scale scores were recorded at 5-minute (min) intervals after DMT administration. RESULTS Group NS had significantly higher BIS scores than groups N and S at 25 min (P=0.045) and 30 min (P=0.030) after DMT administration, indicating lower sedation levels. MBP significantly differed between the 3 groups at all time points, with group N experiencing a lower MBP than groups NS and S. No significant differences were found between the groups in MOAA/S scale scores, SpO₂, or HR. CONCLUSIONS Nonselective alpha-1 adrenergic blockers can reduce the sedative effects of DMT. Consequently, there may be a need for individualized anesthesia management considering the specific subtype of alpha-1 adrenergic blocker medication.

Ureteroscopy under conscious sedation: A proof-of-concept study

INTRODUCTION

Ureteroscopy (URS) is commonly performed under general anesthesia (GA) to maximize patient tolerability and minimize surgical complications; however, given the improvements in endoscopic technology and risks associated with GA, alternate forms of anesthesia have been postulated. We aimed to evaluate the outcomes of URS under conscious sedation.

METHODS

We completed a retrospective cohort study from November 2019 to June 2020 at a tertiary-level hospital. All URSs that were performed under urologist-directed conscious sedation were included. Our primary outcome was the ability to complete URS, defined as success rate. Secondary outcomes included: stone-free rate, intraoperative complication rate, hospital admission rate, and sedation requirement. Univariate- and multivariate-adjusted logistic regression analyses were employed.

RESULTS

Ninety-nine URSs were included. Most (73/99, 73.7%) were performed for urolithiasis. The overall success rate was 83.8% (83/99), with 81.0% (34/42) intra-renal and 70.0% (16/23) proximal ureter success rates. The stone-free rate was 80.8% (59/73). No intraoperative complications nor hospital admissions were reported. The mean amount of sedation required was 3 mg (interquartile range [IQR] 2-4] of midazolam and 100 μg (100-150) of fentanyl. On multivariate analysis, midazolam was significantly associated with increased success (odds ratio 2.496, 95% confidence interval 1.057-5.892, p=0.037).

CONCLUSIONS

We have shown that proximal and intrarenal URS under conscious sedation is safe and effective. We were limited by our lack of followup, small sample size, selection bias to chose healthy patients, and lack of patient tolerability data. Patients and healthcare systems may benefit from implementing this innovation more broadly.

The efficacy and safety of paravertebral block for postoperative analgesia in renal surgery: A systematic review and meta-analysis of randomized controlled trials

Background

Paravertebral block (PVB) has been widely used in postoperative analgesia, especially in thoracic and breast surgery. However, the efficacy and safety of PVB for analgesia after renal surgery remains uncertain. Therefore, this study aimed to determine the postoperative analgesic efficacy and safety of PVB in renal surgery.

Methods

PubMed, Web of Science, Embase, and the Cochrane Library databases were systematically searched up to December 20, 2021. All randomized controlled trials (RCTs) evaluating the postoperative analgesic efficacy of PVB in renal surgery were collected. The meta-analysis was performed using RevMan 5.4 and Stata/MP 14.0 software.

Results

A total of 16 RCTs involving 907 patients were included in the meta-analysis. Ten studies investigated patients under percutaneous nephrolithotomy (PCNL), and six studies were done for patients under other renal surgery (nephrectomy or pyeloplasty). Compared with control groups (no block, sham block, or other nerve blocks), meta-analysis showed that PVB reduced 24-hour postoperative opioid consumption significantly (SMD = −0.99, 95%CI: −1.60–0.38, p = 0.001, I² = 92%) and reduced pain scores at various time points within 24 h at rest and 1 h, 4 h, and 24 h at movement after renal surgery, furthermore, PVB prolonged the time to first postoperative analgesic requirement (SMD = 2.16, 95%CI: 0.94–3.39, p = 0.005, I² = 96%) and reduced the incidence of postoperative additional analgesia (OR = 0.14, 95%CI: 0.06∼0.33, p < 0.00001, I² = 50%). Subgroup analysis revealed that the postoperative analgesia effect of PVB was more significant in PCNL, and the use of bupivacaine for PVB seemed to have a better performance. Besides, there was no difference in the incidence of postoperative nausea, vomiting, and itching between PVB and control groups.

Conclusion

This study indicates that PVB may provide effective postoperative analgesia in patients under renal surgery, especially PCNL patients. Moreover, PVB is a safe analgesic method without significant analgesia-related complications.

Quadratus Lumborum Block Reduces Postoperative Opioid Consumption and Decreases Persistent Postoperative Pain Severity in Patients Undergoing Both Open and Laparoscopic Nephrectomies-A Randomized Controlled Trial

Background: New regional techniques can improve pain management after nephrectomy. Methods: This study was a randomized controlled trial conducted at two teaching hospitals. Patients undergoing elective open and laparoscopic nephrectomy were eligible to participate in the trial. A total of 100 patients were divided into a quadratus lumborum block (QLB) group (50 patients) and a control (CON) group (50 patients). At the end of surgery, but while still under general anesthesia, unilateral QLB with ropivacaine was performed on the side of nephrectomy for patients in the QLB group. The main measured outcome of this study was oxycodone consumption via a patient-controlled anesthesia (PCA) pump during the first 24 h following surgery; other measured outcomes included postoperative pain intensity assessment, patient satisfaction with pain management, and persistent pain evaluation. Results: Patients undergoing QLB needed less oxycodone than those in the CON group (34.5 mg (interquartile range 23 to 40 mg) vs. 47.5 mg (35–50 mg); p < 0.001). No difference between the groups was seen in postoperative pain intensity measured on the visual analog scale, except for the evaluation at hour 2, which was in favor of the QLB group (p = 0.03). Patients who received QLB were more satisfied with postoperative pain management than the CON group. Persistent postoperative pain was assessed with the Neuropathic Pain Symptom Inventory (NPSI) at months 1, 3, and 6, and was found to be significantly lower in the QLB group at each evaluation (p < 0.001). We also analyzed the impact of the surgery type on persistent pain severity, which was significantly lower after laparoscopic procedures than open procedures at months 1, 3, and 6. Conclusions: QLB reduces oxycodone consumption in patients undergoing open and laparoscopic nephrectomy and decreases persistent pain severity months after hospital discharge.