Patients prefer being awake but sedated during urologic procedures

Patients prefer conscious sedation over general anaesthesia (GA) during urologic procedures, according to Canadian researchers who followed patients undergoing various endourologic, ureteric, urethral, or advanced cystoscopic procedures.

The current standard for performing most urologic procedures is to administer GA or spinal anaesthesia to the patient,  said Kapilan Panchendrabose, a medical student from the University of Manitoba in Winnipeg, Manitoba, Canada, at EAU 2022. “However, there are significant risks, including adverse side effects, costs, and increased operating room wait times.”

Panchendrabose sought to investigate if patients under conscious sedation would tolerate the procedure and prefer it over GA in a prospective, nonrandomized cohort study of all patients who underwent urologic procedures at their centre from June through August 2021. [EAU 2022, abstract A0003]

Most patients said if they had to repeat the procedure, they would still opt to be awake but sedated, rather than asleep.

Not the first time

Panchendrabose said they had previously shown that treatment of ureteric calculi and distal ureteroscopy could be safely performed under physician-directed, conscious sedation delivered intravenously. They have since expanded the technique to include other advanced urologic procedures, including rigid and flexible ureteroscopy, ureteric stent insertions/exchanges, scrotal/penile procedures (hydroceles, testicular biopsies, etc), urethral dilations, and advanced cystoscopic procedures, including bladder biopsies and botulinum toxin therapy.

All patients underwent sedation with fentanyl, midazolam, or both.

Four to six weeks after the procedure, the patients were polled via telephone and asked to complete a standardized tolerability questionnaire.

Overall, 196 procedures using conscious sedation were performed during the study period. The success rate was 96.5 percent. There were no intraoperative complications observed.

Yes, to being awake

Of the 161 patients who completed the questionnaires 4–6 weeks after the procedures, 85 percent answered yes when asked whether they would choose conscious sedation if they were to undergo a repeat procedure.

Significant predictors of choosing conscious sedation over GA were older age (odds ratio, 1.049; p= 0.017) and surgeon’s perception (score of 1–10) of the perceived level of tolerability for patients.

In a multivariate analysis, neither BMI, sex, prior conscious sedation experience, Charlson comorbidity index, procedure type, drug type, nor time of the procedure were predictive of anaesthesia choice.

Choose your patients!

Intravenous conscious sedation is a viable alternative for many advanced urologic procedures, said Panchrendabose. “You just have to select carefully the patients you will subject to conscious sedation to ensure a successful procedure.”  

He acknowledged that the study was limited by selection bias because surgeons recommended conscious sedation to patients they considered suitable candidates for less intensive anaesthesia.