Anaesthetic management for robotic-assisted laparoscopic prostatectomy: the first UK national survey of current practice.

Robotic-assisted laparoscopic prostatectomy (RALP) is the most common robotic surgical procedure, but there are little published data to inform anaesthetic practice. We aimed to characterise the range of anaesthetic practice for RALP in the United Kingdom through a national survey. We conducted an online national survey to determine current anaesthetic practice for RALP. The survey was distributed to all NHS hospitals within the UK that perform RALP. Thirty-four (79%) of 43 hospitals responded to the survey. Fourteen (41%) centres routinely provide spinal anaesthesia and 79% of these use diamorphine as their intrathecal opioid of choice. Thirty-one (91%) centres administer intravenous strong opioids intraoperatively, and a wide range of non-opioid analgesic agents are also administered. Five (15%) centres reported that they discharge a minority of patients on the day of surgery. High-volume centres are more likely to have a formalised enhanced recovery after surgery (ERAS) pathway and to provide ambulatory surgery for selected patients. This represents the first UK national survey of anaesthetic practice for RALP. The results of the survey revealed significant variation in anaesthetic practice implying a lack of consensus on best perioperative management.

Anesthesia concerns in prostate brachytherapy: An institutional experience.

BACKGROUND: Prostate cancer is a common cancer found in men worldwide. Brachytherapy is an established modality used for the treatment of these patients. Although anesthetic management of such patients is challenging but the ideal anesthetic technique has not yet been established. Our study aims to identify the most efficacious anesthetic technique for perioperative management of prostate cancer patients undergoing brachytherapy. METHODS: Retrospective analysis of ten patients who underwent 16 brachytherapy sessions under combined spinal epidural (CSE) anesthesia between April 2016 and December 2016 was done. The data were collected, tabulated using MS Excel, and statistically analyzed with EPI Info 6 and SPSS-16 statistical software (SPSS Inc. Chicago, USA) to draw relative conclusions. RESULTS: The median peak sensory dermatome level achieved was T6 and the median maximum motor block achieved was grade 2. The mean (± standard deviation (SD)) time to sensory regression to T10 (range T5-T8) dermatome was found to be 118.00 ± 47.110 (range = 0-238) minutes. Despite the presence of co-morbidities, minor intraoperative complications were observed only in two patients. The postoperative numerical rating scale (NRS) was less than 4 in all patients during the first 24 hours. None of our patients complained of nausea, vomiting, pruritus and respiratory depression. The mean (± SD) patient satisfaction score was 44.40 ± 0.871 (range : 1-5) at the end of 24 hours. CONCLUSIONS: CSE anesthesia is a safe and effective technique for anesthetic management of patients undergoing prostate brachytherapy.

General Anaesthesia Versus Regional Anaesthesia For Lumbar Laminectomy: A Review Of The Modern Literature.

BACKGROUND: Lumbar spine surgery can be performed using different anaesthetic techniques such as general endotracheal anaesthesia (GA) or spinal-based regional anaesthesia (RA). Few of the studies have been done to compare the outcomes of spinal anaesthesia versus general anaesthesia for lumbar laminectomies as both having some advantages as well as disadvantages but still it is controversial. The objective of current study is to make a comprehensive review of literature for comparing the outcomes of lumbar laminectomy performed under general anaesthesia versus spinal anaesthesia. METHODS: Literature search was performed by using PubMed, Google scholar and bibliography of related articles. To compare groups of general anaesthesia versus spinal anaesthesia, the variables focused were mean heart rate (HR), mean arterial pressure (MAP), blood loss during surgery, duration of surgery, post-operative anaesthesia care unit (PACU) time, postoperative narcotic use/pain scale, post-operative urinary retention, and post-operative nausea/vomiting. RESULTS: Data of eleven studies were presented in current article, of these five were randomized controlled trials, three case-controls and four were retrospective cohort studies. 5/8 studies reported that SA group having more hemodynamic stability with postoperative outcomes as compared to GA. Likewise, majority of reviewed studies (7/8) reported better pain control or decreased requirement of analgesics in SA group. Additionally, more than half of the reviewed studies (5/8) reported lower incidence of postoperative nausea and vomiting among patients of SA group.. CONCLUSIONS: The current study concluded that SA has better outcomes than GA in terms of hemodynamic stability and decrease postoperative adverse effects. So special attention should be paid for SA as an alternative to GA for lumbar laminectomy.

Nationwide Analysis of Urinary Retention Following Inguinal Hernia Repair: Results from the National Prospective Hernia Registry.

BACKGROUND: Urinary retention is one of the most common early postoperative complications following inguinal hernia repair (IHR). The aim of this study was to assess the incidence of postoperative urinary retention (POUR) and to identify associated risk factors. METHOD: Data of consecutive patients undergoing IHR from 2011 to 2017 were collected from a national multicenter cohort. POUR was defined as the inability to void requiring urinary catheterization. A multivariate analysis was conducted to identify independent risk factors for POUR. RESULTS: Of 13,736 patients, 109 (0.8%) developed POUR. Patients with POUR had longer hospital length of stay (p < 0.001). IHR was performed by a laparoscopic or an open approach in 7012 (51.3%) and 6655 (48.7%) patients, respectively, and spinal anesthesia was realized in 591 (4.3%) patients. Ambulatory surgery was performed in 10,466 (76.6%) patients. Multivariate analysis identified preoperative dysuria (0R 3.73, p < 0.001), diabetes mellitus (OR 1.98, p = 0.029) and spinal anesthesia (OR 7.56, p < 0.001) as independent preoperative risk factors associated with POUR. POUR was the cause of ambulatory failure in 35 (10.2%) patients who required unanticipated admission. CONCLUSION: The incidence of POUR following IHR remains low but impacts hospitalization settings. Preoperative risk factors for POUR should be considered for the choice of the anesthetic technique.

General anesthesia might be associated with early periprosthetic joint infection: an observational study of 3,909 arthroplasties.

Background and purpose - Periprosthetic joint infection (PJI) remains a devastating complication following total knee or total hip arthroplasty (TKA/THA). Nowadays, many studies focus on preventive strategies regarding PJI; however, the potential role of anesthesia in the development of PJI remains unclear.Patients and methods - All consecutive patients undergoing elective primary unilateral TKA or THA from January 2014 through December 2017 were included. Exclusion criteria included femoral fractures as the indication for surgery and previously performed osteosynthesis or hardware removal on the affected joint. Age, sex, BMI, ASA classification, type of arthroplasty surgery, type of anesthesia, duration of surgery, smoking status, and intraoperative hypothermia were recorded. Propensity score-matched univariable logistic regression analysis was used to control for allocation bias.Results - 3,909 procedures consisting of 54% THAs and 46% TKAs were available for analysis. 42% arthroplasties were performed under general anesthesia and 58% under spinal anesthesia. Early PJIs were observed in 1.7% of the general anesthesia group and in 0.8% in the spinal anesthesia group. The multivariable logistic regression model demonstrated an odds ratio for PJI of 2.0 (95% CI 1.0-3.7) after general anesthesia relative to the propensity score-matched patients who received spinal anesthesia.Interpretation - These results suggest a potential association between general anesthesia and early PJI. Future research using large-scale data is required to further elucidate this clinically relevant association.

Decreasing the Incidence of Postoperative Urinary Retention and Incontinence With Total Joint Replacement Patients After Spinal Anesthesia in the Postanesthesia Care Unit: A Quality Improvement Project.

PURPOSE: Patients with postoperative urinary retention (POUR) can develop bladder atrophy, urinary incontinence, and hypertension. The purpose of this quality improvement project was to implement standardized guidelines for bladder scanning for patients who have total knee or hip replacement to decrease POUR and incontinent episodes. DESIGN: A retrospective descriptive study was implemented in a 425-bed Magnet community hospital. METHODS: Patients were bladder scanned within the first hour of postanesthesia care unit admission. Straight catheterization was performed for those who had more than 400 mL of retained urine. The protocol included both total knee and total hip replacement surgeries with spinal anesthesia. Compliance with scanning, percentages with POUR, and incontinent episodes were reviewed. FINDINGS: POUR was detected in 46% of total knee replacement patients and 36% of total hip replacement patients. Incontinence rates for knee replacement patients decreased by 14% and by 2% for patients with total hip replacements. CONCLUSIONS: A bladder scanning protocol decreases postoperative incontinence. Bladder scanning also helps to decrease POUR by decreasing the potential risk of complications.

The morbidity associated with a TURP procedure in routine clinical practice, as graded by the modified Clavien-Dindo system.

Background: Transurethral resection of the prostate (TURP) is considered the reference surgical method of treating benign prostatic enlargement (BPE) causing obstruction. The procedure still carries a significant risk of perioperative morbidity according to previous reports. The aim of the present study was to disclose complications after TURP undertaken in routine clinical practice at a non-academic center.Methods: All patients with BPE submitted to TURP from January 2010 to December 2012 were evaluated for complications occurring during hospital stay, after discharge up to the end of the third post-operative month and finally for any late endourological re-interventions undertaken up to five years after TURP. All complications were graded according to the Clavien-Dindo system.Results: In total, 354 men underwent a TURP during the study period. In total, 47% had pre-operative urinary retention. Significant co-morbidity was seen in 17% of men (ASA III-IV). Spinal anaesthesia was applied to 312 men (88%). During hospital stay, major complications, graded as Clavien-Dindo ≥ III, was seen in only eight men (2.3%). Minor complications occurred in 91 men (26%). Between hospital discharge and follow-up visit major complications were noted in 12 men (3.4%). Minor complications occurred in 79 men (22%). The only factor that was associated with an increased risk of a major complication was general anaesthesia. Late complications, requiring an endourological re-intervention, occurred in 30 men (9.7%).Conclusion: TUR-P in routine clinical practice was associated with a low incidence of severe complications. TUR syndrome was very rare. Within five years a small proportion of men require the transurethral intervention to be redone.

A survey of anesthetic preference and preoperative anxiety in hip and knee arthroplasty patients: the utility of the outpatient preoperative anesthesia appointment.

PURPOSE: The general public's perceptions of anesthesia and the risks associated with it may be skewed. The outpatient preoperative appointment with an anesthesiologist allows for patient education regarding different anesthetic options and counseling regarding anxiety related to anesthesia and surgery. This study investigates whether the preoperative appointment for hip and knee arthroplasty alters patient preference for general or spinal anesthesia and reduces patient anxiety. METHODS: Sixty-two patients undergoing hip or knee arthroplasty were administered two verbal questionnaires at the preoperative clinic. The first questionnaire was completed prior to meeting the anesthesiologist and addressed patient anesthetic preferences, previous anesthetic experiences, and perioperative anxiety and need for information using the Amsterdam Preoperative Anxiety and Information Scale (APAIS). The second questionnaire was completed immediately following the appointment and addressed the patient's anesthetic preference, reasons for any preference changes, and anxiety levels and need for information using the APAIS. The clinic anesthesiologist was blinded to the nature of the study. RESULTS: Following the clinic appointment, a significant decrease in patients wanting general anesthesia (from 48 to 18%, P < 0.001) and a significant increase in patients wanting spinal anesthesia (from 39 to 76%, 95%, P < 0.01) was noted. A significant decrease in overall anxiety and anxiety related to the patients' upcoming surgeries and need for information was also noted. CONCLUSIONS: The preoperative anesthesia meeting serves an important role in educating patients regarding anesthesia, and can influence patients' choice of anesthetic while also reducing overall patient anxiety.

Determining the incidence of postoperative delirium in elderly patients who undergo orthopaedic surgical interventions in Turkey.

OBJECTIVE: To determine the incidence of postoperative delirium in elderly patients having undergone orthopaedic surgical interventions. METHODS: The cross-sectional study was conducted at the traumatology clinic of GATA Haydarpasa Training and Research Hospital in Istanbul, Turkey, from April 2014 to April 2015 and comprised patients who underwent orthopaedic surgical interventions. The subjects included were aged >65 years, had no mental disorders, no acute cerebrovascular disease, no known history of delirium and/or dementia. Data was collected using a self-generated questionnaire, mini mental state examination and delirium rating scale. SPSS 18 was used for data analysis. RESULTS: Of the 60 participants, 39(65%) were female and 21(35%) were male. The overall mean age was 77.07±8.66 years. Besides, 22(36.7%) patients hadmoderate cognitive impairment preoperatively, and 51(85%) had no delirium postoperatively while 9(15%) had delirium. CONCLUSIONS: Degree of cognitive impairment,advanced age and type of surgery were determined to be risk factors for delirium.

Effect of the menstrual cycle on circulation during combined spinal-epidural anaesthesia.

BACKGROUND: From adolescence to menopause, hormone levels during the menstrual cycle affect various body systems, from the cardiovascular system to the water and electrolyte balance. This study investigated the effect of different phases of the menstrual cycle on circulatory function relative to changes in body position and combined spinal-epidural anaesthesia (CSEA). METHODS: Forty-six women were selected who underwent scheduled gynaecological surgery, were classified as American Society of Anesthesiology (ASA) I-II, and met the test criteria. The sample was divided into the follicular and corpus luteal groups. Preoperative heart rate and blood pressure measurements were taken from the supine and standing positions. Heart rate measurements as well as systolic, diastolic, and mean blood pressure measurements were taken upon entering the operating room, at the beginning of the spinal-epidural anaesthesia, and 10, 20, and 30 min after anaesthesia was administered. RESULTS: The heart rates of patients in the corpus luteal group were higher than those of patients in the follicular group both before and after anaesthesia (P <  0.05). Significantly more ephedrine was used during the first 30 min of CSEA in the corpus luteal group than in the follicular group (P <  0.05). CONCLUSIONS: Although the effect was slight, women in the follicular phase were better able to compensate and tolerate circulatory fluctuations than those in the luteal phase.

Survey on the practice of anaesthesiologists in inguinal hernia surgery in Galicia. / Encuesta sobre la práctica de los anestesiólogos en la cirugía de hernia inguinal en Galicia.

OBJECTIVES: To evaluate the preference in the anaesthetic technique by anaesthesiologists for the management of inguinal hernia surgery in Galicia. MATERIAL AND METHODS: Using the National Catalogue of Hospitals of the Ministry of Health and Consumer Affairs in Galicia, a questionnair was sent to the Heads of Anaesthesiology Service and Coordinators of the Postanaesthesia Care Unit (PACU) with 11 questions on the anaesthetic technique chosen by anaesthesiologists in the management of patients for inguinal hernia surgery, as well as their reasons. RESULTS: The questionnaire was sent to 11 hospitals: 8 with PACU and 3 District. A total of 94 professionals responded, 56% with more than 10 years of experience, who performed between 8-10 procedures/month (58%) on an outpatient basis (61.54%). The most used anaesthetic technique was intradural in 52.8%, compared to 41.8% of general anaesthesia. Respondents with more than 10 years of experience preferred spinal anaesthesia in 38.6% of cases, compared to those with less experience (6.8%) (P=.037). One in 4 of those who chose general anaesthesia used ultrasound-guided interfascial blocks (27.5%). The local anaesthetic most used in intradural anaesthesia was hyperbaric bupivacaine (70.8%) at doses higher than 7mg. CONCLUSION: Intradural anaesthesia with hyperbaric bupivacaine was the technique most chosen by anaesthesiologists for the management of inguinal hernia surgery. The anaesthetic techniques chosen among the different hospitals did not follow a homogenous distribution. In this survey, there was a tendency to choose the technique associated with the experience of the anaesthesiologist.

Spinal anaesthesia in outpatient and conventional surgery: A point of view from experienced French anaesthetists.

INTRODUCTION: The objective of this investigation was to evaluate the practice of spinal anaesthesia among French anaesthetists in inpatient and outpatient settings. METHODS AND MATERIALS: A questionnaire was sent to members of the French Association of Anaesthetists involved in regional anaesthesia during the first 4months of 2015. The questionnaire included items on the practice of spinal anaesthesia (type of needle, local anaesthetic available, puncture and disinfection techniques, etc.) and on the anaesthetic techniques usually used in 5 surgical situations eligible for outpatient surgery (knee arthroscopy, inguinal hernia, transobturator tape, haemorrhoids, varicose veins in the lower limbs). RESULTS: Responses from 703 anaesthesiologists were analysed. Spinal anaesthesia was usually performed in a sitting position (76%) using a Whitacre needle (60%) with a 25 G (57%) diameter. Ultrasound before puncture was reported in 26% of cases due to obesity or spinal abnormalities. Among the 5 surgical situations eligible for outpatient spinal anaesthesia, the technique was typically proposed in 29-49% of cases. Bupivacaine was the most used local anaesthetic. Concerns over delays in attaining readiness for hospital discharge, urine retention, operation length, and surgeon's preference were the main reasons for choosing another anaesthetic technique in these situations. DISCUSSION: New local anaesthetics are beginning to be used for outpatient spinal anaesthesia due to their interesting pharmacodynamic profile in this context. This study will provide a basis for evaluating future changes in practice.

Anesthesia and analgesia methods for outpatient anterior cruciate ligament reconstruction.

INTRODUCTION: More and more anterior cruciate ligament (ACL) reconstructions are being performed as outpatient surgery in France, because of economic considerations. Postoperative pain is the most common reason for delayed discharge that could require hospitalization, and the main reason for unanticipated hospital admission. The purpose of this study was to define the best anesthesia and analgesia methods for ACL reconstruction. MATERIALS AND METHODS: This was a prospective, multicenter, comparative study performed between January 2014 and April 2015. Inclusion criteria were ACL reconstruction in patients above 15 years of age performed as an outpatient surgical procedure. The anesthesia techniques analyzed were general anesthesia, spinal anesthesia and quadruple nerve blockade. The analgesic methods studied were single-shot nerve blocks, continuous nerve blocks, peri-articular and intra-articular local infiltration analgesia (LIA), non-steroidal anti-inflammatory agents (NSAIDs) and intravenous corticosteroids. The main outcome criterion was pain on a visual analog scale (VAS). The secondary outcome criteria were delayed discharge of a patient who had undergone outpatient surgery, consumption of opioids and complications for the various anesthesia techniques and analgesia methods. RESULTS: In all, 680 patients were included in this study, which was 63% of the ACL reconstruction procedures performed during this period. The study population was 69% male and 31% female, with an average age of 30 years. Twenty-three patients (3.4%) could not be discharged on the day of surgery. No correlation was found with the anesthesia technique used. NSAID treatment was protective relative to delayed discharge (P=0.009), while opioid consumption was a risk factor (P<0.01). There were no differences in the pain levels related to the type of anesthesia. Peri-articular LIA of the hamstring tendon harvest site was effective. Intra-articular LIA did not provide better analgesia. Continuous nerve block had complication rates above 13%. DISCUSSION: All types of anesthesia were compatible with outpatient ACL reconstruction. No gold standard analgesia method can be defined based on this study's findings. However, we recommend multimodal analgesia associating peri-articular LIA or one-shot sensory saphenous nerve block, NSAIDs and corticosteroid treatment, and cryotherapy. LEVEL OF EVIDENCE: II, prospective comparative non-randomized study.

Anesthesia Technique and Mortality after Total Hip or Knee Arthroplasty: A Retrospective, Propensity Score-matched Cohort Study.

BACKGROUND: This propensity score-matched cohort study evaluates the effect of anesthetic technique on a 30-day mortality after total hip or knee arthroplasty. METHODS: All patients who had hip or knee arthroplasty between January 1, 2003, and December 31, 2014, were evaluated. The principal exposure was spinal versus general anesthesia. The primary outcome was 30-day mortality. Secondary outcomes were (1) perioperative myocardial infarction; (2) a composite of major adverse cardiac events that includes cardiac arrest, myocardial infarction, or newly diagnosed arrhythmia; (3) pulmonary embolism; (4) major blood loss; (5) hospital length of stay; and (6) operating room procedure time. A propensity score-matched-pair analysis was performed using a nonparsimonious logistic regression model of regional anesthetic use. RESULTS: We identified 10,868 patients, of whom 8,553 had spinal anesthesia and 2,315 had general anesthesia. Ninety-two percent (n = 2,135) of the patients who had general anesthesia were matched to similar patients who did not have general anesthesia. In the matched cohort, the 30-day mortality rate was 0.19% (n = 4) in the spinal anesthesia group and 0.8% (n = 17) in the general anesthesia group (risk ratio, 0.42; 95% CI, 0.21 to 0.83; P = 0.0045). Spinal anesthesia was also associated with a shorter hospital length of stay (5.7 vs. 6.6 days; P < 0.001). CONCLUSIONS: The results of this observational, propensity score-matched cohort study suggest a strong association between spinal anesthesia and lower 30-day mortality, as well as a shorter hospital length of stay, after elective joint replacement surgery.

Determinants of peri-operative blood transfusion in a contemporary series of open prostatectomy for benign prostate hyperplasia.

BACKGROUND: The objective of this study was to determine the factors responsible for peri-operative blood transfusion in a contemporary series of open prostatectomy for benign prostate hyperplasia and thus offer a guide for blood product management for the procedure. METHODS: This was a prospective study of 200 consecutive patients who underwent open prostatectomy for BPH from January 2010 to September 2013 at the Korle Bu Teaching Hospital, Accra. The data analyzed included the pre-operative blood haemoglobin level (Hb), presence of co-morbidities, the case type, indication for the surgery, ASA score, anaesthetic method used, systolic blood pressure, status of the operating surgeon, duration of surgery and the operative prostate weight. The transfusion of blood peri-operatively was also documented. RESULTS: The mean age of the patients was 69.1 years. Elective cases formed 83.5 % with refractory retention of urine being the commonest indication for surgery (68.0 %). The mean pre-operative Hb was 12.1 g/dl. Consultants performed 56.0 % of the prostatectomies. Transvesical approach was used in 90.0 % of the cases. The mean operative time was 101.3mins (range 35.0-240.0) with a mean operative prostate weight of 110.8 g (range 15-550 g). Most of the patients (82.0 %) had spinal anaesthesia. The blood transfusion rate was 23.5 %. The transfusion rate was significantly higher in patients with anaemia (p = .000), emergency cases (p = .000), the use of general anaesthesia (p = .002), a resident as the operating surgeons (p = .034), prostate weight >100 g (p = .000) and duration of surgery (p = .011). In a multivariable logistic regression analysis however only the pre-operative Hb (p = .000. OR 0.95, 95 % CI [0.035-0.257]) and the duration of surgery (p = .025, OR 1.021, 95 % CI [1.003-1.039]) could predict blood transfusion in open prostatectomy for BPH in this series. CONCLUSIONS: A 'group and save' policy should be the preferred blood ordering procedure for patients with Hb ≥ 13.0 g/dl scheduled for an elective open prostatectomy for BPH under spinal anaesthesia. A long operative time however may increase the need for blood transfusion.

Cost Analysis of Spinal Versus General Anesthesia for Lumbar Diskectomy and Laminectomy Spine Surgery.

BACKGROUND: Lumbar spine surgery can be performed using various anesthetic modalities, most notably general or spinal anesthesia. Because data comparing the cost of these anesthetic modalities in spine surgery are scarce, this study asks whether spinal anesthesia is less costly than general anesthesia. METHODS: A total of 542 patients who underwent elective lumbar diskectomy or laminectomy spine surgery between 2007 and 2011 were retrospectively identified, with 364 having received spinal anesthesia and 178 having received general anesthesia. Mean direct operating cost, indirect cost (general support staff, insurance, taxes, floor space, facility, and administrative costs), and total cost were compared among patients who received general and spinal anesthesia. Linear multiple regression analysis was used to identify the effect of anesthesia type on cost and determine the factors underlying this effect, while controlling for patient and procedure characteristics. RESULTS: When controlling for patient and procedure characteristics, use of spinal anesthesia was associated with a 41.1% lower direct operating cost (-$3629 ± $343, P < 0.001), 36.6% lower indirect cost (-$1603 ± $168, P < 0.001), and 39.6% lower total cost (-$5232 ± $482, P < 0.001) compared with general anesthesia. Shorter hospital stay, shorter duration of anesthesia, shorter duration of operation, and lower estimated blood loss contributed to lower costs for spinal anesthesia, but other factors beyond these were also responsible for lower direct operating and total costs. CONCLUSIONS: When comparing the benefits of spinal and general anesthesia, spinal anesthesia is less costly when used in patients undergoing lumbar diskectomy and laminectomy spine surgery.

Neuraxial vs general anaesthesia for total hip and total knee arthroplasty: a systematic review of comparative-effectiveness research.

BACKGROUND: This systematic review evaluated the evidence comparing patient-important outcomes in spinal or epidural vs general anaesthesia for total hip and total knee arthroplasty. METHODS: MEDLINE, Ovid EMBASE, EBSCO CINAHL, Thomson Reuters Web of Science, and the Cochrane Central Register of Controlled Trials from inception until March 2015 were searched. Eligible randomized controlled trials or prospective comparative studies investigating mortality, major morbidity, and patient-experience outcomes directly comparing neuraxial (spinal or epidural) with general anaesthesia for total hip arthroplasty, total knee arthroplasty, or both were included. Independent reviewers working in duplicate extracted study characteristics, validity, and outcomes data. Meta-analysis was conducted using the random-effects model. RESULTS: We included 29 studies involving 10 488 patients. Compared with general anaesthesia, neuraxial anaesthesia significantly reduced length of stay (weighted mean difference -0.40 days; 95% confidence interval -0.76 to -0.03; P=0.03; I2 73%; 12 studies). No statistically significant differences were found between neuraxial and general anaesthesia for mortality, surgical duration, surgical site or chest infections, nerve palsies, postoperative nausea and vomiting, or thromboembolic disease when antithrombotic prophylaxis was used. Subgroup analyses failed to find statistically significant interactions (P>0.05) based on risk of bias, type of surgery, or type of neuraxial anaesthesia. CONCLUSION: Neuraxial anaesthesia for total hip or total knee arthroplasty, or both appears equally effective without increased morbidity when compared with general anaesthesia. There is limited quantitative evidence to suggest that neuraxial anaesthesia is associated with improved perioperative outcomes. Future investigations should compare intermediate and long-term outcome differences to better inform anaesthesiologists, surgeons, and patients on importance of anaesthetic selection.

Is micro-percutaneous nephrolithotomy surgery technically feasible and efficient under spinal anesthesia?

The objective of the study was to present the clinical and operative effects of two types of anesthesia on micro-percutaneous nephrolithotomy ("microperc"). We retrospectively reviewed 116 patients who underwent microperc between August 2011 and September 2013. Patients were sorted into one of the two groups according to the type of anesthesia received: general (Group 1, n:53) or spinal (Group 2, n:63). Perioperative variables (age, stone size, location) and outcomes (operation time, success, complication rate) were evaluated and compared. Although there was a statistically significant difference in the mean age of patients (30.3 ± 22.1 vs. 45.8 ± 14.6, respectively, p < 0.001), mean body mass indexes were similar (p = 0.689). There was no substantial difference in terms of sizes and localizations of stones in the two groups (p = 0.970 and p = 0.795). While a significant difference was found in comparison of operative times (59.62 ± 32.56 vs. 40.98 ± 26.45 min, p < 0.001), there was no statistically significant difference in mean fluoroscopy times (124.92 ± 84.2 vs. 105.2 ± 61.0 s, p = 0.441). Stone-free rates were similar (90.5% vs. 93.6%, p = 0.297). We found no statistical differences between the two groups with respect to mean hemoglobin drop and hospitalization time (p = 0.015 and p = 0.917, respectively). The complication rates and analog pain scores were also similar (p = 0.543 and p = 0.365). Our results show that microperc is a feasible surgical modality in the treatment of kidney stone disease under both spinal and general anesthesia. Spinal anesthesia may be considered for patients at a high risk for general anesthesia, and also may be an alternative for patients who are concerned about and/or fearful of general anesthesia.