ENDOUROLOGY AND STONE DISEASE Limitations of Spinal Anesthesia for Patient and Surgeon During Percutaneous Nephrolithotomy Abbas Basiri1, Amir H Kashi1,2*, Mahdi Zeinali1, Mahmoudreza Nasiri1, Reza Valipour1, Reza Sarhangnejad1 Purpose: To evaluate the intraoperative pain score of patients who undergo percutaneous nephrolithotomy under spinal anesthesia and to evaluate surgeons' and patients' convenience with this type of anesthesia. Materials and Methods: PCNL cases who were performed by two endourology fellows under spinal anesthesia during June to July 2014 were included. Spinal anesthesia was performed using injection of 0.25mg/kg bupiv- acaine 0.5% in the intrathecal space. All procedures were performed with the patient in the prone position. Stone access was made by using fluoroscopic guidance, and the tract was dilated using a single-stage technique. Visual analogue pain score was used to assess patients' pain during operation, immediately after, and 2 hours later. Results: 50 patients were enrolled during the study period. Visual analogue pain score of 10 and 8 were observed in 5 and three patients respectively. In two patients the operation was terminated because of patient anxiety and pain. In another patient a second access was not obtained to remove a staghorn stone because of patient's agitation. Gross agitation was observed in six patients. Apart from flank pain, intraoperative pain was felt in the flank, scap- ula, abdomen and/or chest. Conclusion: Spinal anesthesia does not provide enough analgesia for the patient in a limited frequency of percu- taneous nephrolithotomy operations. We could not find statistically significant predictors of insufficient analgesia based on patients' demographics, stone characteristics or access location. Keywords: percutaneous nephrolithotomy; spinal anesthesia; pain perception; satisfaction. INTRODUCTION In the decades after introduction of percutaneous nephrolithotomy (PCNL), urologists have proposed modifications to the procedure to improve its safety and efficacy. Different positions (supine, prone, flank and flank-flexed), tubeless PCNL and regional anesthesia were introduced by several researchers.(1,2) Regional anesthesia has been used for PCNL by spi- nal and combined spinal-epidural (CSEA) methods.(3-8) Both spinal and CSEA were reported to be as effective as general anesthesia by some researchers including one previous publication from our center.(2,4,9-12) After this previous publication on the efficacy and safety of spi- nal anesthesia for PCNL, PCNL procedures were often performed under spinal anesthesia in our center. We encountered some cases in which the patient was rest- less during the procedure or in extraordinary pain. This study was designed to investigate patients' pain during PCNL under spinal anesthesia, surgeons' and patients' convenience during the procedure and to explore fac- tors that can affect the above variables. MATERIALS AND METHODS All patients who were scheduled for PCNL operation under spinal anesthesia by two endourology fellows during June to July 2014were included in this study. PCNL is typically scheduled in our center for renal stones larger than 2 cm, stones resistant to ESWL, large 1Urology and Nephrology Research Center, Shahid Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 2Hasheminejad Kidney Center, Iran University of Medical Sciences, Tehran, Iran. *Correspondence: Urology and Nephrology Research Center, No. 103, 9th Boustan St., Pasdaran Ave., Tehran, 16666, Iran. Tel & Fax: +98 21 22588016, Email address: ahkashi@gmail.com. Received June 2017 & Accepted September 2017 upper ureteral stones and large stones in horseshoe kid- neys. Preoperative evaluation included serum electro- lytes and hemoglobin, ultrasonography of the kidney and urinary system and either intravenous pyelography or computed tomography of the kidney and urinary sys- tem. Typically patients with any contraindication to spinal anesthesia (e.g. spinal deformity), renal anomaly, his- tory of bleeding disorders, and anticoagulant or an- tithrombotic medication and addiction to opium and alcohol and those patients who were anticipated to have a long operation duration underwent general anesthesia and were excluded from the study. Anesthesia specialists were unaware of the study objec- tives. Patients were explained about Visual Analogue Pain Score (VAS) before the operation in the waiting room by the operating surgeon. Patients who were se- lected for general anesthesia were excluded from the study. The protocol for spinal anesthesia has been de- fined previously and is summarized below. Spinal anesthesia The anesthesia protocol has been previously described and is summarized below.(2) Patients were placed ini- tially in the lateral position and then 0.25 mg/kg bupi- vacaine 0.5% (up to 40 mg) was injected in the intrath- ecal space (L3–L4). The induction of spinal anesthesia was achieved when at least the T6 dermatome was an- esthetized; regression to T9 was considered as failure of Endourology and Stone Diseases 164 anesthesia. Then the patients were returned to the lithot- omy position after 3 minutes. Drug fixation time was 13 to 15minutes (3 to 5 minutes for drug administration in the lateral position and 10 minutes for repositioning to the supine position and then lithotomy). PCNL procedure All procedures were performed with the patient in the prone position. The details of PCNL is our center has been previously published(13,14) and is summarized below. Stone access was made by using fluoroscopic guidance, and the tract was dilated using a single-stage technique until 28 F to 30 F. Stones were extracted by grasper after breaking them by pneumatic lithotripter. A Double-J stent was not inserted in patients routinely, and nephrostomy tube insertion was optional and de- pended on surgeon preference. After transfer of the patients to recovery room, they were asked about their VAPS during the operation and VAS on entry to recovery room. The surgeon was also asked about his convenience with anesthesia during the operation period and any reason for inconvenience was recorded. VAS was also asked from the patient 2 hours after operation termination. Patient satisfaction with an- esthesia during the operation was asked according to a likert type 5 scale questions on the 1st postoperative morning. Anesthesia duration was defined as from be- ginning of spinal anesthesia to nephrostomy fixation. Operation duration was defined from the start of per- cutaneous access needle insertion to nephrostomy fix- ation. Statistical analysis Statistical package for social sciences Ver. 16 (Chicago, IL) was used for data entry and analysis. VAS and pa- tient or surgeon satisfaction were compared by nonpar- amentric Mann-Whitney or Kruskal-Wallis tests. The association of VAS and satisfaction scores with opera- tion duration was analyzed by spearman r. The ethics of this study have been approved by the eth- ics committee of the Urology and Nephrology Research Center and are in accordance with the 1964 declaration of Helsinki and its later amendments. Patients were ex- plained about the study objectives and informed con- sent was obtained. RESULTS 50 patients were enrolled during the study period. Ta- ble 1 summarizes patients' demographic data and oper- ation characteristics. There was one patient with mal- rotated kidney in the studied patients. Figure 1 shows surgeons' and patients' satisfaction scores and intraop- erative, immediately postoperative and 2 hours after operation VAS scores. Five patients experienced intraoperative VAS of ten and in three of these five patients the following compli- cations were observed. One patient experienced severe pain and agitation which caused leaving a residual frag- ment and no further try to remove it. Another patient experienced gross nausea and vomiting. In the third pa- tient, the operation was terminated upon request of the anesthesia specialist. In all these three cases pain was associated with patient agitation. Three patients experienced intraoperative VAS of 8 and in two patients pain was associated with patient's agitation. Intraoperative VAS scores of 5 to 6.5 were observed in seven patients and in one patient it was associated with patient's agitation. Intraoperative VAS scores of 1 to 4.5 were observed in eight patients and in one patient because of patient anxiety and agitation, the anesthesia specialist did not agree on obtaining a second access for complete removal of a staghorn stone. Excessive talking was observed in one patient during the operation. Intraoperative nausea and vomiting was observed in two patients (one patient with intraopera- tive VAS of ten described before and another patient with intraoperative VAS of zero). Intraoperative and postoperative headache were observed in one and one patient respectively. Intraoperative pain was felt in areas other than the flank and consisted of scapula, abdomen and chest. Moderate inconvenience of the surgeon was observed in six cases because of patients' pain, agitation and/or obligatory termination of the operation. Severe incon- venience of the surgeon was observed in three patients because of patients' pain and/or agitation during the op- eration. Intraoperative and immediately postoperative VAS scores were associated with duration of anesthesia (rsp= 0.300, P = .034 and rsp= 0.285, P = .045 respec- tively). Two-hour postoperative VAPS score was not associated with duration of anesthesia (rsp = 0.222, P = .12).Operation duration was not associated with VAS scores. Surgeons' satisfaction scores were negatively Table 1. Patients' and operations' characteristics Variable Age (years), mean ± SD 48.1 ± 12.2 Gender (Male), N(%) 29(58) Access, N Upper, Middle, and Lower pole 11, 4, 35 Anesthesia duration (minutes) , mean ± SD 83.4 ± 21.5 Operation duration (minutes), mean ± SD 52.7 ± 23.0 Preoperative Hemoglobin (mg/dl), mean ± SD 13.9 ± 1.5 Postoperative Hemoglobin (mg/dl), mean ± SD 12.3 ± 1.4 Figure 1. Boxplots for likert satisfaction scores for surgeons and patients plus visual analogue pain scores during operation, imme- diately after operation and 2 hours after operation. Limitations of spinal anesthesia for PCNL-Basiri et al. Vol 15 No 04 July-August 2018 165 associated with patient's intraoperative VAS score (rsp = -0.73, P <.001). Patients' satisfaction scores were negatively correlated with intraoperative VAS (rsp = -0.597, P < .001), immediately postoperative VAS (rsp = -0.538, P < .001), and 2 hour postoperative VAS (rsp = -0.474, P = .001). VAS scores and patient or surgeon satisfaction scores were not associated with access location (lower calyx, middle calyx or upper calyx; all P > .05). DISCUSSION PCNL was originally performed under general anesthe- sia. In general anesthesia there is risk of tube displace- ment during change of position from supine to prone. (8) General anesthesia is also less cost effective and is carried with a higher risk of pulmonary complications. (8) Therefore, some researchers were motivated to evaluate the role of regional anesthesia in PCNL due to the regional nature of the procedure. Use of spinal and CSEA were reported in some previous publications with satisfactory results. The use of analgesic medica- tions and patient satisfaction were reported higher in CSEA relative to general anesthesia in the studies by Kuzgunbay et al.,(5) Saeid et al.(7) and Karacalar et al.(4) Spinal anesthesia has also been reported to be associat- ed with less postoperative pain and favorable operative factors by Mehrabi et al.(11,15) and Nouralizadeh et al.(2) Yet only one study has evaluated convenience of the surgeon with the anesthesia(4) and up to our knowledge no study has evaluated the intraoperative pain score of the patients in spinal anesthesia or CSEA. Most studies focused on postoperative pain of the patients. Intraop- erative convenience of the patient is of outmost impor- tance because it provides a safe and stable condition in awake patient for successful operation. Furthermore, in some previous studies large exclusion criteria were applied. For example in a previous report from our center,(2) patients with history of PCNL or open stone surgery were excluded from the study compromising the generalization of the results of the study to the pop- ulation of PCNL patients. The results of this study reveal that spinal anesthesia has been associated with intolerable pain or discom- fort in some patients (5 patients, 10%). This has caused premature termination of the operation upon request of anesthesia specialist (1patients) or gross inconvenience of the operating surgeon due to movement and/or anx- iety of the patient (4 patients). In our opinion this is of outmost concern because the primary objective of anes- thesia is to provide enough intraoperative analgesia dur- ing the operation and continuation of anesthesia into the postoperative period (that has been the concern of most previous studies) is a second less important purpose. As general anesthesia usually provides pain free operation, it was expected that regional anesthesia provides little and tolerable pain during the operation relative to gen- eral anesthesia. However, unfortunately the pain scores were severe(8-10) in 5 patients (10%) and moderate in an- other 10 patients. In this study, the duration of anesthesia was associated with increasing intraoperative VAS in patients. This ob- servation has previously been reported by Karacalar et al. They reported insufficiency of spinal anesthesia for PCNL operations longer than 160 minutes.(4) CONCLUSIONS Spinal anesthesia does not provide enough analgesia for the patient in a limited frequency of percutaneous neph- rolithotomy operations. Increasing anesthesia duration is associated with increasing pain during operation. We could not find other statistically significant predictors of insufficient analgesia based on patients' demograph- ics, stone characteristics or access location. 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