Presentation Authors: Arun Panackal*, Manjeet Singh, Lal Krishnan, Srinivasa Rao, muscat, Oman
Introduction: Retrograde intra renal surgery(RIRS) for renal stone and ureteroscopic laser lithotripsy(URS) for proximal ureteric stone are considered to be the most challenging stone operation due to high risk of stone migration and complication. Many factors attribute to the complicity of this operation and one of the most challenging issue during operation is the intra operative ventilation induced renal movement which is an inconvenient factor that could make endoscopic targeting of stone challenging. Various types of anesthesia have been used to deceases the renal mobility during surgery like general anesthesia combined with spinal epidural anesthesia ,sacral block anesthesia and jet ventilation. In our study we incorporate a technique of short intraoperative apnea during general anesthesia and evaluated it outcome compared to normal general anesthesia.
Methods: We evaluated 500 patient of which 100 patient underwent RIRS for renal stone and 400 underwent URS for proximal ureteric stone from September 2015 to September 2018.All of them had stone >8mm and above diagnosed with ultrasound or CT scan as the primary imaging modality. Patients were randomized into two groups, group 1 patients (n = 250)underwent normal general anesthesia(GA)and patients in Group 2 (n = 250)underwent general anesthesia with short intra-operative apnea(GAIA), an interruption of ventilation between 3-5 min is induced during the operation .We adapted the anesthesia protocol that included the above implementation, patient with cardiac and respiratory issue were excluded for this maneuver. The operative and stone fragmentation time, stone migration, incidence of complication, stone free rate and hospital stay between the groups were compared.
Results: The two groups were well balanced in terms of baseline patient and stone characteristics.Average stone size was( 8mm-2.5cm).Short intraoperative apnea was a significant factor in improving all endpoints.Some endpoints were also affected by the stone's volume, number and density as well as the surgeon and anesthetist expertise. Patient received GAIP significantly improved in all four of the fellows endpoints, the mean operative and stone fragmentation time 45.6min and 25.5min in the GA and GAIPA groups respectively, the stone migration (75% vs 15%), incidence of complication (10% vs 2%), and stone free rate (63% vs 83%).However, there was no difference between GA and GAIA groups with regard to hospital stay.
Conclusions: The use of apnea during RIRIS AND URS under the hand of well experienced anesthetist has a significant positive impact on the overall improvement of surgical performance and effectiveness.It does not negatively affect the patient's anesthesia-related safety. Our results shows that GAIP provides safe and effective anesthesia with better surgical outcomes over GA in terms of operative time, stone migration,incidence of complication and stone free rate for RIRIS and URS in carefully evaluated and selected patients.