Ureteroscopy under local anaesthesia with and without intravenous analgesia

The initial experience of 4.5/6.5 Fr ureteroscopic laser lithotripsy under topical intraurethral anesthesia supplemented by preoperative and intraoperative medications

PURPOSE

To assess the safety and effectiveness of the 4.5/6.5 Fr ureteroscopic laser lithotripsy (URSL) under topical intraurethral anesthesia (TIUA) compared to spinal anesthesia (SA).

METHODS

A retrospective study was conducted on 47 (TIUA: SA = 23:24) patients receiving 4.5/6.5 Fr URSL from July 2022 to September 2022. For the TIUA group, atropine, pethidine, and phloroglucinol were used apart from lidocaine. In the SA group, patients received lidocaine and bupivacaine. We compare the two groups including stone-free rate (SFR), procedure time, anesthesia time, overall operative time, hospital stay, anesthesia failure, intraoperative pain, need for additional analgesia, cost, and complications.

RESULTS

The conversion rate in the TIUA group was 4.35% (1/23). SFR was 100% in both groups. Surgical waiting time and anesthesia time were longer in the SA group (P < 0.001). There were no statistical differences in operational time and intraoperative pain. Patients developed grade 0-1 ureteral injuries. Post-surgical time out of bed was noticeably faster in the TIUA group (P < 0.001). The post-operative complication rate including vomiting and back pain was lower in the TIUA group (P = 0.005).

CONCLUSION

TIUA had an equal surgical success rate and controlled patients' intraoperative pain as SA. It was superior in terms of TIUA's patient admission, waiting time for surgery, anesthesia time, post-operative time out of bed, low complications, and costs, especially for females.

Outcomes of loco-regional anaesthesia in ureteroscopy for stone disease: a systematic review

PURPOSE OF REVIEW

Routine ureteroscopy (URS) for stone disease is performed under a general anaesthesia. However, controversy exists on the role of loco-regional anaesthesia and the outcomes associated with it. Here we review the challenges, outcomes and complications of loco-regional anaesthesia for URS. A Cochrane style review was performed in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines to evaluate the outcomes of loco-reginal anaesthesia for URS in stone disease, including all English language articles from January 1980 and December 2019.

RECENT FINDINGS

Twenty-one studies (1843 procedures) with a mean age of 46 years and a male : female ratio of 1.2 : 1 underwent URS under loco-regional anaesthesia. The mean stone size was 9 mm (range:4-21 mm) and except five papers, all other papers included stones in the ureter of which the majority were in the distal ureter. The conversion to general anaesthesia was needed in 2.7% patients (range 1-21%) across studies, with a stone free rate of 48-100%. The complication rate varied from 1.4 to 36%. Although the intraoperative complications included ureteric injury (n = 21) or perforation (n = 4), the postoperative complications included fever (n = 37), urinary tract infection (n = 20), haematuria (n = 4), urosepsis (n = 4) and others (n = 7).

SUMMARY

The present systematic review shows that local anaesthetic URS is a potential alternative to general anaesthetic URS in carefully selected patients. Randomised controlled trials with subgroup analysis are required to further assess whether loco-regional anaesthesia URS is noninferior to general anaesthesia URS and might help determine if the former approach should become more widespread.

Anesthetic considerations for urologic surgeries

Urologic surgeries are widely performed, and the cases have increased owing to the fact that the elderly population is growing. The narrow and limited surgical space is a challenge in performing most urologic surgeries. Additionally, the elderly population is exposed to the risk of perioperative complications; therefore, a comprehensive understanding and approach are required to provide optimized anesthesia during surgery. We have searched the literature on anesthesia for urologic surgeries and summarized the anesthetic considerations for urologic surgeries.

Local Anesthetic Flexible Ureterorenoscopy in the Management of Urolithiasis

Introduction: Patients unfit for general anesthesia who present with renal tract pathology currently have limited options. Many of these patients present in the emergency setting with imperative reasons for intervention, including sepsis, renal failure, and pain. Conservative management and temporizing measures, such as percutaneous nephrostomy, are associated with significant morbidity. Ureterorenoscopy (URS) is a central component of the management of upper tract disease and is routinely performed under general anesthesia. We describe our institution's experience of URS using only local anesthetic (LA) lubricating gel per urethra. Methods: A single centre, retrospective analysis of 78 patients was performed for an 11 year period. Demographic data and Charlson comorbidity index scoring were collected for all patients. Outcomes, including stone-free rates, tolerability, and complications, were analyzed. Results: In total 58% of patients were men. Mean age was 68 and Charlson comorbidity index was 5.2. Indications for URS included pain (68%) and renal failure (15%). Totally 10% of patients previously had retrograde stenting because of sepsis. Median stone size was 8 mm. All patients were able to tolerate the procedure and none were abandoned because of pain. The overall stone-free rate was 82% after one procedure. The stone-free rate for mid and distal ureteral stones was 97%. Nineteen percent of patients were left with a ureteral stent after the procedure, with the remaining patients left totally tubeless. Median length of stay was 1 day. There were no complications above Clavien Grade 2. Conclusion: Urologists are increasingly faced with unfit patients presenting with urolithiasis. In the appropriately selected patient, LA flexible ureterorenoscopy is a feasible option with good outcomes. This approach is a useful addition to the armamentarium available to patients deemed unsuitable for general or regional anesthesia.

Office-based ureteral stent placement under local anesthesia for obstructing stones is safe and efficacious

OBJECTIVE

To evaluate the outcomes of urgent ureteral stent placement under local anesthesia (LA) with those placed under general anesthesia (GA) for obstructing stones.

MATERIALS AND METHODS

After institutional review board approval, ureteral stents placed from January 2007 to July 2011 at our institution were reviewed. Only primary stent placement for obstructing renal or ureteral calculi was included in the present analysis. Data were evaluated for 2 groups: GA and LA. The primary outcomes were demographics, interval from presentation to stent insertion, interval from stent insertion to stone removal, success and complication rates, and secondary outcomes were costs per encounter.

RESULTS

A total of 119 primary stent insertion procedures in 110 unique patients were assessed; 73 (GA) and 46 (LA). No differences were found in the mean age or sex between the 2 groups. Both GA and LA groups were stented within 12 hours of presentation, at 58% and 54%, respectively (P = .69); and the interval from stent insertion to stone removal was similar in both groups (mean 33 days and 35 days in the GA and LA groups, respectively, P = .79). No significant differences were found in the failure to place the stent between the GA and LA groups (1.3% vs 8.7%, respectively, P = .07). No complications related to stent placement occurred in either group. The average cost per encounter was nearly 4 times greater in the GA group.

CONCLUSION

Urgent ureteral stent placement for obstructing stones can be safely and effectively performed under LA in the office. Although avoiding GA and reducing costs, this approach did not prolong the interval to definitive stone management.

Ureteroscopic removal of mildly migrated stents using local anesthesia only

PURPOSE

In the outpatient office setting we evaluated the feasibility and efficacy of ureteroscopic removal of upward migrated ureteral stents using local or no anesthesia.

MATERIALS AND METHODS

Prospectively 37 patients with mild upward stent migration underwent ureteroscopic stent removal under local or no anesthesia. Stent migration was always below the pelvic brim. It was diagnosed by plain x-ray of the kidneys, ureters and bladder, and flexible cystoscopy. Semirigid ureteroscopy was performed in the office outpatient setting. After each procedure patients graded the discomfort and/or pain level experienced by completing 2 separate 5-scale visual analog pain scores, including 1 for flexible cystoscopy and 1 for the ureteroscopic procedure. Pain scores were compared between the 2 procedures.

RESULTS

Stent removal was successful in 34 of 37 patients (91.9%). Successful procedures were never interrupted due to pain intolerance. No complications occurred. The mean visual analog pain score for ureteroscopic stent removal was 1.73 and it was similar in men and women (p = 0.199). The mean visual analog pain score for flexible cystoscopy was 1.27. This procedure was significantly more painful in men than in women (p = 0.018). Ureteroscopic stent removal was more painful than flexible cystoscopy overall and in women (each p <0.01) but not in men (p = 0.3). All patients were discharged home within 1 hour after the procedure and no patient required hospital admission or a new hospital visit.

CONCLUSIONS

Ureteroscopic removal of a migrated stent using local anesthesia is effective, safe and tolerable in select patients. Preventing the complications and costs associated with general or spinal anesthesia makes this option appealing to patients and it should be offered when possible.

Initial Experience with a Prototype Ureteroscope

BACKGROUND AND PURPOSE

We report our initial experience with a prototype ureteroscope having the smallest tip diameter and shaft with an offset eyepiece for the treatment of ureteral stones.

PATIENTS AND METHODS

A series of 21 male and 4 female patients between the ages of 1.5 and 57 years underwent treatment with the new ureteroscope for stones in the lower (24) and middle (1) ureter. All four of the children were boys. All patients were operated on by a single urologist. Patient sex, age, side, location and size of stone, type of anesthesia, requirement for a guidewire, use of stent, requirement for ureteral dilatation, operative time, type of intracorporeal lithotripsy used if any, type of stone-grasping device used, success rate, length of hospital stay, and complications were recorded.

RESULTS

None of the patients required ureteral dilatation, and a guidewire was used in only three patients. Eight patients were operated on with instillation of 2% lidocaine gel alone, while another five patients required intravenous pentazocine and midazolam. Eight patients were operated on with monitored anesthesia care under propofol and one under ketamine. Three patients required general anesthesia. A double-J stent was not required in 15 patients. The success rate was 100%, and complications were minor.

CONCLUSION

The new ureteroscope can treat the majority of lower-ureteral stones of up to 1.2 cm even in male patients under lidocaine gel with or without intravenous sedation or monitored anesthesia care. These patients can be treated as day-care cases. None of the patients required ureteral dilatation, and stent is now being omitted in most patients. All children were treated in one session.

How painful are shockwave lithotripsy and endoscopic procedures performed at outpatient urology clinics?

Our aim was to investigate the subjective pain felt by patients during shockwave lithotripsy (SWL) and endoscopic procedures such as cystoscopy, retrograde ureteral stenting, retrograde pyelography (RGP), and ureteroscopic lithotripsy performed in an outpatient clinic, and to identify how severe pain during such procedures is. We estimated subjective pain in 984 patients after SWL (186), cystoscopy (489), retrograde ureteral stenting (127), RGP (97), and ureteroscopic lithotripsy (85) performed by a single expert in an outpatient clinic using a prospective questionnaire with a ten point visual analog scale between January 2001 and December 2003. There was no premedication in any procedure except ureteroscopic lithotripsy for which an intramuscular injection of analgesics (pethidine HCl 50 mg) was used. The pain scale score in SWL was 6.62+/-2.27, the highest among the procedures (P<0.05). Pain scores for endoscopies were 4.48+/-2.07 in retrograde ureteral stenting, 3.81+/-2.06 in ureteroscopic lithotripsy, 3.72+/-1.75 in RGP, and 3.08+/-1.95 in cystoscopy. In this study, we observed that patients feel most pain in SWL without anesthesia, and that pain during ureteroscopic lithotripsy under local anesthesia is not high, compared with other endoscopic procedures.

Safety and Efficacy of Ureteroscopic Lithotripsy for Ureteral Calculi Under Sedoanalgesia – A Prospective Study

OBJECTIVE

To establish the safety and efficacy of ureteroscopic lithotripsy (URSL) under sedoanalgesia.

PATIENTS AND METHODS

This study was conducted at Department of Urology (Banaras Hindu University, India) among 124 patients with ureteral stones, between July 2000 and August 2003. Majority of the patients (59.68%) presented with lower ureteric calculi, 24.19% presented with upper ureteric calculi and 16.13% had middle ureteric calculi. All patients were given injection diclofenac sodium (75 mg) promethazine hydrochloride (12.5 mg) deep intramuscular 30 minutes the before procedure. Injection midazolam 0.03 mg/kg body weight slowly given intravenously immediately before the procedure for achieving sedation. Injection fentanyl 50 mcg intravenously given slowly just before introducing the ureteroscope into ureter for achieving intravenous analgesia. Patients were observed for few hours after completion of procedure and oral questions were asked as per proforma, which included tolerance, intensity of pain and percentage of pain experienced by the patients. Patients were discharged thereafter.

RESULTS

87.10% of patients opined that the procedure was acceptable. Only 4.84% opined this procedure was painful. According to present pain intensity score (PPI) in this study 79.03 patients experienced only mild pain, 11.29% cases rated procedure as discomforting, 6.45 rated procedure as distressing and only 3.23% rated as horrible procedure. As per visual analogue scale for assessment of pain 80.65 of cases rated only 20% pain score (in a scale of 0-100). 9.68% cases rated 30% and 6.45% rated 50%. Only two patients in middle ureteric group rated 100% pain. Overall success rate in fragmenting stone was 91.94, where as for lower ureteric calculi it was 97.30%; for upper and, middle ureteric calculi it was 86.66% and 80%, respectively.

CONCLUSION

Ureteroscopic lithotripsy can be performed on day care basis under sedoanalgesia which is fairly tolerated by the patients with unremarkable complications and difficulty.

Ureteroscopic Lithotripsy under Local Anesthesia: Analysis of the Effectiveness and Patient Tolerability

OBJECTIVES

We tried to evaluate the feasibility and effectiveness of ureteroscopic lithotripsy under local anesthesia.

METHODS

We evaluated the results of ureteroscopic lithotripsy under local anesthesia performed on 200 patients (male 91; female 109). We compared the pain perception during local ureteroscopic procedure to that of cystoscopy using a visual analogue pain scale recorded by the patient.

RESULTS

The overall success rate was 93% (185/200). The success rates of the upper, mid and lower ureteral calculi were 83% (5/6), 78% (14/18), and 94% (166/176), respectively. The success rate was 94% (166/176) in calculi less than 10 mm, and 86% (30/35) in those more than 10 mm. There were 5 cases (3%) of complications: ureteral injury (1), pyelonephritis (2), and ureteral stricture (2). Although the mean pain scale score was higher in the ureteroscopy group (3.36+/-1.75) than in the cystoscopy group (3.13+/-1.92), the difference between the two groups was not statistically significant (p>0.05). Most of the patients tolerated pain during the procedure and only two patients required general anesthesia. Postoperative pain was also tolerable in most patients and only 8 (4%) patients required additional analgesics after the procedure.

CONCLUSION

As the effectiveness and morbidity of ureteroscopic lithotripsy under local anesthesia are comparable to those of many other previous reports and as most of the patients could tolerate the pain of the procedure, we suggest that ureteroscopic lithotripsy can be performed effectively and safely under local anesthesia.

[Ureteroscopy under intravenous analgesia with remifentanil]

In a prospective study, from September 2000 to September 2001, all ureteroscopies ( n=140) were performed under local and intravenous patient controlled analgesia using continuous infusion of remifentanil (Ultiva). The dosage of 0.15 micro g/kg/min was adapted to changing intraoperative pain (range 0.08-0.30 micro g/kg/min). Preoperative sedation with midazolam 2 mg was given 5 min prior to ureteroscopy. The efficacy of monitored anesthesia care ("Big MAC") was quantified by the patient using a visual analogue pain scale. A total of 97.1% (136/140) of the procedures were performed and finished under remifentanil. Only four male patients underwent conversion to general anesthesia due to insufficient analgesia. All but one patient would choose remifentanil again for first line anesthesia. Significant differences in pain scale values were noticed for male/female patients and ureteroscopies above/below the iliac vessel crossing. Side effects were rare being mainly hypoxic events (pO(2)<90% in 5.1%). Indication, intraoperative procedure, average surgery time (24 min), complications and primary success rate (96.6/90/63.3% stone free for distal/mid/proximal ureter, respectively) did not differ from the control group under general anesthesia. Ureteroscopies with remifentanil are safe, universally applicable because of refifentanil's organ independent esterase metabolism and as effective as general anesthesia. There is no need for PACU stay for patients due to the ultra-short drug half-life, and therefore remifentanil is cost effective and perfect in an outpatient setting.

Ureteroscopy: anesthetic considerations

Ureterorenoscopy (URS) is a vital procedure in the armamentarium of the modern-day urologist for the management of ureteral and renal pathology. With advances in ureteroscopic design and the introduction of short-acting anesthetics, URS can now be performed efficiently with high patient satisfaction and minimal posteroperative recovery time. Recently, URS under local anesthesia, with or without sedation, has become a viable option for a high percentage of correctly selected patients. For those patients who then require deeper sedation or general anesthesia, anesthesia can be induced quickly with the new agents such as remifentanil, propofol, and desflurane, without a prolonged postoperative recovery period.

Complicaciones de la uretero-renoscopia

INTRODUCTION

Since its clinical introduction ureteroscopy (URS) has experienced an impressive development due to the technical improvements of new and smaller urological armamentarium. Currently, ureteroscopy is a worldwide procedure with a varied number of diagnostic and therapeutic possibilities. However, the technique has complications.

MATERIAL AND METHODS

We analyse the complications of URS in a series of 4.645 ureteroscopic procedures performed from january 1990 to december 2001, 2972 (64%) female and 1673 (36) male. The objectives of URS were diagnostic (haematuria) and therapeutic (ureteral stones, tumors, strictures and placement of stents).

RESULTS

Fever was the most frequent complication (11.7%), with sepsis in 15 patients. Another complications were: ureteral perforation (1.2%), ureteral avulsion (0.06%), renal injury (0.04%), extrusion (0.4%) and uretero-iliac fistulae (0.02%). The most common treatment was conservative with endourological approach.

CONCLUSION

Carefully performed ureteroscopy is a superb tool for the urologist either for diagnostic or therapeutic purposes with a low ratio of complications. The majority of these complications can be solved with conservative management.

Ureteroscopy: current practice and long-term complications

PURPOSE

We compared a current cohort of patients who underwent ureteroscopy to a cohort from the early 1980s to determine changes in success, indications and long-term complications of the procedure.

MATERIALS AND METHODS

A chart review was performed of 194 patients who underwent 209 ureteroscopic procedures at our institution during 1992. This group was then statistically compared to 317 patients who underwent 346 ureteroscopies between 1982 and 1985.

RESULTS

The current indications for ureteroscopy were calculus extraction (67% of the cases), diagnosis (28%) and stent manipulation (5%). These indications differed from those of the early series, in which 84% of all ureteroscopies were performed for calculus extraction and 16% for diagnosis. Overall ureteroscopic success rate increased from 86 to 96% (p < 0.001). Success of stone extraction improved from 89 to 95% (p = 0.08, distal success rate 95 to 97% and proximal success rate 72 to 77%). Success of diagnostic inspections increased from 73 to 98% (p < 0.001). In the early series failure was usually due to inability to traverse the ureter (54% of the cases), while currently failure is due almost exclusively to impassable ureteral strictures (63%). The overall complication rate decreased from 20 to 12% (p = 0.01) and the rate of significant complications decreased from 6.6 to 1.5% (p < 0.05). Clinical followup (mean 36 months) for all patients and radiological followup (mean 9.8 months) for 67% of eligible patients detected only 1 ureteral stricture. The remaining patients were asymptomatic after the ureteroscopic procedure.

CONCLUSIONS

Improvements in ureteroscope design, accessories and technique have led to a significant increase in the success of diagnostic and therapeutic ureteroscopy while decreasing morbidity. Outpatient ureteroscopic stone extraction, particularly for distal ureteral calculi, is almost uniformly successful with low morbidity. The long-term complication rate of ureteroscopy is 0.5%.

Is general anaesthesia necessary for URS in women?

A total of 65 women with ureteral stone who underwent ureteroscopy were divided randomly into two groups between April 1993 and March 1994. URS was performed under general anaesthesia in the first group (35 patients), and under local anaesthesia with sedation analgesia in the second group (30 patients). Only 2 patients of the second group did not tolerate the operation. The success rate was 88% in the first group and 83.3% in the second. There was no significant difference between the two groups. Since URS under local anaesthesia is time-saving, cost-effective, and highly tolerable in women, it is a good choice for ureteral stones.