Presented by: Kunal Jain MD, Urology resident (PGY-4)
Section of Urology, Department of Surgery, University of Manitoba

Introduction

Administration of general or spinal anesthesia is associated with anesthetic-related complications, long operating room wait times, and high costs. The use of intravenous (IV) conscious sedation and/or local anesthesia is an emerging alternative for a myriad of urologic procedures. Our objective was to prospectively evaluate patient-reported and surgical outcomes of patients undergoing urologic procedures with conscious sedation and/or local anesthesia.

Materials

Patients were enrolled from June 2021 to August 2021. All procedures were completed using fentanyl, midazolam or both and patient and procedural data were recorded upon completion. Patients were telephoned 4-6 weeks after their procedure to complete a standardized patient tolerability questionnaire. A multivariable adjusted logistic regression analysis was performed to evaluate whether a patient would opt for conscious sedation again as opposed to general/spinal anesthesia.

Results

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A total of 196 procedures were performed: 27 (13.8%) for rigid URS, 34 (17.3%) for flexible URS, 57 (29.1%) for stent insertion or exchange, 14 (7.1%) for scrotal or penile surgery, 36 (18.4%) for urethral dilation, and 28 (14.3%) for advanced cystoscopic procedures. There was an overall success rate of 98.5% and 0% intraoperative complication rate. The stent insertion/exchange cohort was the only group without a 100% success rate due to one patient’s inability to tolerate pain. For those who underwent management of urolithiasis (n = 34), 2 were in the bladder, 15 in the lower ureter, 2 in the mid ureter, 7 in the upper ureter, 6 in the renal pelvis and 2 with multiple calculi. Mean stone size was 5.9 mm (range: 3-15 mm). In our subgroup stone analysis, there was no difference in tolerability for rigid or flexible URS, stone location, stone size, or procedure side. At 4-6 weeks follow-up, 85.6% of patients reported they would opt for conscious sedation as opposed to general/spinal anesthesia. Predictors of opting for conscious sedation were older age (OR: 1.049; p = 0.017) and surgeon perceived level of patient tolerability (OR: 2.124; p < 0.001, scored 1-10). No statistically significant differences were found with respect to BMI, gender, prior conscious sedation experience, procedure, IV drug administration, or length of procedure.

Conclusion

Physician-directed, nursing-administered IV conscious sedation is a viable alternative for many urologic procedures, especially endourologic procedures, and has minimal risk of perioperative complications.

Funding

None.

Co-Authors

Kapilan Panchendrabose, BSc, MSc
Max Rady College of Medicine, University of Manitoba

Andrew Pierce, BSc
Max Rady College of Medicine, University of Manitoba

Dhiraj S Bal, BSc
Max Rady College of Medicine, University of Manitoba

Naomi T Gebru,
Department of Microbiology, University of Manitoba

Raman Grewal,
Department of Microbiology, University of Manitoba

Kunal Jain, MD
Section of Urology, Department of Surgery, University of Manitoba

Micah Grubert Van Iderstine, BSc
Max Rady College of Medicine, University of Manitoba

Ruben Blachman-Braun, MD
Department of Urology, University of Miami

Gregory W Hosier, MD, MSc, FRCSC
Section of Urology, Department of Surgery, University of Manitoba

M Eric J Saltel, MD, FRCSC
Section of Urology, Department of Surgery, University of Manitoba

Brian GT Peters, MD, FRCSC
Section of Urology, Department of Surgery, University of Manitoba

Robert J Bard, MD, FRCSC
Section of Urology, Department of Surgery, University of Manitoba

Jeffrey Saranchuk, MD, FRCSC
Section of Urology, Department of Surgery, University of Manitoba

Premal Patel, MD, FRCSC
Section of Urology, Department of Surgery, University of Manitoba