A Systematic Review and Single-Centre Experience of Ureterorenoscopy Under Local Anesthetic: A Safer Option for Anesthetically High-Risk Patients?

Abstract

Patients are living longer with an increasing number of co-morbidities. Minimally invasive ureterorenoscopy (URS) to manage upper tract calculi or transitional cell carcinoma (TCC) can be performed under general or spinal anaesthesia, however certain co-morbid patients are not suitable for this and may benefit from a different approach. We report on URS under local anaesthesia (LA) using intra-ureteric marcaine as the primary form of anaesthesia. We also aimed to perform a robust systematic review of this topic.   A retrospective analysis over 6 years was undertaken on all patients who underwent URS for calculi or TCC under LA, with the use of intra-urethral lidocaine gel (2%) and intra-ureteric marcaine (0.5%, 20ml) with sedoanalgesia as an adjunct. A systematic review and all English Language articles on ureteroscopic procedures with the use of LA with or without intravenous sedoanalgesia were selected and data extracted.   In our case series, twelve patients had a total of 42 procedures. Stone size varied from 4-35mm. Twenty-two percent of procedures (9/41) did not require any sedation or intravenous analgesia as an adjunct to the bupivacaine with a further 49% (20/41) requiring midazolam. (The anaesthetic chart was not available for one procedure). No procedures were abandoned and there were no conversions to general/spinal anaesthesia. There were no complications secondary to the use of LA. Eighty-one percent of cases (34/42) were performed as day-case or overnight stays. The complication rate was similar to that for conventional anaesthesia. The systematic review yielded 1121 procedures from 11 papers and 7 countries. In 32 cases the procedure was converted to general anaesthesia.  Stone clearance rates were between 78-100%. The procedures were well tolerated in 80-90% of cases.   This study highlights that URS can be safely performed under LA. It is well tolerated and represents an option for carefully selected patients who have been adequately counselled, and who would be at high risk from anaesthesia. Such patients may otherwise be considered “unfit” for endourological intervention.