Comparison of General versus Spinal Anesthesia in Patients undergoing Percutaneous Nephrolithotomy : A Prospective Randomized Study

Background Percutaneous Nephrolithotomy, widely used procedure by urologists for removing renal stones nowadays. Generally, it is preferred in general anesthesia but here in our study we have compared it with spinal anesthesia to know its safety and efficacy. Material and Methods Sixty patients of either sex, aged between 20-60 years, ASA – Grade I and II, with stones size larger than 15 mm posted for Percutaneous Nephrolithotomy were randomly selected. Patient was divided in two groups 30 each, Spinal Anesthesia (S) and General Anesthesia (G). Patient’s stones sizes, numbers & location, Anesthesia duration, Surgical duration, Recovery duration, Blood loss and Blood transfusion, Analgesic demand, post-operative Nausea & Vomiting, Patient satisfaction, Hospital stays and Heart Rate and Mean arterial pressure between two groups were compared. Results There was no significant difference in terms of mean age, weight, stones sizes, numbers and its location. The p value for Anesthesia duration and surgical duration were 0.144 and 0.22 which was insignificant. Recovery duration (p-value 0.007), Blood loss (p-value 0.004) were significantly lesser in spinal anesthesia group. There was no significant difference in nausea and vomiting, patient satisfaction when compared between two groups. But Analgesic demand, Blood Transfusion and Hospital stays significantly found to be decreased in spinal anesthesia groups (p<0.05). The mean of MAP showed no significant difference except in 10 and 20 minutes. Conclusion Spinal anesthesia tends to be as effective as general anesthesia for PCNL and beneficial in terms of recovery duration, blood loss, analgesic demands, hospital stays, hence decrease the cost of patient.


Introduction
Percutanous nephrolithomy (PCNL) is one of the most popular techniques to remove the renal stones in today's world.Its popularity is increasing day by day due to its less hospital stay, less scar marks, less post operative pain, fast ambulatory.Surgical Stages for PCNL are classified as Renal access, Tract dilatation, Nephroscopy & Stone disintegration and Nephrostomy tube insertion [1].General anesthesia during PCNL enables control of ventilation and also subjected to comfort of patients [2].Therefore, choice of anesthesia mostly choosen by anesthesiologists is general anesthesia [3].But, Anesthetics complications and patient's costs seems to be higher with general anesthesia when compared with spinal anesthesia [4].Hence, some of the previous studies shown that PCNL with spinal anesthesia have better outcomes in comparison with general anesthesia [5].Neuraxial block like spinal, epidural has advantage over general anesthesia in many urogenital surgeries including PCNL and is a choice of anesthesia in patients who are at high risk for surgery under general anesthesia [6].In this study, comparison between spinal & general anesthesia has been done in PCNL, its surgical outcomes and complications to know which one has better outcome.

Material and Methods
The study was conducted at Nobel Medical College Teaching Hospital Pvt.Ltd, Biratnagar, Nepal, during the period of 15 Patient was made prone after stabilization of anesthesia and cystoscopy and urethral catheterization was done on lithotomy position.HR, SPO2, SBP, DBP, MAP were recorded though-out the surgery and noted in every 10 minutes.Patient was reversed with Neostigmine & Glycopyrolate and transferred to PACU for monitoring.In Group S, Patients were placed in sitting position and under aseptic technique Inj.0.5% Bupivacaine (hyperbaric) was given in L3-L4 intervertebral space using 25 G quincke spinal needle.After placing the patient on supine position, the head end of table in tilted down for few minutes until the desired level being obtained.Then cystoscopy and urethral catheterization was done by urologist in lithotomy position and patient made prone.HR, SPO2, SBP, DBP, MAP were monitored through-out the surgery, every two minutes for the first 10 minutes and then every 5 minutes for another 20 minutes and noted in every 10 minutes intervals.Patient was shifted to PACU after the procedure for monitoring.PCNL was done in both groups with fluoroscopy control to locate the stone and nephrostomy tube was placed in case of residual stones.p-value <0.05 was considered significant.

Results
Out of 60 patients of ASA grade I between 20-60 years of age, of either sex posted for PCNL, randomly divided into two groups -Group G and Group S. and concluded that spinal is as effective and safe as GA and also under SA requirement of analgesics was less and showed hemodynamically stability during surgery and recovery period.This is same with our results where the need of analgesia was less in spinal group and also recovery time was less and hemodynamic stability was more in spinal groups.B. Borzouei et al [9] found that spinal anesthesia is feasible, safe and well tolerated in management of patient with renal stones, which also is our finding with spinal anesthesia group.Kuzgunbay B,et al [10] studied 82 patients undergoing PCNL and compared general anesthesia with Spinal anesthesia and found no significant differences in two groups in terms of age, location of stone, operative time and hospital stays, which was also insignificant in our study except hospital stays in spinal anesthesia was less than in general anesthesia group.Andreoni C,et al [11] studied impact of single dose of spinal analgesia on postoperative pain and recovery following PCNL, and found significant decrease in postoperative parenteral pain medication requirement and early ambulation and also found the decrease incidence of PONV, which was similar to our findings where spinal anesthesia group needed less amount of analgesic demand when compared with the general anesthesia groups.Sung soo kim et al [12] studied and compared two groups and reported that post operative fever rates and hospital stays were greater in the general anesthesia group in compared with Spinal anesthesia group and this was common finding in our study where general anesthesia group required more hospital stay than spinal anesthesia group.Mehrabi et al [13] studied 160 patients posted for PCNL in prone position and concluded that spinal anesthesia was an good alternative technique compared with general anesthesia and was similar in our findings.Singh et al [14] studied and compared PCNL under general anesthesia and CSEA and found that CSEA was as effective and safe, and also found that the requirement of analgesia within first 24 hours was lesser in CSEA group with shorter hospital stays.Though our study was with spinal anesthesia but single shot Spinal anesthesia showed a similar beneficial effect when compared with general anesthesia group.Tangpaitoon T et al [15] studied and compared Spinal with Regional anesthesia undergoing PCNL in 50 patients and found that regional anesthesia was associated with greater patient satisfaction, lesser post-operative pain and lesser adverse effects.Karacalar et al [16] compared spinal epidural block with general anesthesia and found that more patient satisfaction, less postoperative pain and lesser requirement of analgesia in spinal epidural group.Incidence of Vomiting, hypotension and bradycardia, there were no significant difference between two groups.Here the comparison was with epidural block and our study was with spinal anesthesia, despite this they showed more or less similar to our findings.Therefore, on the basis of above studies and the results of above findings spinal anesthesia seems to be superior when compared with general anesthesia for performing the PCNL.In our study as the location of stones, sizes were more or less similar, duration of anesthesia and surgery were not significant in both groups.But, overall findings like less analgesics demand, faster recovery and less blood loss, patient's satisfaction and less hospital stays in spinal groups and hemodynamically stability with less blood transfusion showed spinal anesthesia as superior or equally beneficial in performing a PCNL.Conclusion Thus, we can conclude that Spinal Anesthesia during PCNL is more acceptable and stable in terms of hemodynamic stability, less blood loss, reduced analgesic demand, faster recovery which in turn improved the patient's quality of life with less hospital stay.Therefore, spinal anesthesia can be preferable choice for an anesthesiologists & urologists thereby

Table 1 : Comparison of Patient's Characteristics:
We noted that there were no significant differences between two groups in terms of age, sex and weight.The demographic data are shown in Table1.

Table 4 : Comparison of Post-Operative OutcomesTable 4 :
In terms of Post operative outcomes,