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The selection of the regional anaesthesia in the transurethral resection of the

prostate (TURP) operation

Article  in  International Urology and Nephrology · December 2003

DOI: 10.1023/B:UROL.0000025616.21293.6c · Source: PubMed

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 International Urology and Nephrology 35: 507–512, 2003.
© 2004 Kluwer Academic Publishers. Printed in the Netherlands.
507

The selection of the regional anaesthesia in the transurethral resection of

the prostate (TURP) operation

S. Özmen2 , A. Koşar1 , S. Soyupek1 , A. Armağan1 , M.B. Hoşcan1 & C. Aydin2

Department of 1 Urology and 2 Anaesthesiology, Süleyman Demirel University Faculty of Medicine, Isparta, Turkey

Abstract. Background and objectives: The aim of our study was to compare the three different regional
anaesthesia methods in patients who underwent transurethral resection of the prostate (TURP) and to determine
the ideal anaesthesia method for TURP operation. Methods: Totally 77 ASA II–III patients were preloaded with
500 ml 0.9% NaCl solution before regional anaesthesia. In group E (n:27) epidural anaesthesia were achieved
by applying 75 mg bupivacaine heavy + 50 µg fentanyl in the L3–L4 intervertebral space. In group SP (n:28)
15 mg bupivacaine heavy + 50 µg fentanyl were used for spinal anaesthesia (L3–L4 intervertebral space) while
in group SA (n:30) 10 mg bupivacaine heavy + 50 µg fentanyl were used with saddle blockade. Systolic arterial
pressure (SAP), heart rate (HR), peripheral oxygen saturation (SpO2), serum sodium measurement was recorded
before and after hydration and during operation. The motor block and sensory level have been measured. Results:
Intraoperative SAP values were more stable than the other groups in group SA. The decrease in HR values were
significant 15 minutes after prehydration in three groups (p < 0.05). SpO2 values of the groups were stable during
the operation. The time to reach the maximum block was very short in patients in Group SA (p < 0.0001). There
was a statistically significant difference between the groups in terms of motor block values (p < 0.0001). No fully
paralysed sample was seen in Group SA even though there was a sufficient surgical anaesthesia. Conclusions:
Saddle block has some advantages compared to spinal and epidural anaesthesia methods such as achieving
adequate anaesthesia, stable haemodynami, the lower degree of motor blockage and no full blockage in patients.
Saddle block is an the most optimal anaesthesia method for TURP operation.

Key words: Epidural anaesthesia and bupivacaine, Transurethral prostatectomy

Introduction becomes very important to keep a stable anaesthesia

Transurethral resection of the prostate (TURP) is
the gold standard treatment for patients with bladder
outlet obstruction due to benign prostatic hyper-
plasia (BPH), with subjective and objective success
rate of 85–90% [1]. TURP is mostly applied on
elderly patients who have hypertension, problems
with breathing, circulation system, and kidney func-
tions. Large studies on TURP have reported morbidity
rates as high as 18%, including bleeding, TUR
syndrome, bladder perforation, hypothermia, dissem-
inated intravascular coagulation intraoperatively and
at early postoperative period [1–6]. There is a rela-
tively increase in the prevalence of cardiac and
pulmonary problems and mortality rate is 0.2% in
the patients who underwent TURP [1], therefore, it
that will minimise the haemodynamic differences in
these patients.
It is difficult to recognise these symptoms using
general anaesthesia. Besides, on the patients treated
by TURP, general anaesthesia causes more haemo-
dynamic differences compare to regional anaesthesia
[5]. Thus, regional anaesthesia is highly preferable
in TURP applications. In this study, elective methods
used in TURP have been divided into three groups;
epidural, spinal, and saddle block as one of the vari-
ation of the spinal anaesthesia. The purpose of this
study was to find the optimal regional anaesthesia
method for the TURP operation by comparing the
haemodynamic difference, locating time of the block,
and degree of the motor block.
508
Patients and method
The study was conducted on 85 male patients, ASA
physical status II–III, scheduled for TURP. The
patients did not have any contraindications for regional
anaesthesia. The patients were not premedicated. In
the anaesthesia induction room, 500 ml of normal
saline 0.9% was applied prior to the regional anaes-
thesia to the patients. The same anaesthesiologist
performed all anaesthetic interventions. An 18-gauge
cannula was inserted in a peripheral vein. The systolic
arterial pressure (SAP) was measured by an auto-
mated non-invasive arterial pressure monitor (Omega
1400). All of the patients were treated by normal
saline 0.9% solution in the dosage of 6 ml/kg/h during
the operation. Regional anaesthesia was applied while
the patients were in sitting position. The patients
were randomly divided into the three groups. In the
Group E (n:27), in order to apply the epidural anaes-
thesia, the hanging drop technique was employed to
place the catheter into the epidural area by using a
16 g tuohy needle through L3–L4. Hyperbaric 0.5%
bupivacaine 3 ml (15 mg) via epidural catheter was
given as a test dosage. After realising that the spinal
block was not formed in 5 minutes, 0.5% bupiva-
caine 12 ml (60 mg) + fentanyl 50 µg was given via
epidural catheter. In the Group SP (n:28), in order
to apply spinal anaesthesia, hyperbaric 0.5% bupi-
vacaine 2 ml + fentanyl 50 µg was given by using
25-gauge Pencil point tip needle (Pencan, Braun).
Spinal injection was performed at the L3–4 interspace
via a midline approach, with the patient in a sitting
position. The solutions were injected over 60 s, aspir-
ating once to check free flow of cerebrospinal fluid.
Patients were placed supine with one pillow, after
completion of subarachnoid injection. In the Group
SA (n:30), in order to apply saddle block, hyperbaric
0.5% bupivacaine 2 ml (10 mg) + fentanyl 50 µg
was given by using 25-gauge Pencil point tip needle
(Pencan, Braun) through L3–L4. After the medica-
tion was given, the patients of Group SA were kept
in the sitting position for 7–8 minutes. The patients
in all three groups lay down on their backs while
their shoulders and heads were 30◦ higher than their
bodies. During the operation, nasal 3 L/min oxygen
was given to the patients. Before the preloading, in the
supine position, a baseline SAP, heart rate (HR), and
peripheral oxygen saturation (SpO2) were recorded as
baseline parameters. After preloading is completed,
SAP, HR and SpO2 were recorded at 5-min intervals
starting from the 5th minute. Serum sodium concen-
trations were assessed before, 1 and 24 hour after
operation.
The sensory level was assessed bilaterally using
pinprick test. Motor block was assessed using the
Bromage scale:0 = no block, 1 = inability to raise
the extended leg, 2 = inability to flex the knee, 3 =
inability to flex the ankle join or first digit of the foot.
Sensory and motor levels were recorded at 3-min
intervals during onset of the block, 5-min intervals
during surgery and then at 15-min intervals until
resolution.
Reaching time to maximum sensory block, motor
block level, operation time, amount of irrigating fluid
and peroperative complications were recorded. The
operations were performed with a Storz 24 Fr resecto-
scope (Germany) by same surgeon. Patients with
prostatic volume of 20–60 g underwent TURP oper-
ation. The operation time was lower than 60 minutes
in all patients. During the operations, the bladder
was irrigated with a solution containing 5% mannitol
(resectisol, Baxter), which was prewarmed to 37 ◦ C
before use.
Data were analysed with Instant tm Statistic
program on computer. One Way ANOVA Post Hoc test
was used to compare age, weight, operation time, and
reaching time to maximum block of the groups; Paired
t-test was used to compare haemodynamic results
and Na+ values of the groups with baseline values;
Chi-square test was used to compare the results of
Bromage scores. P < 0.05 was considered statistically
significant.
Results
Table 1 indicates age, weight, and ASA distribu-
tions of the patients. The time to reach the maximum
sensory block and operating time of the patients were
shown in Table 2. There was no difference between the
groups in terms of age, weight, duration of surgery and
the total volume of irrigating fluid (p > 0.05). There
was a statistically significant difference between all
three groups in terms of reaching time to maximum
block (p < 0.0001). This time was very short in
patients in Group SA. There was a statistically signifi-
cant difference between the groups in terms of motor
block values (p < 0.0001). The distribution of the
Bromage scores was shown in Table 3. Complete
motor blockage was never seen in SA group and the
Bromage score in SA group, which was usually score
1 (56.66%), was different from the other groups. No
 509
Table 1. Age, weight, and ASA distributions of the patients

Group E Group SP Group SA p values

(n:27) (n:28) (n:30)

Number of ASA II/III 7/20 8/20 9/21 p > 0.05

Age (year ± SD) (Min–max) 71 ± 7.82 68.3 ± 5.8 67.1 ± 8.4 p > 0.05
(60–92) (51–78) (46–83)
Weight (kg ± SD) (Min–max) 76.1 ± 6.5 78.7 ± 8.1 77.9 ± 7.5 p > 0.05
(64–86) (60–90) (64–89)

Values was expressed as a mean value.

Table 2. Reaching time to maximum sensory block and operating time and amount of
irrigating fluid of the patients

Group E Group SP Group SB p value

(n:27) (n:28) (n:30)

Reaching time to maximum

sensory block (minute)
(mean ± SD) 25.1 ± 3.1 16.0 ± 3.5 9.2 ± 1.3 p < 0,0001
(Min–max) (20–30) (10–24) (7–12)
Operating time (minute)
(mean ± SD) 40 ± 9.7 42.4 ±8.9 39.6 ± 9 p > 0,05
(Min–max) (30–60) (30–62) (25–57)
Amount of irrigating fluid
(L ± SD) 9.5±5.8 10.2±6.1 9.1±5.4 p > 0,05

Values was expressed as a mean value.

Table 3. The distribution of the Bromage scores of the groups

Bromage 0 Bromage 1 Bromage 2 Bromage 3

Group E (n:27) — — 10 (37.1%) 17 (62.9%)

Group SP (n:28) — — 4 (14.2%) 24 (85.7%)
Group SA (n:30) 4 (13.3%) 17 (56.6%) 9 (30%) —

fully paralysed patient was seen in Group SA even
though there was a sufficient surgical anaesthesia.
Figure 1 indicates the statistical comparison
between the average of the SAP values and the
baseline values. The statistical comparison between
the average of HR values and baseline values are
shown in Figure 2. During the operation, the SAP
values were stable in group SA. In Group E and Group
SP, there was a significant decrease in SAP values
relative to baseline values after the anaesthesia.
Although HR values of the groups were in the
normal limits during the operation, there was a stat-
istically significant decrease in the mean HR values
relative to baseline values in all 3 groups (p < 0.05,
p < 0.0001). The mean SpO2 values were 97.1% ±
0.9, 97.2% ± 0.8, and 97.3 %± 0.8 in Group E, Group
SP, and Group SA, respectively.
There was a statistically significant decrease in
Serum Na+ values in all 3 groups 1 hour after oper-
ation (p < 0.0001). These values were close to the
baseline values 24 hour after operation (p > 0.05)
(Table 4).
510

Figure 1. The statistical comparison between the average SAP and the baseline values. ∗∗ p < 0.0001, ∗ p < 0.05.

Figure 2. The statistical comparison between the average HR and the baseline values. ∗∗ p < 0.0001, ∗ p < 0.05.

Table 4. The statistical comparison between average baseline and postoperative sodium values

Baseline Na+ 1 Hour Na+ 24 Hour Na+

Group E (mean ± SD) 139.5 ± 3.1 133.3 ± 2.5∗∗ 138.6 ± 3.1

Group SP (mean ± SD) 140.5 ± 2.5 132.2 ± 2.6∗∗ 139.9 ± 2.2
Group SA (mean ± SD) 139.8 ± 2.7 134.1 ± 3.1∗∗ 140.0 ± 2.9
∗∗ p < 0.0001.

Discussion
Since the cardiac problems during the TURP may
change the mortality and morbidity, using a stable
anaesthesia method with minimal haemodynamic
changes becomes a very important factor. The studies
in which Dobson et al. [5] and Lawson et al.
[21] applied spinal and general anaesthesia under
TURP and compared their haemodynamics indicated
that the general anaesthesia caused more haemody-
namic differences after the induction. Another study
that compared spinal and epidural anaesthesia, noted
that haemodynamic differences were higher in spinal
anaesthesia [7]. Even though the level of sensory block
is the same in both anaesthesia methods, sympathetic
denervation is relatively higher in spinal anaesthesia
compare to epidural anaesthesia. Therefore, functional
blood volume decreases by a fast and wide vasodilata-
tion, and a serious hypotension occurs [8, 9]. Pitkanen
et al. [10] indicated that using 10 mg% 0.5 hyper-
baric bupivacaine causes less blood pressure decreases
compare to other local anesthetics, and haemodynamic
differences can be very low even in elderly patients
if enough prehydration is provided. Other studies
also indicated that hyperbaric and isobaric bupivacaine
both provide sufficient anaesthesia in prostate surgery
[11–13].
Tuominen [14] stressed that the major factors
effecting the distribution of the local an aesthetics are
concentration and volume of the local anaesthetics,
and the position of the patient during the injection
and after the injection; in terms of long-term anaes-
thesia and postoperative anaesthesia, bupivacaine is
a good agent and provides a sufficient anaesthesia in
15 mg dosages; besides, keeping the patient in sitting
position for 2–3 minutes after the injection might be
sufficient to baseline the distribution. Becker et al. [15]
indicated that the physical characteristics of the local
anaesthetic solution and the position of the patient are
the most important factors that affect the distribution
of the local anaesthesia in cerebro spinal fluid, and
applying the injection in sitting position and keeping
the patient in this position for 10 minutes might limit
the block in the sacral and lower spinal roots.
In this study, sufficient surgical anaesthesia was
conducted in all 3 groups. The disadvantages of the
epidural anaesthesia were application dosage, using
local anaesthetic in high dosage, duration of the block
positioning time, and high frequency of the complete
motor block formation. The formation rate of the
complete block using 15 mg bupivacaine was higher
511
in the patients that were treated by spinal anaesthesia
compared to the samples of Group E. We assumed
that in the samples of Group SA, providing sufficient
anaesthesia by saddle block using 10 mg hyperbaric
bupivacaine, lowering the formation rate of motor
block, and providing no complete motor block in any
patients and sufficient block for the operation were
advantages.
In the patients that were treated by saddle
block, block-positioning time was relatively shorter
compared to the samples that were treated by epidural
and spinal block. Besides, full paralyse was not
seen in any samples even though there was enough
surgical anaesthesia. There was a statistically signifi-
cant decrease on SAP values compare to the baseline
values in the patients that were treated by epidural and
spinal block while saddle block provided more stable
haemodynamia to the patients.
In this study, HR values shows similarities with the
results of Baraka et al. [16], which indicated that there
was a significant decrease in HR values after the spinal
anaesthesia and that the maximum decrease occurred
after 15–20 minutes. Some of the studies that also
noted that HR values decreases after the spinal anaes-
thesia supported our results [8, 17]. SpO2 values were
stable in all 3 groups. It was assumed that this stability
was due to using 3 L.min.-1 nasal oxygen.
We assumed that because of applying prehydration
and keeping the block level lower by saddle block
using 2 ml 0,5% (10 mg) hyperbaric bupivacaine,
and lowering the sympathetic denervation, haemody-
namic parameters became stable in Group SA. In this
study, we did not encounter any TUR syndrome during
or just after the TURP. TUR syndrome is related
with dilutional hyponatremia secondary to systemic
absorption of the irrigation fluid (6). In many studies,
it was noted that serious TUR reactions occur along
with 20–50 mmol.L-1 reductions in Na+ [18–20]. In
this study, there was a significant decrease in Na+
values in all 3 groups 1 hour after operation while
these values became closer to the baseline values 24
hour after operation. It is assumed that the differ-
ence during the early postoperative period might be
based on haemodilution. The degree of absorption is
related to the time of resection, degree of bleeding and
type, volume and pressure of irrigating fluid [6]. TUR
syndrome can affect hemodynamic parameters, there-
fore serum sodium concentrations, which is a sign of
this syndrome, were measured in patients. The serum
sodium concentrations in 3 groups were identical to
each other. These 3 groups were compared objectively
 512
because the serum sodium concentrations were nearly
the same and TUR syndrome was never seen. Preoper-
ative prehydration can be used to prevent hypotension
[16].
Finally, we found that all 3 regional techniques
can provide sufficient anaesthesia. Our results have
showed that that saddle block, which is made by
using the combination of% 0.5 hyperbaric bupivacaine
10 mg + 50 µg fentanyl, provides a successful anaes-
thesia, and a stable haemodynamia that is far from
serious complications. It can be preferred as an ideal
regional anaesthesia method for TURP operations.
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Address for correspondence: Sedat Soyupek, MD, Süleyman
Demirel University Hospital, Department of Urology 32050 Isparta,
Turkey
Fax: +902462371762
E-mail: ssoyupek@hotmail.com