Is spinal anaesthesia (Spinal Anesthesia) a suitable approach for a patient undergoing Transurethral Resection of the Bladder (TURBT)?

Spinal Anesthesia for Transurethral Resection of Bladder Tumor (TURBT)

Spinal anesthesia is a highly suitable and recommended approach for patients undergoing Transurethral Resection of Bladder Tumor (TURBT), offering excellent surgical conditions with fewer cardiopulmonary complications compared to general anesthesia. 1

Benefits of Spinal Anesthesia for TURBT

• Reduced cardiopulmonary morbidity: Spinal anesthesia provides a decrease in cardiopulmonary morbidity, making it particularly beneficial for patients with cardiopulmonary risk factors 2

• Effective postoperative pain control: Spinal anesthesia provides good postoperative analgesia compared with systemic approaches 2

• Avoidance of aerosol-generating procedures: During pandemic situations, spinal anesthesia avoids aerosol-generating procedures associated with general anesthesia 1

• Hemodynamic stability: Particularly when using thoracic approach with lower doses of hyperbaric bupivacaine 3

Technical Considerations

Anesthetic Technique

1. Spinal anesthesia with obturator nerve block (SA+ONB) is superior to spinal anesthesia alone for TURBT procedures 1

   • Significantly reduces risk of obturator reflex (p < 0.00001)
   • Decreases bladder perforation risk (p = 0.02)
   • Improves complete tumor resection rates (p < 0.0001)
   • Reduces 12-month tumor recurrence (p = 0.005)

2. Obturator nerve block approaches:

   • Inguinal approach is comparable to classic approach in terms of ease and success rate
   • Inguinal approach has lower incidence of vascular injury compared to classic approach 4

3. Medication recommendations:

   • A combination of local anesthetic and opioid (morphine 0.1–0.2 mg) is recommended based on superior analgesic efficacy and duration 2
   • Single bolus dose is preferred as it provides lasting analgesia and is practical to administer 2

Safety Considerations

• Patient monitoring: Close monitoring throughout the procedure is essential 2

• Positioning verification: Proper positioning of the patient should be verified before and during the procedure 2

• Contraindications: Consider relative contraindications to spinal anesthesia including coagulopathy, infection at injection site, and certain neurological conditions 5

• Risk assessment: For patients with anticoagulant therapy, spinal anesthesia might still be the best option when considering the individual risk of alternative methods 5

Special Considerations for TURBT

• Bimanual examination: Should be performed to assess tumor mobility and local extent 6

• Blue light cystoscopy: Improves tumor detection, particularly for carcinoma in situ and multifocal disease 6

• Adequate muscle sampling: Essential for accurate staging 6

• Postoperative management: Consider immediate postoperative intravesical chemotherapy within 24 hours if non-muscle invasive disease and no bladder perforation 6

Potential Pitfalls and How to Avoid Them

• Obturator reflex: Can cause bladder perforation during lateral wall tumor resection. Use obturator nerve block in addition to spinal anesthesia to prevent this complication 1

• Hypotension: There is a positive correlation between the dose of local anesthetic and incidence of hypotension. Consider using lower doses (7.5-10mg vs 15mg of hyperbaric bupivacaine) to decrease the incidence of hypotension by up to 52.2% 3

• Incomplete tumor resection: More common with spinal anesthesia alone versus spinal with obturator nerve block. Always consider adding ONB for lateral wall tumors 1

• Vascular injury: More common with classic approach for obturator nerve block. Consider using the inguinal approach which has a lower risk of vascular injury 4

By following these recommendations, spinal anesthesia with obturator nerve block provides an optimal anesthetic approach for patients undergoing TURBT, ensuring both patient safety and optimal surgical conditions.