¶ … Spinal vs. General Anesthesia The outcome of patients after undergoing transurethral resection of the prostate is examined under varying clinical situations to assess whether spinal anesthesia is associated with greater likelihood of positive outcome. Also examined in great detail are the potential for increased morbidity and mortality based on whether patients underwent general or spinal anesthesia during surgery. A large body of evidence indicates that there is no statistically significant difference between patient outcomes regardless of choice of anesthetic technique. This paper concludes that patients should be well educated and informed so they may make the choice most appropriate to their personal situation and comfort level preferences. An equal number of adverse side effects are associated with each anesthetic technique; as such patients should choose the technique that will result in the greatest post-operative satisfaction. The implications for practice suggest that physicians and anesthetists have an obligation to educate and inform their patients regarding the side effects and benefits of each anesthetic technique, and guide them in making the decision most appropriate to their personal well being.

Effects of Spinal vs. General Anesthesia

INTRODUCTION

The purpose of this paper is to examine whether the long-term outcome of patients who undergo transurethral prostate resection is affected by the choice of anesthetic technique used in surgery. The effects of spinal vs. general anesthesia including short- and long-term side effects have been studied in detail to ascertain which method of anesthesia will produce the greatest likelihood for a positive outcome. The adverse effects of each type of anesthesia are examined related to patients pre-existing complications, age and likelihood for positive outcome. Factors important to consider including patients perception of post-operative outcome and comfort level post-surgery. Each anesthetic technique is associated with differing post-operative side effects, which a patient must be informed of.

There are many physicians and anesthesiologist in the medical community who would argue that spinal anesthesia is associated with an improved outcome post-operative. This coincides with a mindset that less invasive procedures are related to more positive outcomes. However the greater body of researchers leads to the conclusion that the choice of anesthesia has little adverse effect on patient outcome. Both general anesthesia and spinal anesthesia are associated with minor adverse side effects, none of which are potentially significant related to long-term outcomes. There are certain situations and complications that are associated with each form of anesthesia, as discussed in greater detail below. Important to consider is the notion that patients who are undergoing TURP are at greater increased risk for complications regardless of Effects of Spinal vs. General Anesthesia whether they choose spinal or general anesthesia. Most patients undergoing this type of surgery present with complicating factors prior to surgery.

The most critical factor for anesthesiologists to consider is their patient's personal outcome preferences post-surgery and health prior to surgery. Physicians and anesthesiologists are obligated to discuss the likelihood for complication based on the patient's medical history. In most situations, outcome will be equally positive or negative regardless of anesthetic choice.

Literature Review

Patients undergoing TURP are typically advanced in age; as such the majority of research conducted focuses on the affects of anesthesia on a population of patients at an advanced age. The likelihood that adverse effects will occur as a result of surgery in an elderly population may be greater regardless of the type of anesthesia utilized. This fact is exhibited in a study conducted by the University of Kansas Medical Center on the immediate postoperative complications associated with transurethral prostatectomy. In the study, 13 institutions evaluated 3,885 patients and concluded that greater than 77% of patients had "significant pre-existing medical problems" which resulted in an increased risk for operative mortality and morbidity (Mebust, Holtgrewe, Cockett and Peters, 1989: 245). Such considerations are critical to keep in mind when considering patient outcomes. The adverse effects of anesthetic technique may be exhibited in greater numbers within this population, based on the likelihood that they enter surgery with an increased risk of morbidity and mortality not associated with anesthetic choice.

A primary consideration in selection of anesthesia is the possibility of increasing the chance for a more positive outcome. Patients may go into surgery with the false notion that spinal anesthesia is less invasive and therefore more likely to result in positive outcome post surgery. In many instances, studies reveal that an improved outcome after TURP is not associated with use of spinal anesthesia vs. general however. A study conducted by Alfred Hospital in Victoria Australia surveyed 261 patients who underwent TURP over a three-year...

Outcome measures evaluated included the patient's length of stay in the hospital and measure of patient's personal satisfaction with the outcome of surgery and the effects of anesthesia (Reeves, MD & Myles, 1999: 984). The results of the study revealed that though there were some minor adverse effects more commonly associated with the group receiving general anesthesia, an equal number of side effects different in nature could be associated with the spinal group, including back pain post-operation (Reeves, MD & Myles, 1999: 986).
Neither type of anesthetic was associated with a more positive outcome post-surgery, patients exhibited an equal likelihood to survive. As a result, the study concluded that a more positive outcome could not be associated with use of spinal anesthesia, and that in fact patients should be well informed prior to surgery, and make the decision as to which anesthesia to use on their own based on their knowledge of known side effects of each (Reeves, MD & Myles, 1999).

In a similar study, the outcomes of general anesthesia for a group of patients over 90 years of age was conducted at the Mayo Clinic between 1975-1985. Peri-operative mortality and morbidity were evaluated. In hospital mortality as well as the 30-day mortality rate was examined for patients undergoing prostatic resection under regional or spinal vs. general anesthesia, with results indicating a similar mortality rate in both groups (Hosking, Lobdell, Warner, Offord, Melton, 1989: 145). The study concluded that short-term morbidity and mortality and long-term outcome for patients undergoing prostatic resection was not affected in a statistically significant manner by choice of anesthetic technique (Hosking, Lobdell, Warner, Offord, Melton, 1989:146).

There is research indicating that adverse effects may result from anesthetic choice during prostatectomy, or at least evidence indicating that in general this procedure is more risky and likely to result in a greater likelihood for poor outcome. The Department of Urology at Freeman Hospital in Newcastle, UK conducted a study that examined complications and morbidity resulting from prostatectomy in 1400 men. The patients were examined for a period of 8 months, with patients undergoing TURP examined from 12 separate institutions. Data was collected related to "factors potentially affecting mortality and morbidity" which included the American Society of Anesthesiologists comorbidity scores. Complications post-surgery included 8% of patients developing sepsis, with a large percentage of patients having a "significantly increased rate of deaths and complications" and emergent situations requiring re-admission to the hospital (Thorpe, Clearly, Coldes, Vernon, Reynolds, Neal, 1994). The study concluded that due to the increased likelihood of complications, which were seen across population groups of varying ages, it is essential that care providers further examine potential increased causes for morbidity rates after prostatectomy (Thorpe, Clearly, Coldes, Vernon, Reynolds, Neal, 1994). The increased likelihood of complications was not directly tied to anesthetic technique, but this possibility was also not ruled out.

Some factors that have not been shown affected by anesthetic choice include the likelihood of increased intraoperative blood loss (Smyth, Cheng, Asokumar, Chung:

1995). No significant difference has been found in coagulation variable in patients undergoing TURP between spinal and general anesthesia groups (Smyth, Cheng, Asokumar, Chung: 1995) again supporting the notion those patients should make an informed decision without excessive concern related to significant side effects of general vs. spinal anesthesia. There has been some research however which indicates an increased risk for sub-clinical intravascular coagulopathies in TURP patients, however this is directly related to the mass of resected prostate tissue (Smyth, Cheng, Asokumar, Chung: 1995), and the risk can thus be mitigated based upon informed analysis of patients individual profile.

IMPLICATIONS TO PRACTICE

The majority of research conducted and presented indicates that anesthetic choice has little impact on the outcome of surgery for patients undergoing TURP and related procedures. Physicians should instead take into consideration the likelihood for increased overall morbidity and mortality rates in patients due to the nature of the surgery and increased likelihood that patients are coming into a procedure with increased complications prior to surgery. Physicians and Anesthesiologists might consider based on research the benefit of further educating patients regarding the general side effects of each type of anesthesia technique, and assess ways to assist them in making an anesthetic choice most appropriate to their personal situation. For example, in patients who have an increased mass of prostate tissue to be re-sected, patients must be educated regarding the potential for increased risk of coagulation as a side effect of TURP, and should make the anesthetic choice that is most appropriate for this particular situation.

General and spinal anesthesia both…