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506 Outcomes of percutaneous nephrolithotomy under combined spinal-epidural anesthesia: A single centre experience
506
Outcomes of percutaneous nephrolithotomy under combined spinal-epidural anesthesia: A single centre experience Eur Urol Suppl 2014;13;e506
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Imperatore V. 1 , Creta M. 1 , Di Meo S. 1 , Buonopane R.1 , Maio L. 2 , Scibelli G.2 , Imbimbo C.3 , Longo N.3 , Fusco F.3 , Mirone V. 3 1 Buon
Consiglio Fatebenefratelli Hospital, Dept. of Urology, Naples, Italy, 2 Buon Consiglio Fatebenefratelli Hospital, Dept. of
Anesthesiology, Naples, Italy, 3 University Federico II of Naples, Dept. of Urology, Naples, Italy INTRODUCTION & OBJECTIVES: Percutaneous nephrolithotomy (PCNL) is commonly performed under general anesthesia. Combined spinal-epidural anesthesia (CSEA) has been reported to allow easier and safer tilting of the patients from the lithotomy to the prone position, patient cooperation during surgery, and better postoperative pain relief. Herein we analyzed the outcomes of PCNL under CSEA in a single centre. MATERIAL & METHODS: The records of 210 patients who underwent PCNL under CSEA were prospectively collected and analyzed. A preload of lactated Ringer’s solution was administered, CSEA was performed using 7.5 mg of levobupivacaine and 25 mcg fentanyl through the L1–L2 space, then an epidural catheter was inserted to allow an additional dose of levobupivacaine during the operation and postoperative pain control through a patient-controlled epidural analgesia (PCEA) infusion pump with levobupivacaine 0.125% (infusion rare: 12 mL/h with bolus on demand of 5mL). An ureteral catheter was positioned in the lithotomy position and all the patients were tilted to the prone position. The nephrostomy tract was dilated with Alken metal dilators until 22 Fr. A 20.8 French nephroscope was used in all cases. Lithotripsy was achieved through ultrasonic energy. A 18 French nephrostomy tube was left in place at the end of the procedure. The epidural catheter was removed after 48 hours. RESULTS: Results are depicted in Table 1. Continuous variables are expressed as mean (range) and categorical variables as number of events (percentage). There were no significant intraoperative and post-operative complications related to the anesthesia. All cinically relevant intraoperative bleedings were promptly recognized thanks to patients' cohoperation. None of the patients required conversion to general anesthesia. None of patients required additional oral or intravenous analgesics.
Table 1: Study results Age (years)
56.7 (45-72)
Male : Female ratio
112:98
Left : Right ratio
140:70
Stone size (cm)
3.5 (2.7-4.1)
Stone position Upper calyceal
0 (0)
Middle calyceal
11(5.2)
Lower calyceal
80 (38.0)
Pelvic
101(48.0)
Partial staghorn
10 (4.7)
Staghorn
8 (3.8)
American Society of Anesthesiologists score I/II/III
8/170/32
Body Mass Index (kg/cm2 )
26.4 (23-28)
Success of CSEA, (adequate/inadequate/failure)
205 (97.6)/5(2.3)/0(0)
Patients requiring supplementary epidural doses during operation 5 (2.3) Operative time (minutes)
70.3 (60-130)
Permanence of ureteral catheter (days)
1.2 (1-2)
Permanence of nephrostomy tube (days)
2.5 (2-3)
Patients requiring additional PCEA boluses
12 (5.7)
Additional PCEA boluses per patient
3.2 (1-4)
Post-operative hospital stay (day)
2.8 (2-3)
Success Stone free
175 (83.3)
Fragments < 4 mm
30 (14.2)
Fragments > 4 mm
5 (2.3)
Post operative Visual Analogue Scale (0-10) score 1h
3.4 (1-4)
4h
3.2 (0-4)
12 h
2.4 (0-3)
24 h
2.6 (0-3)
48 h
1.6 (0-3)
72 h
1.2 (0-3)
Complications according to modified Clavien Classification System – Grade, Type Intraoperative
II Bleeding
11(5.2)
Early post operative (within 30 days) I Fever
2 (0.9)
I Urinary leakage
4 (1.9)
II Urinary tract infections
13 (6.1)
I Pain
12 (5.7)
I Nausea and vomiting
7 (3.3)
II Bleeding
5 (2.3)
Total patients with complications
19 (9)
CONCLUSIONS: PCNL under CSEA is feasible, safe and well tolerated. PCEA allows optimal post-operative pain control thus avoiding the administration of anti-inflammatory drugs that may interfere with the coagulation process.
Outcomes of percutaneous nephrolithotomy under combined spinal-epidural anesthesia: A single centre experience Eur Urol Suppl 2014;13;e506
Print! Print!
Imperatore V. 1 , Creta M. 1 , Di Meo S. 1 , Buonopane R.1 , Maio L. 2 , Scibelli G.2 , Imbimbo C.3 , Longo N.3 , Fusco F.3 , Mirone V. 3 1 Buon
Consiglio Fatebenefratelli Hospital, Dept. of Urology, Naples, Italy, 2 Buon Consiglio Fatebenefratelli Hospital, Dept. of
Anesthesiology, Naples, Italy, 3 University Federico II of Naples, Dept. of Urology, Naples, Italy INTRODUCTION & OBJECTIVES: Percutaneous nephrolithotomy (PCNL) is commonly performed under general anesthesia. Combined spinal-epidural anesthesia (CSEA) has been reported to allow easier and safer tilting of the patients from the lithotomy to the prone position, patient cooperation during surgery, and better postoperative pain relief. Herein we analyzed the outcomes of PCNL under CSEA in a single centre. MATERIAL & METHODS: The records of 210 patients who underwent PCNL under CSEA were prospectively collected and analyzed. A preload of lactated Ringer’s solution was administered, CSEA was performed using 7.5 mg of levobupivacaine and 25 mcg fentanyl through the L1–L2 space, then an epidural catheter was inserted to allow an additional dose of levobupivacaine during the operation and postoperative pain control through a patient-controlled epidural analgesia (PCEA) infusion pump with levobupivacaine 0.125% (infusion rare: 12 mL/h with bolus on demand of 5mL). An ureteral catheter was positioned in the lithotomy position and all the patients were tilted to the prone position. The nephrostomy tract was dilated with Alken metal dilators until 22 Fr. A 20.8 French nephroscope was used in all cases. Lithotripsy was achieved through ultrasonic energy. A 18 French nephrostomy tube was left in place at the end of the procedure. The epidural catheter was removed after 48 hours. RESULTS: Results are depicted in Table 1. Continuous variables are expressed as mean (range) and categorical variables as number of events (percentage). There were no significant intraoperative and post-operative complications related to the anesthesia. All cinically relevant intraoperative bleedings were promptly recognized thanks to patients' cohoperation. None of the patients required conversion to general anesthesia. None of patients required additional oral or intravenous analgesics.
Table 1: Study results Age (years)
56.7 (45-72)
Male : Female ratio
112:98
Left : Right ratio
140:70
Stone size (cm)
3.5 (2.7-4.1)
Stone position Upper calyceal
0 (0)
Middle calyceal
11(5.2)
Lower calyceal
80 (38.0)
Pelvic
101(48.0)
Partial staghorn
10 (4.7)
Staghorn
8 (3.8)
American Society of Anesthesiologists score I/II/III
8/170/32
Body Mass Index (kg/cm2 )
26.4 (23-28)
Success of CSEA, (adequate/inadequate/failure)
205 (97.6)/5(2.3)/0(0)
Patients requiring supplementary epidural doses during operation 5 (2.3) Operative time (minutes)
70.3 (60-130)
Permanence of ureteral catheter (days)
1.2 (1-2)
Permanence of nephrostomy tube (days)
2.5 (2-3)
Patients requiring additional PCEA boluses
12 (5.7)
Additional PCEA boluses per patient
3.2 (1-4)
Post-operative hospital stay (day)
2.8 (2-3)
Success Stone free
175 (83.3)
Fragments < 4 mm
30 (14.2)
Fragments > 4 mm
5 (2.3)
Post operative Visual Analogue Scale (0-10) score 1h
3.4 (1-4)
4h
3.2 (0-4)
12 h
2.4 (0-3)
24 h
2.6 (0-3)
48 h
1.6 (0-3)
72 h
1.2 (0-3)
Complications according to modified Clavien Classification System – Grade, Type Intraoperative
II Bleeding
11(5.2)
Early post operative (within 30 days) I Fever
2 (0.9)
I Urinary leakage
4 (1.9)
II Urinary tract infections
13 (6.1)
I Pain
12 (5.7)
I Nausea and vomiting
7 (3.3)
II Bleeding
5 (2.3)
Total patients with complications
19 (9)
CONCLUSIONS: PCNL under CSEA is feasible, safe and well tolerated. PCEA allows optimal post-operative pain control thus avoiding the administration of anti-inflammatory drugs that may interfere with the coagulation process.