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Transurethral resection of prostate with intravenous sedation
TRANSURETHRAL
RESECTION OF PROSTATE
WITH INTRAVENOUS SEDATION
JOHN
R. LICHTWARDT,
SITY GIRGIS,
M.D.
M.D.
From the Department Royal Oak, Michigan
of Urology,
William
Beaumont
Hospital,
ABSTRACTTransurethral resection of the prostate with intravenous sedation was performed with satisfactory results in 65 selected elderly patients, many of whom for medical reasons were not candidates for surgery under anesthesia.
Transurethral resection of the prostate is ideally performed under spinal anesthesia. In some cases medical conditions render the patient unsuited for spinal or other forms of anesthesia. For the patient with significant obstructive symptoms the alternative to surgery may be permanent catheter drainage, intermittent catheterization, or merely observation, all of which may be inconvenient and detrimental to the patient. In selected cases, transurethral resection of the prostate under intravenous sedation is possible in patients who are poor anesthetic risks. Since 1972 we have performed transurethral resections of the prostate under intravenous sedation in 65 selected patients. In all cases intravenous diazepam (Valium) was used, and in all but 10 cases this was supplemented with intravenous fentanyl (Sublimase). In most patients preoperative medication was administered, and at surgery lidocaine liquid or gel was routinely instilled into the urethra prior to the instrumentation. The use of intravenous sedation in our series was initially confined to patients suffering from medical problems and deemed unsuitable for surgery with anesthesia. More recently we have used intravenous sedation in selected prostatic resections in patients who were not anesthetic risks. In all cases the patients were elderly and
112
were obstructed by small to moderate-sized prostates which could be rapidly resected to provide an adequate urinary channel. Benign prostatic hypertrophy was encountered in 57 patients and adenocarcinoma in 8 patients. The amount of prostatic tissue resected varied from 1 to 27 Gm, and the time of resection varied from eight to forty minutes. During surgery divided doses of intravenous diazepam were administered totalling 1.25 mg to 12.5 mg except in 1 case in which 25 mg were used. In 55 cases fentanyl was used in conjunction with diazepam in amounts of 0.025 mg (0.5 ml) to 0.2 mg (4 ml) administered intravenously in increments of 0.5 to 1 ml. In most cases 1 to 2 ml were used. In 3 cases ketamine was used in addition to diazepam and fentanyl in doses up to 10 mg. Most patients experienced some discomfort during surgery, but rarely was it marked or of prolonged duration. It was evident that when the anesthesiologist or anesthetist was thoroughly familiar with this analgesic technique and cognizant of the fact that total lack of discomfort is usually not possible nor desirable throughout the operation, that he or she could titrate the intravenous medication with the patient’s degree of alertness and discomfort, thereby making the procedure tolerable for the patient.
UHOLOGY
’
.4UGUST
1985
)I VOLUME
XXVI,
NUMBEH
9
Under the ideal level of sedation the patient is drowsy but arousable and usually oriented, and while feeling some discomfort he is not actively complaining of pain nor moving. Some tensing of the leg muscles is common especially with use of the cutting current which we limit to 40 on the Bovie unit. There is less response and discomfort to the coagulating current. Bladder distention may be a major cause of discomfort to the patient and should be avoided. During surgery and postoperatively there was no significant or alarming change in the vital signs of any patient in our series. No patient required resuscitative measures nor medications to counteract the intravenous sedative agents. Most patients moved themselves from the operating table to the stretcher at the conclusion of the resection and were usually alert and talkative before leaving the recovery room. Varying degrees of amnesia were present postoperatively in the majority of patients, and of those questioned postoperatively most were pleased and believed that the surgery was accomplished without excessive discomfort.
I’ROLOGY
AUGUST 1985
:
VOLUME XXVI, NUMBER 2
Although
some
patients
had
limited
resec-
tions, all were able to void satisfactorily postoperatively. Only 1 patient required a repeat resection fifteen months after the initial resection. There were no intraoperative nor postoperative deaths. No patients required transfusion. Postoperative morbidity was limited to 1 patient who had delayed bleeding treated with an indwelling catheter. Summary The use of intravenous sedation in selected cases of transurethral resection of the prostate appears to be safe even in patients who for medical reasons are not candidates for anesthesia. The gentle and rapid performance of the surgery by the urologist and the adept administration of the intravenous agents by an anesthesiologist or anesthetist familiar with this analgesic modality combine to make this technique safe and well tolerated by the patient. Royal Oak, Michigan 48072 (DR. LICHTWARDT)
113
RESECTION OF PROSTATE
WITH INTRAVENOUS SEDATION
JOHN
R. LICHTWARDT,
SITY GIRGIS,
M.D.
M.D.
From the Department Royal Oak, Michigan
of Urology,
William
Beaumont
Hospital,
ABSTRACTTransurethral resection of the prostate with intravenous sedation was performed with satisfactory results in 65 selected elderly patients, many of whom for medical reasons were not candidates for surgery under anesthesia.
Transurethral resection of the prostate is ideally performed under spinal anesthesia. In some cases medical conditions render the patient unsuited for spinal or other forms of anesthesia. For the patient with significant obstructive symptoms the alternative to surgery may be permanent catheter drainage, intermittent catheterization, or merely observation, all of which may be inconvenient and detrimental to the patient. In selected cases, transurethral resection of the prostate under intravenous sedation is possible in patients who are poor anesthetic risks. Since 1972 we have performed transurethral resections of the prostate under intravenous sedation in 65 selected patients. In all cases intravenous diazepam (Valium) was used, and in all but 10 cases this was supplemented with intravenous fentanyl (Sublimase). In most patients preoperative medication was administered, and at surgery lidocaine liquid or gel was routinely instilled into the urethra prior to the instrumentation. The use of intravenous sedation in our series was initially confined to patients suffering from medical problems and deemed unsuitable for surgery with anesthesia. More recently we have used intravenous sedation in selected prostatic resections in patients who were not anesthetic risks. In all cases the patients were elderly and
112
were obstructed by small to moderate-sized prostates which could be rapidly resected to provide an adequate urinary channel. Benign prostatic hypertrophy was encountered in 57 patients and adenocarcinoma in 8 patients. The amount of prostatic tissue resected varied from 1 to 27 Gm, and the time of resection varied from eight to forty minutes. During surgery divided doses of intravenous diazepam were administered totalling 1.25 mg to 12.5 mg except in 1 case in which 25 mg were used. In 55 cases fentanyl was used in conjunction with diazepam in amounts of 0.025 mg (0.5 ml) to 0.2 mg (4 ml) administered intravenously in increments of 0.5 to 1 ml. In most cases 1 to 2 ml were used. In 3 cases ketamine was used in addition to diazepam and fentanyl in doses up to 10 mg. Most patients experienced some discomfort during surgery, but rarely was it marked or of prolonged duration. It was evident that when the anesthesiologist or anesthetist was thoroughly familiar with this analgesic technique and cognizant of the fact that total lack of discomfort is usually not possible nor desirable throughout the operation, that he or she could titrate the intravenous medication with the patient’s degree of alertness and discomfort, thereby making the procedure tolerable for the patient.
UHOLOGY
’
.4UGUST
1985
)I VOLUME
XXVI,
NUMBEH
9
Under the ideal level of sedation the patient is drowsy but arousable and usually oriented, and while feeling some discomfort he is not actively complaining of pain nor moving. Some tensing of the leg muscles is common especially with use of the cutting current which we limit to 40 on the Bovie unit. There is less response and discomfort to the coagulating current. Bladder distention may be a major cause of discomfort to the patient and should be avoided. During surgery and postoperatively there was no significant or alarming change in the vital signs of any patient in our series. No patient required resuscitative measures nor medications to counteract the intravenous sedative agents. Most patients moved themselves from the operating table to the stretcher at the conclusion of the resection and were usually alert and talkative before leaving the recovery room. Varying degrees of amnesia were present postoperatively in the majority of patients, and of those questioned postoperatively most were pleased and believed that the surgery was accomplished without excessive discomfort.
I’ROLOGY
AUGUST 1985
:
VOLUME XXVI, NUMBER 2
Although
some
patients
had
limited
resec-
tions, all were able to void satisfactorily postoperatively. Only 1 patient required a repeat resection fifteen months after the initial resection. There were no intraoperative nor postoperative deaths. No patients required transfusion. Postoperative morbidity was limited to 1 patient who had delayed bleeding treated with an indwelling catheter. Summary The use of intravenous sedation in selected cases of transurethral resection of the prostate appears to be safe even in patients who for medical reasons are not candidates for anesthesia. The gentle and rapid performance of the surgery by the urologist and the adept administration of the intravenous agents by an anesthesiologist or anesthetist familiar with this analgesic modality combine to make this technique safe and well tolerated by the patient. Royal Oak, Michigan 48072 (DR. LICHTWARDT)
113