Ureteroscopy under conscious sedation: A proof-of-concept study

Abstract

Introduction: Ureteroscopies (URSs) are commonly performed under general anesthesia (GA) to maximize patient tolerability and minimize surgical complications. However, given the improvements in endoscopic technology and risks associated with GA, alternate forms of anesthesia have been postulated. We aimed to evaluate the outcomes of URS under conscious sedation. Methods: We completed a retrospective cohort study from November 2019 to June 2020 at a tertiary-level hospital. All URSs that were performed under urologist-directed conscious sedation were included. Our primary outcome was the ability to complete URSs, defined as success rate. Secondary outcomes included: stone-free rate, intraoperative complication rate, hospital admission rate, and sedation requirement. Univariate- and multivariate-adjusted logistic regression analyses were employed. Results: Ninety-nine URSs were included. Most (73/99, 73.7%) were performed for urolithiasis. The overall success rate was 83.8% (83/99), with 81.0% (34/42) intra-renal and 70.0% (16/23) proximal ureter success rates. The stone-free rate was 80.8% (59/73). No intraoperative complications nor hospital admissions were reported. The mean amount of sedation required was three (interquartile range [IQR] 2–4] mg of midazolam and 100 (100–150) μg of fentanyl. On multivariate analysis, midazolam was significantly associated with increased success (odds ratio 2.496, 95% confidence interval 1.057–5.892, p=0.037). Conclusions: We have shown that proximal and intra-renal URS under conscious sedation is safe and effective. We were limited by our lack of followup, small sample size, selection bias to chose healthy patients, and lack of patient tolerability data. Patients and healthcare systems may benefit from implementing this innovation more broadly.

Case series – Tolerability of penile fracture repair under conscious sedation

“…However, our institution has a long history of completing urologic procedures including but not limited to ureteroscopy, hydrocelectomy under nursing administered IV sedation with good tolerability. 7,6 Utilization of loco-sedation has potential benefits at multiple levels. At a system level significant cost savings are possible from performing penile fracture outside of an OR, thus not requiring the assistance of anesthesia in addition to helping alleviate the already significant surgical backlog in Canada.…”

“…3,4 As of now, these cases are typically performed in the OR under general or spinal anesthetic. An alternative is to perform the case under loco-sedation -our centre has performed several cases under nursing administered IV sedation 5,6 . Utilizing this anesthetic technique we perform the repair in a timely fashion, circumventing issues associated with limited staff and avoiding the risk inherent to general/spinal anesthetic.…”