What is the recommended anesthesia technique for patients undergoing cystoscopy, cystolithotripsy, urethral stent removal, and possible open pyelolithotomy if pure spinal and regional anesthesia are not feasible?

Recommended Anesthesia for Urological Procedures When Spinal/Regional Anesthesia is Not Feasible

When pure spinal and regional anesthesia are not feasible for cystoscopy, cystolithotripsy, urethral stent removal, and possible open pyelolithotomy, general anesthesia with propofol (without muscle relaxation for minor procedures) or full general anesthesia with endotracheal intubation (for open surgery) should be used. 1

Anesthesia Selection Based on Procedure Type

For Cystoscopy and Stent Removal

• Propofol-based general anesthesia without muscle relaxation provides superior pain control and patient satisfaction compared to intravenous analgesia alone 2
• Patients receiving propofol for rigid cystoscopic stent removal experienced significantly less pain and higher satisfaction rates compared to those receiving only intravenous analgesics or midazolam sedation (P < 0.001) 2
• In the propofol group, zero patients wanted alternative treatment modalities, compared to 85% in the intravenous analgesia group 2
• General or spinal anesthesia should not be used for microwave thermotherapy procedures, but this contraindication does not apply to standard cystoscopic procedures 1

For Cystolithotripsy

• Local anesthesia with suprapubic access can be considered as an alternative when neuraxial techniques are contraindicated 3
• Percutaneous suprapubic cystolithotripsy under local anesthesia showed no significant difference in pain scores compared to rigid cystoscopy under local anesthesia (P = 0.35), with 96.78% complete stone clearance 3
• This approach achieved successful outcomes with average hospitalization of 2.3 days and no major intraoperative complications 3

For Open Pyelolithotomy

• General anesthesia with endotracheal intubation and rapid sequence induction is the standard approach when regional techniques fail or are contraindicated 1
• For patients with anticipated difficult airways, awake flexible bronchoscopic intubation should be considered before proceeding with general anesthesia 1

Critical Safety Considerations

Contraindications to Avoid

• Never use general or spinal anesthesia for certain microwave thermotherapy procedures where patient pain perception serves as a safety mechanism 1
• However, this specific contraindication does not extend to standard urological procedures like cystoscopy or open surgery 1

When Regional Anesthesia Fails

• If an epidural or spinal technique is attempted but fails, do not delay proceeding to general anesthesia, especially in urgent cases 1
• Combined spinal-epidural techniques have theoretical advantages but require successful placement in two anatomical spaces, increasing failure risk 1, 4

Pediatric Considerations

• In pediatric patients, general anesthesia is typically required for cystoscopy and stent removal, as these procedures can be traumatic under local anesthesia 1
• Stent-on-string techniques should be considered to avoid repeated general anesthetics for stent removal 1
• Day-case procedures under general anesthesia are feasible and safe in adults but require further investigation in pediatric populations 1

Common Pitfalls to Avoid

• Do not over-sedate patients to the point where pain perception is completely abolished if using local anesthesia techniques, as pain serves as a safety mechanism 1
• Do not assume that moderate sedation with midazolam alone provides adequate pain control for rigid cystoscopy—propofol-based general anesthesia is superior 2
• For open surgical procedures, do not attempt local anesthesia alone—general anesthesia with appropriate airway management is required 1