DOI: 10.4081/aiua.2022.2.

195
ORIGINAL PAPER

Spinal versus general anesthesia

in retrograde intrarenal surgery
Mehmet Yoldas 1, Tuba Kuvvet Yoldas 2
1 Tepecik Training and Research Hospital Urology Clinic, Izmir, Turkey;
2 Ege University Faculty of Medicine Anesthesiology and Reanimation Department, Izmir, Turkey.

Summary Aim: The indications for retrograde intra- SA also has advantages: it avoids some GA related com-
renal surgery (RIRS) have greatly increased, plications, allows an early mobilization, and is cost effec-
however, there is still no consensus on the use of spinal anesthe- tive. Few studies compared different anesthesia modality
sia (SA) during this procedure. The aim of this study was to during RIRS for renal stones and the only randomized
evaluate the comparability of surgical outcomes of RIRS per- controlled trial (9) compared RIRS performed under
formed under SA versus general GA for renal stones. combined spinal-epidural anesthesia with GA (10).
Materials and methods: This was a retrospective, observational The aim of this study was to compare surgical results,
study in patients scheduled for RIRS in a single teaching hospital intraoperative and postoperative complications, and anal-
in Turkey. Inclusion criteria were age > 18 years and the pres- gesia demand of RIRS performed under SA versus GA.
ence of single or multiple renal stones. We recorded information
concerning the site of lithiasis, the number of calculi, total stone
burden, and the presence of concomitant ureteral stones or MATERIALS AND METHODS
hydronephrosis. Results were evaluated in terms of surgical out- The data of the patient who underwent RIRS due to kid-
come, intraoperative and postoperative complications. Patients ney stones between January 2013 and January 2022 were
were followed-up until day 90 from discharge. reviewed retrospectively.
Results: The data of 502 patients, 252 in GA group and 250 in Those with missing data, bilateral RIRS, additional proce-
SA group, were evaluated. The stone-free rate was 81% in the
dure with RIRS (percutaneous nephrolithotomy, rigid
GA group and 85% in the SA group (p = 0.12). No cases of con-
ureterorenoscopy, etc.), urinary system anomaly (double
version from SA to GA were recorded. Complication rates were
collecting system, horseshoe kidney, pelvic kidney, uri-
similar in the 2 groups (19% vs 14.5%, p = 0.15).
nary diversion, etc.), previous stone surgery, extracorpo-
Conclusions: In our cohort, RIRS performed under SA and GA
was equivalent in terms of surgical results and complications. real shock wave lithotripsy (ESWL) history, patients with
nephrostomy or double J stent were excluded from the
KEY WORDS: Spinal Anesthesia; Retrograde intra-renal surgery; study.
Urolithiasis. A total of 502 patients were evaluated after exclusion cri-
Submitted 21 April 2022; Accepted 20 May 2022 teria. The ethics committee of the study was obtained
from the local Tepecik training and research hospital
local ethics committee. Informed consent was obtained
from all patients.
INTRODUCTION Stones and urinary systems of all patients were evaluated
With the evolution of instruments and techniques, retro- with computed tomography (CT) in the preoperative low-
grade intrarenal surgery (RIRS) gained an established role as dose stone protocol, urinalysis and urine culture, and
a minimally invasive procedure with fast recovery, short biochemistry including urea, creatinine, and hemogram.
hospitalization, and low rates of complications (1-3). All patients underwent the procedure with a clean urine
However, high-grade complications are still possible (4-5), culture or under antibiotic. All patients received pre-
and linked to the use of general anesthesia (GA). operative antibiotic prophylaxis. Stone protocol CT was
In this scenario, the use of spinal anesthesia (SA) could performed for stone-free rate assessment at 4 week post
move toward the reduction of invasiveness, costs, and operative in all patients, and patients with residual stone
hospitalization (6-7). less than 4 mm were considered as stone-free.
Endoscopic procedure of renal stones has increased in the We divided the patients in 2 groups, according to the
last decade in accordance with minimally invasive princi- anesthesia regimen chosen by the anesthesiologist: SA
ples. Ureteral stone treatment has been described and and GA.
widely accepted under SA (8-9), however, GA is usually Patients in both groups were compared in terms of demo-
offered during RIRS because it has some advantages: in graphic data such as age and gender, stone size, stone side,
case of a large stone burden the lithotripsy is easier with stone localization, number of stones, and stone density as
reduced renal movement caused by respiration, the com- Hounsfield Unit. The complications that developed within
fort for the patient is expected to be better, and there is both groups were grouped according to the modified
no risk for the anesthesia duration to be exceeded. Clavien-Dindo classification and compared one by one.
No conflict of interest declared.
Archivio Italiano di Urologia e Andrologia 2022; 94, 2 195
 M. Yoldas, T. Kuvvet Yoldas

RIRS procedure The mean age of GA group was 47.31(16-83) years and
Under spinal or general anesthesia, ureter and renal pelvis the mean age of SA group was 46.16 (20-75) years; GA
were evaluated under direct vision with a 7 F semi rigid group included 156 (62%) men and 96 (38%) women,
ureteroscope. The distance between the ureteropelvic SA group 176 (71%) males and 74 (29%) females.
junction and the external meatus was marked on the rigid The mean stone size was 13.57(+-2,6) mm2 in GA group
scope and a 0.038 inch guide wire was placed in the col- and 12.43(+-2,8) mm2 in SA group. There was no statis-
lecting system, 9.5 F ureteral access sheet was placed in tically significant difference between the two groups for
the collecting system on the guide as long as the measured stone size (p = 0.21).
distance. After the guide was taken out, a 7-8 F flexible In GA group, 124 patients had a stone in the right side
scope was entered. The stone was broken with a 272 or and 128 in the left side, in SA group 128 patients had a
360 micron laser probe. At the end of the procedure, the stone in the right side and 122 patients in the left side
ureter was evaluated with a semi-rigid scope. When nec- (p = 0.25).
essary, a double J stent stent was placed in the ureter. In GA group the stone was in the lower calyx, which was
the most difficult to reach, in 71 (28.4%) patients, where-
Anesthesia as in SA it was in the lower calyx in 71 (28.7%) patients
In all patients, a peripheral vein was cannulated and a sin- (p = 0.13).
gle dose of antibiotic prophylaxis was administered and The demographic and stone data of the patients are shown
normothermia maintained with warm air devices. in Table 1 and intraoperative and post-operative data of
Perioperative heart rate, peripheral oxygen saturation, the patients in Table 2.
and blood pressure values were monitored until transfer The operation time of the patients in GA group was 57.65
to the urological ward, when the Aldrete score was ≥ 8. (+-11.56) min, in SA group 54.3 (+-12.1) min. The dura-
In the SA group, anesthesia was administered using a 25 tion of scopy in the GA group was 24.29 (+-2.3) sec, in
gauge atraumatic Sprotte type needle with 10-20 mg the SA group. 26.32 (+-3.2) sec. Operation time and
hyperbaric 1% or 0.05% bupivacaine at L2-3 level to pro- duration of scopy was equal between the two groups (p =
vide a sensitive block up to T8-10. We administered an 0.29 and p = 0.35, respectively).
intranasal oxygen supply only if SpO2 was below 92%. Mean hospital stay was 1.06 (+-0.25) days in GA group,
Additional sedation was based on 2 mg midazolam bolus- and 1.37 (+-0.22) days in SA group. Although in SA
es or low-dose propofol infusion according to the group hospital stay was longer, there was no statistically
Schneider model effect-site target-controlled infusion 1 significant difference between groups (p = 0.12).
mg/mL, plus additional low-dose remifentanil (Minto Complications developed in 48 (19%) patients in the GA
model effectsite target-controlled infusion 0.5-2 ng/mL) if group and in 36 (14.5%) patients in SA group. No differ-
analgesia was inadequate. Target controlled infusion was ence was observed for grade 1 (p = 0.18) and grade 2 (p =
titrated based on the clinical response in the SA group. 0.11) complication rate between the two groups.
In the GA group, anesthesia was induced with propofol 2 None of our patients needed blood transfusion.
mg/kg and fentanyl 1 mg/kg and maintained with either Due to stenosis in the distal ureter in 3 of our patients in
propofol Schneider model effect-site target-controlled GA group, access to the renal pelvis was achieved by
infusion, sevoflurane or desflurane plus remifentanil with using baloon dilatation.
the Minto model effect-site target-controlled infusion High post-operative fever was detected in 20 patients of
according to the anesthesiologist’s choice. GA group: two of them received parenteral antibiotic in
In all cases in the GA group, anesthesia depth was moni- hospital, 2 of them were treated with oral antibiotic as
tored with the entropy index, targeting values between 40 outpatients, 16 patients were treated with antipiretic as
and 60. After induction, a laryngeal mask was placed outpatients; 16 patients in SA group developed fever and
avoiding the use of neuromuscular blockade when clinical- were treated with antipiretic as outpatients; 5 were treat-
ly feasible. We administered ranitidine plus ondansetron ed with oral antibiotic as outpatients.
intraoperatively as prevention of postoperative nausea and
vomiting. An opioid-free postoperative analgesia regimen
was preferred, based on acetaminophen 1000 mg plus Table 1.
ketorolac 30 mg. Rescue doses were administered if the The demographic and stone data of the patients.
pain numeric rating scale was above 4. GA group (252) SA group (250) P-value
Age 47.31+-3.5 46.16+-3.8 0.39
Statistical analysis
Stono size cm2 13.57(+-2.6) 12.43(+-2.8) 0.25
Continuous variables are reported as a mean ± SD and
Gender F 96(38%) 74 (29%) 0.22
compared with the Student’s t-test. Categorical variables
M 156 (62%) 176 (71%)
are presented as the absolute frequency (percentage) and
Laterality Right 124 128 0.52
compared with the chisquare or Fisher’s test, as appro-
Left 128 122
priate. All the statistical analyses were performed using
Localization 0.19
SPSS v.23 (IBM Corp., Armonk, NY), and significance con-
Lower calix 71 (28.4%) 71 (28.3%) 0.16
sidered for two-tailed p < 0.05. Middle calix 11 (4.4%) 21 (8.3%) 0.08
Upper calix 9 (3.7%) 5 (2%) 0.08
RESULTS Pelvis 118 (46.4%) 117 (46.2%) 0.15
The data of 502 patients, 252 in GA group and 250 in SA More than one calix 43 (16.9%) 36 (14.5%) 0.15
group, were evaluated retrospectively.

196 Archivio Italiano di Urologia e Andrologia 2022; 94, 2

 Spinal versus general anesthesia in retrograde intrarenal surgery

Table 2. laser technology have led to the increased use of URS for
Intraoperative and post-operative data of the patients. kidney and ureteral stones (12).
The 2022 EAU Urolithiasis Guidelines states that for retro-
GA group SA group P-value
grade stone removal both local and SA is feasible, howev-
Operation time (min) 57.65 54.3 0.29
er, the majority of patient still undergo GA (13). SA
(+/-11.56) (+/-12.1)
reduces anesthesiologic costs and hospital stay when com-
Scopy time (sc) 24.29 26.32 0.35
pared with GA. Generally, the anesthesiologist for rapid
(+/-2.3) (+/-3.2)
endoscopic procedures proposes SA because it has lower
Postoperative hospitalization (days) 1.06 1.37 0.12
risks of anaphylaxis, vascular, pulmonary, and neurologi-
(+-0.25) (+/- 0.22)
cal complications and compared with GA it does not pres-
Complications 48 (19%) 36 (14.5%) 0.15
ent the risk of intubation-related problems (14).
Degree 1 Use of antiemetics, antipyretics,
analgesics etc. 16 (6.2%) 11 (4.4%) 0.18
The overall complication rate was found to be 3.5% in a
Degree 1 Headache (cerebrospinal fluid leak series of 11.885 prospectively studied RIRS published by
after spinal anesthesia) 4 (1.6%) CROES. According to the modified Clavien classification,
Degree 2 Fever requiring antibiotics 4 (1.7%) 5 (2%) 0.11 2.8% of these complications are grade 1 and 2 (15).
Degree 3a Hematoma, urinoma 1 (0.4%) 1 (0.4%) 0.25 In our study, general complications were 48 (19%) in GA
Degree 3a Low grade ureteral injury 4 (1.7%) 5 (2%) 0.09 group, 36 (14.5%) in SA group; grade 1-2 complications
Degree 3a Nephrostomy insertion 3 (1.3%) 5 (2%) 0.08 20 (7.9%) in GA group and 20 (8%) in SA group.
Degree 3a Installing post op djs 2 (0.1%) 0 1.00 This may have been caused by the high density of diffi-
Degree 3b Urs again (due to ureteral stone) 8 (1.7%) 0 1.00 cult cases (lower pole, more than 1 stone and large stone
Degree 3b Foreign body in the ureter (djs guide
size) because we are a third-level hospital.
wire basket ureteral sheed etc.) 3 (1.3%) 0 1.00
Degree 4 Intensive care follow-up due to sepsis 6 (1.2%) 5 (2%) 0.19
For grade 1-2 complications, no significant difference was
Degree 5 Ex 1 (0.2%) 0 1.00 found between the two groups.
Stone free rate (SFR) 202 (81%) 214 (85%) 0.12
Urinoma and hematoma have been reported in the litera-
ture to be more likely in patients over 70 years of age,
using anticoagulants and having chronic kidney disease;
the probability of this complication is less than 1%.
Subcapsular hematoma and then urinoma developed in In our study, 2 (0.4%) patients in GA group had supcap-
GA group in 2 patients who were treated with double J sular hematoma cured with nephrostomy and double J
stent and percutaneous drainage. stent insertion. Bleeding is seen at a rate of 0.3-2.1% after
Low-grade ureteral injury occurred in 8 patients in GA URS, due to the introduction of the scope, stone breakage
group and 1 patient in SA group, and they were followed procedure or damage caused by the guide wire in the
up with double J stent. No avulsion occurred in any of calyceal structures. Bleeding often stops spontaneously,
our patients. but the hematoma caused by it may cause colic pain and
Nephrostomy or double J stents were placed in 8 patients hydronephrosis in the postoperative period. Six patients
in GA group and 1 patient in SA group due to renal colic in GA group, and one patient in SA group had nephros-
and hydronephrosis. Stents were removed 2 weeks later tomy due to clot hydronephrosis and renal colic. Two
due to regression of hydronephrosis and colic. patients in GA group had double J stent for the same rea-
Re-URS was performed in 8 of our patients in GA group sons and the catheters were removed 2 weeks later in
because of the steinstrasse; this complication was not their follow-up.
observed in any of our patients in SA group. Stone tract (Clavien 3b), which is an important complica-
In GA group, the laser probe tip or the hydrophilic tip of tion, was seen in 9 (0.6%) patients in a study conducted
the Sensor guide remained in the renal pelvis in 3 patients with 1571 patients (16). This complication is the only that
as a result of a fracture of the device. was found associated to stone size. In fact, SFR after RIRS
Six patients in GA group and one patient in SA group were was found significantly correlated with the stone size (17).
followed up in the post-operative intensive care unit. In our study, Steinstrasse was observed in 8 (1.7%)
In GA group, one patient died due to post-operative patients in GA group who had stones larger than 3 cm
multi-organ failure and sepsis. according with the literature. The fragments were endo-
scopically extracted and the stones cured. This complica-
tion was not observed in any patient in SA group.
DISCUSSION Loss of the integrity of the stents is also an important
The first treatment choice for intrarenal stones < 2 cm in problem. Zisman et al. (18) evaluated ureteral stents with
size and hard stones is RIRS (11). spontaneous multiple fragmentations observing that the
In this study, we report similar SFR, intraoperative and fracture resistance was decreased dramatically. Fractured
postoperative outcomes and complications in patients stents were removed after 4 weeks. Due to cost problems,
treated with RIRS under GA versus SA. Our results concord some materials were used longer than the recommended
with the previous published studies and added value to the time. We may have encountered this complication due to
use of SA for RIRS, particularly when a fast recovery and a the high stone load in our cases and the long duration of
short hospitalization are intended to be achieved. Kidney the cases.
stone surgeries are developing towards to non-invasive In the prospective study of CROES, it was reported death
methods. Endoscope miniaturization, improved deflection in 5 cases due to sepsis, pulmonary embolism, multiple
mechanism, improved optical quality, and advancement in organ dysfunction, and cardiac causes (15).

Archivio Italiano di Urologia e Andrologia 2022; 94, 2 197

 M. Yoldas, T. Kuvvet Yoldas

In our series, 6 patients were followed up with post-oper- cations of spinal anaesthesia in percutaneous nephrolithotomy: our
ative sepsis: 2 with hydronephrosis due to ureteral stone, experience. J Clin Diagn Res. 2017; 11:UC08.
1 with hemorrhage and clot-related hydronephrosis with- 8. Cybulski PA, Joo H, Honey RJ. Ureteroscopy: anesthetic consider-
out stones, and 3 patients with sepsis without any stone ations. Urol Clin North Am. 2004; 31:43.
or hydronephrosis. All the patients had pre-operative
hydronephrosis. These results are comparable to most 9. Zeng G, Zhao Z, Yang F, et al. Retrograde intrarenal surgery with
combined spinal-epidural vs general anesthesia: a prospective ran-
previous report of the literature. domized controlled trial. J Endourol. 2015; 29:401.
One of our patients died due to post-operative sepsis and
multiorgan failure in GA group. This 76-year-old patient 10. Bosio A, Dalmasso E, Alessandria E, et al. Retrograde intra-renal
had a stone size of 0.9 cm2 and 2 stones in the lower calyx surgery under spinal anesthesia: the first large series. Minerva Urol
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but preoperative hydronephrosis was present. The stone 11. Wendt-Nordahl G, et al. Do new generation flexible ureteroreno-
size was small but the stone was difficult to reach and the scopes offer a higher treatment success than their predecessors? Urol
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stenosis. In the literature, it is emphasized that sepsis is ureterorenoscopy and laser fragmentation (URSL) for large renal
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Consequently, UAS should be used during RIRS and high 13. Skolarikos A, Neisius A, Petr̆ík A, et al. EAU Guidelines on
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In the study of 207 patients conducted by Reşorlu et al.
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(19) in 2012, it was described a new scoring system
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198 Archivio Italiano di Urologia e Andrologia 2022; 94, 2