Neuraxial anesthesia versus general anesthesia for urological surgery: systematic review

Barbosa, Fabiano Timbó; Castro, Aldemar Araújo

doi:10.1590/1516-3180.2013.1313535

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Sao Paulo Medical Journal

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Sumário

Original Article • São Paulo Med J. 131 (3) • 2013 • https://doi.org/10.1590/1516-3180.2013.1313535 copy

Neuraxial anesthesia versus general anesthesia for urological surgery: systematic review

Anestesia neuroaxial versus anestesia geral para cirurgias urológicas: revisão sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

CONTEXT AND OBJECTIVE

Choosing the best anesthetic technique for urological surgery with the aim of mortality reduction remains controversial. The objective here was to compare the effectiveness and safety of neuraxial anesthesia versus general anesthesia for urological surgery.

DESIGN AND SETTING

Systematic review, Universidade Federal de Alagoas.

METHODS

We searched the Cochrane Central Register of Controlled Trials in the Cochrane Library (Issue 10, 2012), Medline via PubMed (1966 to October 2012), Lilacs (1982 to October 2012), SciELO and EMBASE (1974 to October 2012). The reference lists of the studies included and of one systematic review in the same field were also analyzed. The studies included were randomized controlled trials (RCT) that analyzed neuraxial anesthesia and general anesthesia for urological surgery.

RESULTS

The titles and abstracts of 2720 articles were analyzed. Among these, 16 studies were identified and 11 fulfilled the inclusion criteria. One RCT was published twice. The study validity was: Jadad score > 3 in one RCT; seven RCTs with unclear risk of bias as the most common response; and five RCTs not fulfilling half of the Delphi list items. The frequency of mortality was not significant between study groups in three RCTs. Meta-analysis was not performed.

CONCLUSION

At the moment, the evidence available cannot prove that neuraxial anesthesia is more effective and safer than general anesthesia for urological surgery. There were insufficient data to pool the results relating to mortality, stroke, myocardial infarction, length of hospitalization, quality of life, degree of satisfaction, postoperative cognitive dysfunction and blood transfusion requirements.

Mortality; Anesthesia, general. Anesthesia, epidural; Anesthesia, spinal; Review [publication type]

Database	Search strategy
PubMed	(“anesthesia, general”[MeSH Terms] OR “anesthesia, inhalation”[MeSH Terms] OR “anesthesia, intravenous”[MeSH Terms] AND “anesthesia, conduction”[MeSH Terms] OR “anesthesia, epidural”[MeSH Terms] OR “anesthesia, spinal”[MeSH Terms])
	AND
	(“urologic surgical procedures”[MeSH Terms] OR urologic surgery[Text Word])
	AND
	(randomized controlled trial [Publication Type] OR controlled clinical trial [Publication Type] OR randomized controlled trials [MeSH Terms] OR random allocation [MeSH Terms] OR double blind method [MeSH Terms] OR single blind method [MeSH Terms] OR clinical trial [Publication Type] OR clinical trials [MeSH Terms] OR (clinical* [Text Word] AND trial* [Text Word]) OR single* [Text Word] OR double* [Text Word] OR treble* [Text Word] OR triple* [Text Word] OR placebos [MeSH Terms] OR placebo* [Text Word] OR random* [Text Word] OR research design [MeSH Terms] OR comparative study [MeSH Terms] OR evaluation studies [MeSH Terms] OR follow-up studies [MeSH Terms] OR prospective studies [MeSH Terms] OR control* [Text Word] OR prospectiv* [Text Word] OR volunteer* [Text Word])

Study (year)	Anesthesia	n	Type of surgery	% Male	Outcome	P value	Remarks
Karakalar et al.¹¹11. Karacalar S, Bilen CY, Sarihasan B, Sarikaya S. Spinal-epidural anesthesia versus general anesthesia in the management of percutaneous nephrolithotripsy. J Endourol. 2009;23(10):1591-7.	CSE	86	PNL	47.8	Satisfaction degree: CSE had better patient satisfaction.	0.001	Some patients received blood transfusion before surgery.
	GA	90	PNL	47.7	Satisfaction degree: CSE had better patient satisfaction.	0.001	Some patients received blood transfusion before surgery.
Tikuisis et al.¹²12. Tikuisis R, Miliauskas P, Samalavicius NE, Zurauskas A, Sruogis A. Epidural and general anesthesia versus general anesthesia in radical prostatectomy. Medicina (Kaunas). 2009;45(10):772-7.	EA + GA	27	RP	100	Blood transfusion requirements: less blood was transfused under EA + GA.	0.007	Duration of surgery under EA + GA was lower.
	GA	27	RP	100		0.007	Duration of surgery under EA + GA was lower.
O'Connor et al.¹³13. O'Connor PJ, Hanson J, Finucane BT. Induced hypotension with epidural/general anesthesia reduces transfusion in radical prostate surgery. Can J Anaesth. 2006;53(9):873-80.	EA + GA	49	RP	100	1. Myocardial infarction: EA + GA showed one episode of ST segment depression.2. Length of hospitalization.3. Blood transfusion requirements: number of patients transfused under EA + GA was lower.	1. NS2. NS3. 0.028	Duration of surgery under EA + GA was lower.Controlled hypotension was used only under EA + GA.
	GA	50		100		1. NS2. NS3. 0.028
Ozyuvaci et al.¹⁴14. Ozyuvaci E, Altan A, Karadeniz T, et al. General anesthesia versus epidural and general anesthesia in radical cystectomy. Urol Int. 2005;74(1):62-7.	EA + GA	25	RC	100	Blood transfusion requirements: more units of blood transfusion were used in GA group.	< 0.01	The anesthesiologists were free to use drugs and doses under general anesthesia.
	GA	25	RC	100		< 0.01
Salonia et al.¹⁵15. Salonia A, Crescenti A, Suardi N, et al. General versus spinal anesthesia in patients undergoing radical retropubic prostatectomy: results of a prospective, randomized study. Urology. 2004;64(1):95-100.	GA	36	RRP	100	Blood transfusion requirements: overall blood loss was less under SA.	0.04	Intraoperative autologous and homologous transfusions were used.
	SA	34	RRP	100		0.04
Brown et al.¹⁶16. Brown DR, Hoter RE, Patterson DE, et al. Intrathecal anesthesia and recovery from radical prostatectomy: a prospective, randomized, controlled trial. Anesthesiology. 2004;100(4):926-34.	SA + GA	49	RP	100	1. Mortality, myocardial infarction and length of hospitalization: were reported as ‘other perioperative outcomes’.2. Length of hospitalization: GA had more time.3. Quality of life: eight subscales and two composite scores of the SF-36 were used.	1. N/A2. 0.013. NS	There was no mortality or myocardial infarction data in results section.Quality of life in the study population was better than U.S. population.
	GA	50	RP	100		1. N/A2. 0.013. NS
Dauri et al.¹⁷17. Dauri M, Costa F, Servetti S, et al. Combined general and epidural anesthesia with ropivacaine for renal transplantation. Minerva Anestesiol. 2003;69(12):873-84.	EA + GA	11	RT	53.8	Length of hospitalization: EA + GA had lower mean.	N/A	Demographic data were not reported.
	GA	9	RT	58.3	Length of hospitalization: EA + GA had lower mean.	N/A	Demographic data were not reported.
Shir et al.¹⁹19. Shir Y, Raja SN, Frank SM. The effect of epidural versus general anesthesia on postoperative pain and analgesic requirements in patients undergoing radical prostatectomy. Anesthesiology. 1994;80(1):49-56.	EA	33	RRP	100	1. Mortality: no deaths for three months.2. Stroke: no neurological complications for three months.3. Myocardial infarction: Length of hospitalization: median was similar.4. Blood transfusion requirements: less blood transfusion was performed under EA during surgery.	1. N/A2. N/A3. 0.124. 0.02	This study was published twice.¹⁷17. Dauri M, Costa F, Servetti S, et al. Combined general and epidural anesthesia with ropivacaine for renal transplantation. Minerva Anestesiol. 2003;69(12):873-84.,¹⁸18. Shir Y, Raja SN, Frank SM, Brendler CB. Intraoperative blood loss during radical retropubic prostatectomy: epidural versus general anesthesia. Urology. 1995;45(6):993-9.
	EA + GA	34		100
	GA	33		100
Hendolin et al.²⁰20. Hendolin H, Alhava E. Effect of epidural versus general anaesthesia on peroperative blood loss during retropubic prostatectomy. Int Urol Nephrol. 1982;14(4):399-405.	EA	17	RRP	100	Blood transfusion requirements: five patients under GA and one under EA received blood transfusion.	N/A	Correlation test was used but was not reported in ‘material and methods’.
	GA	21	RRP	100		N/A
McGowan et al.²¹21. McGowan SW, Smith GF. Anaesthesia for transurethral prostatectomy. A comparison of spinal intradural analgesia with two methods of general anaesthesia. Anaesthesia. 1980;35(9):847-53.	SA	50	TP	100	1. Mortality: four patients died (2.6%).2. Myocardial infarction: one patient in GACV group.3. Length of hospitalization: means were statistically the same.4. Blood transfusion requirements: number of patients transfused was greater in GACV group.	1. N/A2. N/A3. >0.054. N/A	Surgical procedures were performed by two urologists.GSCV group had more patients transfused but had the biggest prostate between the three groups.
	GASV	50		100
	GACV	50
	GACV	50

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[1] Address for correspondence: Fabiano Timbó Barbosa, Universidade Federal de Alagoas – Faculdade de Medicina, Av. Lourival Melo Mota, s/n^o, Tabuleiro do Martins — Maceió (AL) — Brasil, CEP 57072-970, Tel. (+55 82) 3202-3800, E-mail: fabianotimbo@yahoo.com.br