Diagnostic and operative endoscopy of the low urinary tract: a new anesthetic approach
The endoscopic procedures of the low urinary tract are one of the urologists’s most common procedures, but not always well tollerated particurarly by the male patients. Urethrocistoscopy, urethral dilatation, endoscopic removing of urethral stones, electrocution of urethral warts and many other endoscopic procedures of the low urinary tract are minimally invasive due to flexible instruments, but many patients still feel those procedures as a painfull moment. The anesthetic approaches are well documented, but still not standardized: they space from the lidocain gel to the intraspongiosum block, from the spinal anesthesia to the narcosis (1,2,3). We intend, with this new approach, to make safer and painless the endoscopic procedures, avoiding useless or risky anesthesia. The procedure requires an endourethral injection of an anesthetic mix made by Prilocain 5%, Lidocain 10% and a common uretral gel, made in foam and injected 5 to 15 minutes before the endoscopic procedure.
Materials and Methods
We selected 68 patients, all man with a median age of 43±2.6 years, whose needed endoscopic procedures of the low urinary tract from May 2014 to Dicember 2014. 7 of them underwent urethral dilatation, 23 observative cistoscopy, 2 urethral stone removing, 3 bladder neck incision, 16 internal urethrotomy (anterior urethra), 12 ureteral stent removing and 5 electocution of urethral warts. The anesthetic foam is made by 4 ml of Prilocaine cream 5%, 10 ml of Lidocaine solution 10%, 6 ml common urethral gel and 2 cc of air mixed by a three way stopcock connector for 1 minute. Right after the mixing, the compound was injected into the urethra and blocked there by a penis clamp from 5 to 15 minutes.
We ask the patients to quantify the pain they felt by the VAD scale (points 1 to 10) just after and 3 hours after the end of the procedure.
For no one of the patients was required the suspension of the procedures due to the pain or to switch to another anesthetic procedure. The mean VAD’s value just after the procedure was 2,47±1,31 and the mean value after 3 hours was 2,31±1,32. In both groups just the 5,8% of the patients had a VAD score ≥5. In literatur is described just in four cases a local ulceration and desquamation of gengival mucosa after a 30-minute application of EMLA (0.3 g) as a topical anaesthetic (4). In no one of the 68 patients was recorded short term advent events as stricture, rash, ulceration.
In health services and medical care, the actual costs of hospitalisationand not less the risks connected with spinal anesthesia, or narcosis, need a different approach, at least for the routine endoscopy that may be tolerated by the patient. In our study we found that the pain tolerance is effective and justify a minimal invasive anesthesia. This effectivenes is due to to the charateristics of the foam that has this kind of grip to the urethral mucosa and for his stay into all the urethral canal urethal , even up to the bladder neck, that give to the anesthetic compounds this kind of anesthetic power.
The limit of our study is that is just a safety and tolerability study, where we have insured that the anesthetic power of the foam we created was good enough to proceed with the endoscopy, and has no kind of adverse effect.
Another limit of our study is that it makes no comparison with all the other kind of anesthetic procedures. Despite this limits the power of this local anesthesia is surprising and should develop sufficient interest to encourage further studies, particularly the long term effects on the urethral mucosa and maybe a possible effect on bladder for other procedures.
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