Is prostatectomy done under general anesthesia (GA)?

Prostatectomy Anesthesia: General Anesthesia is Standard Practice

Prostatectomy is typically performed under general anesthesia, though neuraxial anesthesia (spinal or epidural) is a viable alternative in specific cases. 1, 2

Types of Anesthesia Used for Prostatectomy

General Anesthesia

• Standard approach for most prostatectomy procedures, especially:
  • Robot-assisted laparoscopic prostatectomy
  • Open radical prostatectomy
  • Transurethral resection of prostate (TURP)

Neuraxial Anesthesia

• Spinal anesthesia or epidural anesthesia can be used as alternatives
• Benefits compared to general anesthesia:
  • Reduced intraoperative blood loss 3
  • Less postoperative pain 2, 3
  • Faster postoperative recovery 3
  • Lower rate of minor complications 2
  • Shorter hospital stay (median 5 vs 6 days) 2

Combined Approaches

• General anesthesia with epidural analgesia:
  • May offer better outcomes including potentially reduced cancer recurrence 4
  • Provides excellent pain control during and after surgery 1

Evidence-Based Considerations

Open Radical Prostatectomy

• Spinal anesthesia has shown advantages over general anesthesia:
  • Significantly less intraoperative blood loss
  • Better immediate postoperative pain control
  • Faster return of bowel function (earlier passage of flatus)
  • Better postoperative mobility 3

Laparoscopic Prostatectomy

• Recent evidence shows three-dimensional laparoscopic radical prostatectomy can be safely performed under neuraxial anesthesia with:
  • Adequate muscle relaxation
  • Less postoperative pain
  • Fewer minor complications
  • Higher patient satisfaction 2

Robot-Assisted Prostatectomy

• Traditionally performed under general anesthesia
• Intrathecal morphine combined with general anesthesia has shown improved pain control 1

Special Considerations

Patient Positioning

• Careful positioning is essential to prevent nerve injuries during robot-assisted procedures
• PROSPECT guidelines recommend:
  • Limiting excessive hip abduction and external rotation
  • Adequate padding at pressure points
  • Careful port placement 5

Local Anesthesia Applications

• Local anesthesia alone is generally insufficient for radical prostatectomy
• Can be used for:
  • Prostate brachytherapy with good patient satisfaction 6
  • Small to moderate TURP procedures in select patients 7

Pitfalls and Caveats

1. Contraindications to neuraxial anesthesia must be considered:

   • Coagulopathy
   • Infection at insertion site
   • Patient refusal
   • Severe spinal deformity

2. Positioning-related complications are a risk, particularly with robotic procedures:

   • Femoral nerve injury from excessive hip abduction
   • Pressure injuries at contact points during prolonged procedures

3. FDA safety recommendations for certain procedures (like microwave therapies) advise against general or spinal anesthesia as patient perception of pain serves as a safety mechanism 1

4. Duration of procedure may influence anesthesia choice, with longer cases typically favoring general anesthesia

In conclusion, while general anesthesia remains the most common approach for prostatectomy procedures, there is growing evidence supporting the safety and potential benefits of neuraxial techniques in appropriate candidates.