Objective To evaluate the use of local anaesthesia in patients with benign pro-static hyperplasia (BPH) undergoing trans-urethral resection of the prostate (TURP) who are deemed to be unfit because of a high anaesthesia risk.
Patients and Methods Twenty patients with grade III and IV ASA (American Society of Anesthesiologists) and a functional capacity <5 MET (metabolic equivalent) were sub-jected to TURP using local anaesthesia. 10 ml xylocaine gel was instilled into the urethra and a penile clamp was used for 5 minutes. Bladder anaesthesia was obtained by intravesical instillation of 10 ml xylocaine 2% and 10 ml sodium bicarbonate 8.4% through a 14 Fr. Foley catheter. Then a transperineal local periprostatic injection of 10 ml xylocaine 2% was done on each side. This was supplemented by an intravenous injection of 3-5 mg midazolam and 100-150 mg fentanyl. The operative conditions were assessed for feasibility of the technique, smoothness of the surgical steps and

patient comfort during the procedure. The haemodynamic parameters were con-tinuously monitored during the operation and in the immediate postoperative hours (Space-Lab Monitor, USA).
Results An adequate anaesthesia could be obtained by using this technique. Four patients experienced some discomfort during the operation which was relieved by a supplemental dose of fentanyl. No con-version to general or spinal anaesthesia was needed in any patient. There was no postoperative pain up to 3 – 4 hours. All patients began with fluid intake after one hour. No complications related to the technique were encountered. Follow up after three months showed no major com-plications or requirements of an admission to the intensive care unit.
Conclusion Local anaesthesia can effectively and safely be applied in patients at high risk for anaesthesia undergoing TURP.
Key Words local anaesthesia, prostate, TURP, high-risk patients

INTRODUCTION

ASA III and IV patients are patients with coexisting diseases, such as cardiovascular and respiratory diseases and diabetes. How-ever, the ASA physical status is a broad indicator of underlying diseases and insuf-ficient per se to identify patients at risk. ASA criteria do not take into account the patient age, which is a risk factor by itself.

Patients with a limited functional capacity (exercise tolerance in daily life) (MET < 5) during most of their normal daily activity have an increased perioperative short-term and long-term cardiac risk. When such patients are subjected to transurethral resection of the prostate (TURP) which has been classified as

Table 1: Co-Morbidities Encountered in 20 Patients

* most patients presented with more than one co-morbidity
v 1 patient with ventricular pacemaker
as postoperative nausea and vomiting2. Also, general anaesthesia cannot provide post-operative analgesia.

Recently, cardiac risk factors were studied as predictors of the outcome in patients with cardiovascular disease, and it was found that postoperative cardiac complications were good predictors of the outcome. It has been shown that spinal anaesthesia is a better choice with old myocardial infarction.

Edward et al.3 demonstrated in 100 patients subjected to TURP under general or spinal anaesthesia that the incidence of perioperative myocardial ischaemia ranged from 18% to 26% between the preoperative and post-operative period. Patients with ischaemic heart disease had a significantly higher incidence of postoperative myocardial ischaemia. There was an increased incidence and duration of myocardial ischaemia after operations using both anaesthetic techniques, but no significant difference between the two techniques was found.

On the other hand, local anaesthesia seems to be very beneficial when used in high-

choice between general or spinal anaesthesia is not clear. Spinal anesthesia seems to be of greater benefit for patients in ASA III, while the reverse is true for ASA IV as mortality with spinal anesthesia is more frequent than with general anesthesia. The working rule in classical teaching appears to be: the sicker the patient, the greater the indication for inhalational anaesthesia.

Several laboratory and clinical studies have demonstrated that general anaesthesia (with exception of large dose opiods), although it produces the desired state of unconscious-ness, does not eliminate the surgical stress response. It may aggravate immunosuppres-sion and cause undesirable side effects, such

.

The goal is to ensure patient comfort during surgery but also to keep the patient awake and conversant4.

This study included 20 patients deemed to be unfit for our ordinary endoscopic list to study the feasibility and safety of local anaes-thesia plus sedoanalgesia technique for trans-urethral resection of the prostate.

PATIENTS AND METHODS

After obtaining approval from the Institu-tional Ethics Committee and a written informed consent of the patients, twenty patients with symptomatic BPH with various co-morbidities were operated upon under prostatic local anaesthesia. The patients’ age ranged from 50 to 84 years (mean age 64.1 years). The criteria for surgery included acute or chronic urinary retention, haematuria, a maximum flow rate (Qmax) below 10 ml/s, a post-void residual urine of more than 75 ml and nocturia more than four times per night.

Each patient was evaluated by an expert anaesthetist and ranked according to the ASA criteria for surgical fitness. All patients included in this study were grade III and IV according to the ASA classification. The patients co-morbidities are shown in Table 1.

All patients were subjected to the following investigations: abdominal ultrasound, trans-rectal ultrasound (TRUS), maximal flow rate (Qmax), blood urea and serum creatinine, intravenous urography, PSA, X-ray of the chest, ECG, echocardiography when indicated, liver function tests and assessment of the blood glucose level.

On arrival to the operation theatre, ECG monitoring was established for every patient as well as non-invasive blood pressure, pulse oximetry and capnography (Space-Lab, USA). Oxygen 4 l/min was given via a facemask.

10 ml xylocaine gel (2%) was instilled into the urethra with a 10 ml syringe and a penile clamp was applied for 5 minutes. Bladder