Patients Favor Conscious Sedation for Urologic Procedures

Neil Osterweil

July 01, 2022

AMSTERDAM — Many urologic procedures can be safely performed with the use of conscious sedation rather than general anesthesia, and both clinicians and their patients say they prefer the lighter touch.

That's according to Canadian researchers who followed patients undergoing various endourologic, ureteric, urethral, or advanced cystoscopic procedures. Most patients said that they if had to repeat the procedure, they would still opt to be awake but sedated rather than asleep, according to Kapilan Panchendrabose, MSc, a medical student from the University of Manitoba in Winnipeg, Manitoba, Canada.

"The current standard for performing most urologic procedures is to administer general or spinal anesthesia to the patient," Panchendrabose reported at the European Association of Urology (EAU) 2022 Annual Meeting. "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 urologic procedures, and it has been used for many years here in our center."

Out of One, Many

Researchers at the University of Manitoba previously showed that for the treatment of ureteric calculi, distal ureteroscopy could be safely performed under physician-directed, conscious sedation delivered intravenously by a nurse. Since then, they have expanded the technique to include other advanced urologic procedures.

To see whether, as they hypothesized, patients under conscious sedation would tolerate the procedure and prefer it to general anesthesia for later surgeries, they conducted a prospective, nonrandomized cohort study of all patients who underwent urologic procedures under conscious sedation at their center from June through August 2021.

The procedures included rigid and flexible ureteroscopy, ureteric stent insertions/exchanges, scrotal/penile procedures (hydroceles, testicular biopsies, etc), urethral dilations, and advanced cystoscopic procedures, including bladder biopsies and botox therapy.

All patients underwent sedation with fentanyl, midazolam, or both agents.

Four to six weeks after the procedure, the patients were telephoned and were asked to complete a standardized tolerability questionnaire.

In all, 196 procedures with patients under conscious sedation 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 a question as to whether they would choose conscious sedation again if they had a repeat procedure.

Significant predictors of choosing conscious sedation over general anesthesia were older age (odds ratio, 1.049; P = .017) and the surgeon's perception, on a score of 1 to 10, of the perceived level of tolerability for patients.

In multivariate analysis, neither body mass index, sex, prior conscious sedation experience, Charlson comorbidity index, procedure type, drug type, nor time of the procedure were predictive of anesthesia choice.

"IV conscious sedation is a viable alternative for the majority of advanced urologic procedures. Careful patient selection is paramount to ensure a successful procedure," Panchrendabose said.

He acknowledged that the study was limited by selection bias, because surgeons recommended it to patients whom they considered to be suitable candidates for less intensive anesthesia.

I'll Take the Local

A urologist who was not involved in the study told Medscape Medical News that he prefers to use local anesthesia plus nitrous oxide to help patients relax during the procedure, rather than conscious sedation.

"You don't need to sedate patients or use anxiolytics or anything like that, and therefore you can satisfy the premise we're looking for, which is safety. It makes the process of coming in, undergoing a procedure, and coming out really unstressful and uneventful," said Fernando Bianco, MD, from the Miami Lakes Surgery Center in Florida.

For procedures such as transperineal fusion laser ablation for the treatment of benign prostatic hyperplasia, performing a perineal block and administering nitrous oxide allow for an average "room in, room out" time of 25 minutes, Bianco said.

The study was internally supported. Panchendrabose and Bianco reported no relevant financial relationships.

European Association of Urology (EAU) 2022 Annual Meeting: Abstract A0003. Presented July 1, 2022.

Neil Osterweil, an award-winning medical journalist, is a long-standing and frequent contributor to Medscape.

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