AMSTERDAM – Many urological procedures can be performed safely with the use of conscious sedation rather than General anaesthesiaand clinicians and their patients say they prefer the lighter touch.
So say Canadian researchers who followed patients undergoing various endourological, ureteral, urethral or advanced cystoscopic procedures. Most patients said that if they were to repeat the procedure, they would still choose to be awake but sedated rather than asleep, according to Kapilan Panchendrabose, MSc, a medical student at the University of Manitoba in Winnipeg, Manitoba, Canada .
“The current standard for performing most urological procedures is to administer anesthesia for the patient,” Panchendrabose reported at the 2022 annual meeting of the European Urological Association (UAE). “However, there are significant risks, including adverse side effects, costs and increased operating room wait times. One way to address these risks is the use of conscious sedation for anesthetic and analgesic relief during certain urological procedures, and it has been used for many years here at our center.
On one, many
Researchers at the University of Manitoba have previously shown that for the treatment of ureteric stones, distal ureteroscopy can be performed safely under conscious sedation directed by a physician and administered intravenously by a nurse. Since then, they have expanded the technique to include other advanced urological procedures.
To see if, as they had assumed, patients under conscious sedation would tolerate the procedure and prefer it to general anesthesia for subsequent surgeries, they conducted a prospective, non-randomized cohort study of all patients who underwent urological procedures under conscious sedation in their center from June to August 2021.
Procedures included rigid and flexible ureteroscopy, ureteral stent insertions/exchanges, scrotal/penile procedures (hydroceles, testicular biopsies, etc.), urethral dilatations, and advanced cystoscopic procedures including bladder biopsies and botox therapy.
Four to six weeks after the procedure, patients were telephoned and asked to complete a standardized tolerance questionnaire.
A total of 196 procedures with consciously sedated patients were performed during the study period. The success rate was 96.5% and there were no intraoperative complications.
Of the 161 patients who completed the questionnaires 4 to 6 weeks after the procedure, 85% answered yes to the question of whether they would choose conscious sedation again if they had to repeat the procedure.
Significant predictors of choosing conscious sedation over general anesthesia were advanced age (odds ratio, 1.049; P = .017) and the surgeon’s perception, on a score of 1 to 10, of the perceived level of tolerance for the patients.
In multivariate analysis, neither body mass index, sex, previous experience of conscious sedation, Charlson comorbidity index, type of procedure, type of medication, nor time of procedure n were predictive of the choice of anesthesia.
“IV conscious sedation is a viable alternative for the majority of advanced urological procedures. Careful patient selection is paramount to ensuring the success of the procedure,” Panchrendabose said.
He acknowledged that the study was limited by selection bias, as surgeons recommended it to patients they considered suitable candidates for less intensive anesthesia.
I will take the local
A urologist who was not involved in the study said Medscape Medical News which he prefers to use local anesthesia more nitrous oxide to help patients relax during the procedure, rather than conscious sedation.
“You don’t have to put patients to sleep or use anxiolytics or anything like that, and so you can satisfy the premise that we’re looking for, which is safety. It makes the process of getting in, going through a procedure and come out really stress-free and uneventful,” said Fernando Bianco, MD, of Miami Lakes Surgery Center in Florida.
For procedures such as transperineal fusion laser ablation for the treatment of benign prostatic hyperplasiaperforming a perineal block and administering nitrous oxide allows for an average “room in, room out” time of 25 minutes, Bianco said.
The study received internal support. Panchendrabose and Bianco reported no relevant financial relationship.
European Urological Association (EAU) Annual Meeting 2022: Abstract A0003. Presented July 1, 2022.
Neil Osterweil, award-winning medical journalist, is a longtime and frequent contributor to Medscape.