[Downloaded free from http://www.saudija.org on Monday, February 11, 2019, IP: 115.178.237.

166]

Page | 268 ORIGINAL ARTICLE

Regional anesthesia in transurethral resection

of prostate (TURP) surgery: A comparative study
between saddle block and subarachnoid block
Susmita Bhattacharyya, A B S T R A C T
Subrata Bisai, Hirak Biswas,
Background: Spinal anesthesia is the technique of choice in transurethral resection of
Mandeep Kumar Tiwary, prostate (TURP). The major complication of spinal technique is risk of hypotension.
Suchismita Mallik, Saddle block paralyzed pelvic muscles and sacral nerve roots and hemodynamic
Swarna Mukul Saha derangement is less. Aims and objectives: To compare the hemodynamic changes and
adequate surgical condition between saddle block and subarachnoid block for TURP.
Department of Anaesthesiology, Material and methods: Ninety patients of aged between 50 to 70 years of ASA-PS
Burdwan Medical College and I, II scheduled for TURP were randomly allocated into 2 groups of 45 in each group.
Hospital, Kolkata, West Bengal,
Group A patients were received spinal (2 ml of hyperbaric bupivacaine) and Group
India
B were received saddle block (2 ml of hyperbaric bupivacaine). Baseline systolic,
diastolic and mean arterial pressure, heart rate, oxygen saturation were recorded and
measured subsequently. The height of block was noted in both groups. Hypotension
was corrected by administration of phenylephrine 50 mcg bolus and total requirement
of vasopressor was noted. Complications (volume overload, TURP syndrome etc.)
Address for correspondence:
were noted. Results: Incidence of hypotension and vasopressor requirement was less
Dr. Susmita Bhattacharyya, (P < 0.01) in Gr B patients.Adequate surgical condition was achieved in both groups.
Department of Anaesthesiology, There was no incidence of volume overload, TURP syndrome, and bladder perforation.
Burdwan Medical College and Conclusion: TURP can be safely performed under saddle block without hypotension
Hospital, Burdwan, and less vasopressor requirement.
West Bengal, India.
E-mail: agamoni_bhat@ Key words: Saddle block, spinal anesthesia, transurethral resection of the prostate
rediffmail.com

in peripheral pooling of blood , reducing the chance of

INTRODUCTION
circulatory overload and early detection of complications
Transurethral resection of the prostate (TURP) is the most like TURP syndrome, bladder perforation. Other advantages
common surgical intervention for patients with benign of spinal technique are it provides post-operative analgesia,
prostatic hyperplasia. Spinal anesthesia is the technique of reduces blood loss during surgery and prevents the need
choice in TURP. There is a chance of circulatory overload for tracheal intubation that may irritate the airway leading
due to excessive absorption of irrigation solution through to coughing and straining and may exacerbate postoperative
open prostatic venous sinuses during the surgical procedure. hemorrhage. Spinal anesthesia helps in reducing deep vein
Surgery is performed in lithotomy position. Increased venous thrombosis that is beneficial in TURP patients.
return due to lithotomy position may aggravate the situation.
TURP patients are particularly vulnerable to volume overload The major problem of spinal technique is risk of
as most of them belong to elderly age group and suffer hypotension. In spinal anesthesia due to sympathetic
from cardiopulmonary disorder. Spinal anesthesia helps blockade, there is vasodilatation leading to diminished
venous return which is the main contributory factor for
Access this article online
hypotension. The chemical sympathectomy due to spinal
Quick Response Code:
anesthesia extends for 2-6 dermatomes above the sensory
Website: level and at the same level with epidural anesthesia. In elderly
www.saudija.org patients with cardiac disease systemic vascular resistance may
decrease 25% whereas in normovolumic healthy patients
DOI: it may decrease only 15-18%.[1] This hypotension is usually
10.4103/1658-354X.158497 corrected by either administration of intravenous (i.v) fluids
or vasopressor. But liberal use of i.v fluid administration is

Vol. 9, Issue 3, July-September 2015 Saudi Journal of Anesthesia

[Downloaded free from http://www.saudija.org on Monday, February 11, 2019, IP: 115.178.237.166]

Bhattacharyya, et al.: Comparison between saddle block and suarachnoid block during transurethral resection of prostate surgery
Page | 269
dangerous particularly elderly patients with compromised the intraoperative period. If MAP falls >20% of baseline
cardiopulmonary function. The hemodynamic swinging is value i.v phenylephrine at a dose of 50 mcg bolus was given
more gradual and of less magnitude with epidural technique and repeated after 5 min if required. If HR was < than
but there is a chance of sacral sparing which may produce 60/min, Atropine (0.6 mg) i.v was given.
incomplete sacral nerve root block leading to inadequate
surgical anesthesia. Saddle block paralyzed pelvic muscles The level of sensory block was assessed by temperature
and sacral nerve roots. As lower level of block is achieved, (cold) sensation bilaterally and height of the block was noted
hemodynamic derangement is less and fluid requirement in both groups. Motor block was tested using modified
is also less. So there is minimum chance of circulatory Bromage scale as: 0 = no block, 1 = inability to raise the
overload. Considering all these merits and demerits of extended leg, 2 = inability to flex the knee, 3 = inability to
regional block, the aim of our study is to compare the flex the ankle joint or great toe. The operating condition
hemodynamic changes, vasopressor requirement and was assessed by block height and adequate relaxation of
adequate surgical condition between saddle block and pelvic floor muscles. TURP was performed with a Storz
subarachnoid block for TURP operation. 24 Fr resectoscope by the same surgeon by 1.5% glycine.
Any complication like TURP syndrome, congestive cardiac
failure, bladder perforation was noted.
MATERIALS AND METHODS
Statistics
This prospective randomized comparative study was Data were analyzed by SPSS 16.0 (Statistical Package
performed after obtaining consent approval from for the Social Sciences Inc, Chicago, IL, USA). version.
institutional ethics committee for six months. After taking Numerical variables were compared among t hese groups
written informed consent 90 patients of aged between by independent t test. All analysis was two tailed and P value
50 and 70 years of AmericanSociety of Anesthesiologist < 0.05 was considered as statistically significant.
physical status I,II having prostatic volume of 30-80 cc with
approximate operation time of 60-90 mins scheduled for
TURP were selected for our study. Taking into consideration RESULTS
the results of previous studies with an alpha error of 0.05
and a power of 80%, we calculated the sample size should be The two groups were comparable regarding age, weight,
at least 30 patients per group. Those having contraindication height, duration of surgery [Table 1]. The baseline SBP,
of regional anesthesia (local site infection, coagulopathy, DBP, MAP, HR, SpO2 were comparable between the
neurological disorder) were excluded from our study. two groups [Table 2]. Baseline SBP, DBP, MAP, HR,
SpO2 (Mean±SD): The fall of SBP, DBP, MAP was less
Anaesthetic procedure and protocol in Group B (saddle) than Group A (spinal) which was
In the operating room i.v. access was done with 18 gaze statistically significant [Table 3 and Figures 1 and 2]. Fall
cannula and patients were co-loaded with normal saline at of HR was more in Group A (11.84±5.85) than Group B
a rate of 6 ml/kg/hr. Standard monitors were attached to (4.76±2.01) which was statistically significant (P<0.0001).
record heart rate (HR), non-invasive blood pressure (BP), Phenylephrine requirement was significantly less in
electrocardiography and oxygen saturation (SpO2). (Group  B) [Table 4 and Figure 3].

The study population was randomly allocated into two Table 4 Phenylephrine consumption in both groups:
groups of 45 in each group in the following way: Group
A: received 2 ml of 0.5% bupivacaine with 25 gaze pencil DISCUSSION
point tip needle at L3-L4 or L4-L5 inter-vertebral space via
midline or paramedian approach in sitting position after The nerve supply to the prostate originates from the
ensuring free flow of cerebrospinal fluid. Patients were inferior hypogastric plexus and carries both sympathetic
placed supine with one pillow after administration of the fibers from T11 to L2 and parasympathetic fibers from S2
drug in the subarachnoid space. Group B received 2 ml of to S4. Pain fibers from the prostate, prostatic urethra and
hyperbaric 0.5% in the same manner as Group A but were bladder mucosa originate from S2 to S4 sacral nerves. Pain
remained in the sitting position for 10 minutes and then signal from bladder distension travels along with T11 to L2
were made supine with one pillow under the head. If block sympathetic fibers. The stretch sensation of bladder is carried
was not achieved, we excluded the patients from our study. by parasympathetic fibers of S2 to S4. Considering this
Baseline systolic BP, diastolic BP and mean arterial pressure innervation, height of regional block up to T10 is sufficient
(MAP), HR, SPO2 were recorded before administration of for TURP operation. Higher level of block may mask the
the drug intrathecally and then at 5 minutes interval during pain on perforation of the prostatic capsule [Table 5].

Saudi Journal of Anesthesia Vol. 9, Issue 3, July-September 2015

 [Downloaded free from http://www.saudija.org on Monday, February 11, 2019, IP: 115.178.237.166]

Bhattacharyya, et al.: Comparison between saddle block and suarachnoid block during transurethral resection of prostate surgery
Page | 270
Spinal anesthesia is technique of choice in TURP but the of 0.5% hyperbaric bupivacaine produce less fall of BP
height of the block should not cross T10 level. Various compared to other local anesthetics and hemodynamic
factors (baricity of anesthetic solution, age, position of differences may be very low even in elderly patients if
the patient, drug dosage, site of injection, drug volume) enough prehydration is provided.[3] Other studies also
influence the height of block following spinal anesthesia. used 2 ml of hyperbaric bupivacaine in TURP.[4] So we
There is no dose specification for per segmental spread used 10 mg of 0.5% hyperbaric bupivacaine in each group
in spinal anesthesia unlike epidural technique. Toumiren of our study population. There is a chance of the highest
stressed that concentration and volume of local anesthetics risk of irrigation fluid absorption during spinal anesthesia
along with position during and after injection are the major with spontaneous ventilation due to fall of central venous
factors affecting the distribution of local anesthetics.[2] pressure coupled with negative intrathoracic pressure
Pitkänen et al. suggested that administration of 10 mg in comparison during general anesthesia either with
spontaneous or mechanical ventilation.[5] Saddle block sets
up quickly, paralyzed pelvic muscles and sacral nerve roots

Table 1: Demographic data: Age, Weight,

Height, duration of surgery
Variables Spinal (gr. A) Saddle (gr. B) P-value
Age (years) 62.64±3.83 63.33±4.16 0.416
Weight (Kg) 53.93±9.28 53.29±9.31 0.743
Height (cm) 161.84±3.84 162.36±1.71 0.418
Duration of surgery (min) 82.49±1.53 82.27±1.01 0.419

Table 2: Baseline SBP, DBP, MAP, HR, SpO2

(Mean ± SD)
Baseline Gr. A Gr. B P-value
Figure 1: Fall of SBP, DBP, MAP SBP (mmHg) 135.87±3.24 134.27±4.54 0.06
DBP (mmHg) 84.20±4.78 84.20±5.23 0.21
MAP (mmHg) 100.40±3.85 99.09±4.43 0.137
HR (mins) 89.40±7.81 88.40±4.81 0.467
Spo2 (%) 99.87±0.97 99.80±1.01 0.750

Table 3: Maximum fall of SBP, DBP, MAP in

two groups
Maximum change of BP (mmHg) Gr. A Gr. B P-value
SBP 26.40±1.47 6.42±4.15 <0.0001
DBP 21.67±4.82 6.76±5.43 <0.0001
MAP 22.27±3.01 6.73±3.96 <0.0001

Table 4: Phenylephrine consumption in both

groups
Figure 2: Fall of heart rate in both the groups
Groups Phenylephrine consumption (µg)
Spinal (Gr. A) 120±30.90
Saddle (Gr. B) 7.78±2.60
P-value <0.0001

Table 5: Fall of heart rate in two groups

Groups Fall of heart rate
Gr. A 11.84±5.85
Gr. B 4.76±2.01
P-value <0.0001
Figure 3: Phenylephrine consumption between two groups

Vol. 9, Issue 3, July-September 2015 Saudi Journal of Anesthesia

[Downloaded free from http://www.saudija.org on Monday, February 11, 2019, IP: 115.178.237.166]

Bhattacharyya, et al.: Comparison between saddle block and suarachnoid block during transurethral resection of prostate surgery
Page | 271
and height of the block is less. So there is less chance of more deleterious for them and their observation was fall
hypotension. In saddle block lowest amount of drug is of heart rate by 10% in five subjects and rise of heart rate
administered intrathecally and patients are allowed in sitting by 10% or more in four subjects but not more than 90/
posture till the drug is fixed. Saddle block is used mainly min.[1] Jindal et al.[11]found that fall of heart rate was more
for anal and perineal surgeries. We used higher doses (2 ml) (21%) following spinal anesthesia than epidural (17%) and
than a conventional saddle technique but allow sufficient general anesthesia (14%). In our study we also found that
time to settle down hyper baric bupivacaine to achieve fall of HR was more in Group. A (11.84 ± 5.85) patients
higher block level. received spinal anesthesia than gr. B (4.76 ± 2.01) received
saddle block which was statistically significant (P<0.0001).
We found that the hemodynamic changes were more in in the
spinal group (Group A) than the saddle group (Group B). Limitations of the present study include we administered
Maximum fall of SBP, DBP, MAP of Group A were 26.40 higher doses of bupivacaine than conventional dose in
± 1.47, 21.67 ± 4.82, 22.27 ± 3.01 and those of Group B saddle block, did not estimate serum sodium, did not
were 6.42 ± 4.15, 6.76 ± 5.43, 6.73 ± 3.96 respectively and measure blood loss and absorption of irrigation fluid.
this fall of BP were statistically significant (P < 0.0001).
Fall of HR was more in Group A (11.84± 5.85) than In conclusion, transurethral resection of the prostate can
Group B (4.76 ± 2.01) which was statistically significant be safely performed under saddle block with less chance
(P < 0.0001). Phenylephrine consumption was significantly of hypotension and less vasopressor requirement.
less in Group B (7.78 ± 2.60) than Group A (120 ± 30.90)
which was statistically significant (P < 0.0001). Surgical REFERENCES
anesthesia was achieved in both groups. Motor block was
less in Group B (modified Bromage scale 1) than Group A 1. Rooke GA, Freund PR, Jacobson AF. Hemodynamic response and
(modified Bromage scale 3). There was no incidence of change in organ blood volume during spinal anesthesia in elderly
men with cardiac disease. Anesth Analg 1997;85:99-105.
TURP syndrome, congestive cardiac failure but one case 2. Tuominan M. Bupivacaine spinal anesthesia. Acta
of bladder perforation occurred in Group A which was Anaesthesiol Scand 1991; 35:1
treated by conservative approach. 3. Pitkanen M, Haapaniemi L, Tuominen M, Rosenberg PH.
Influence of age on spinal anesthesia with isobaric 0.5%
bupivacaine. Br J Anesth 1984;56:279-84.
Dobson et al., administered spinal and general anesthesia in 4. Ozmen S, Koşar A, Soyupek S, Armağan A, Hoşcan MB,
TURP patients and compared their efficacy. They found that Aydin C. The selection of regional anesthesia in TURP
general anesthesia produce more hemodynamic difference operation.Int Urol Nephrol 2003;35:507-12
5. Gehring H, Nahm W, Barewald J. Irrigation fluid absorption
after induction.[6] Bowmen compared post-operative pain during transurethral resection of prostrate. Spinal: GA Acta
in TURP patient after giving spinal and general anesthesia Anaesthesiol Scand1999;43:458.
and found that spinal group required less post-operative 6. Dobson PM, Caldicott LD, Gerrish SP, Cole JR, Channer KS.
Changes in hemodynamics variables during transurethral
analgesic.[7] Blake found that blood loss was less during resection of prostate: Comparison of general and spinal
regional than general anesthesia.[8] Gurajala et al. performed anesthesia Br J Anaesth 1994 , 72:267-71.
performed saddle block with 1ml of hyperbaric bupivacaine 7. Bowman GW, Hoerth JW, McGlotheen JS. Anesthesia for
transurethral resection of prostate: Spinal or general?. J Am
mixed with 50 mcg fentanyl in patient with aortic and Assoc Nurse Anesth 1981; 49:63-68.
mitral valve replacement for TURP without any deleterious 8. Blake DW. The general vs. regional anesthesia debate: Time
cardiovascular effect.[9] Hartmann et al. found 20-30% to re-examine the goals. Aust N Z J Surg 1995; 65:51-56.
9. Gujrala I, Vaddi S, Devraj R. Anaesthetic management of
incidence of hypotension after spinal anesthesia.[10] Ozmen
transurethral resection of prostate in a patient with aortic and
et al.[4] compared epidural (75 mg hyperbaric bupivacaine mitral valve replacement. Indian J Anesthesia 2011;55: 435-37.
mixed with 50 mcg fentanyl), spinal (15 mg hyperbaric 10. Hartmann B, Klasen J. The incidence risk factor for
bupivacaine mixed with 50 mcg fentanyl), saddle (10 mg hypotension after spinal anesthesia induction: an analysis
with automated data collection. Anesth Anal 2002;
hyperbaric bupivacaine mixed with 50 mcg fentanyl) 94:1521-29.
anesthesia during TURP. They found that intraoperative 11. Jindal P, Khurana G, Sharma CU, Sharma PJ, Chopra G, Lal
systolic arterial pressure and SpO2 remained more stable S. Haemodynamic and central venous pressure changes in
transurethral resection of prostate during general, spinal and
and sufficient surgical anesthesia was achieved quickly epidural anaesthesia: Acomparative Study. Indian J Anaesth
without statistically significant motor block (P < 0.001) in 2007;51:121-26.
the saddle group. All these findings corroborate with our
results. But fall of heart rate were significant (P value < How to cite this article: Bhattacharyya S, Bisai S, Biswas H, Tiwary
0.05) in three groups. Rooke GA, Freund PR, Jacobson MK, Mallik S, Saha SM. Regional anesthesia in transurethral resection
AF studied cardiovascular effects of spinal anesthesia on of prostate (TURP) surgery: A comparative study between saddle
block and subarachnoid block. Saudi J Anaesth 2015;9:268-71.
fifteen elderly patients with heart disease to evaluate the
Source of Support: Nil, Conflict of Interest: None declared.
consequences of hemodynamic changes which may be

Saudi Journal of Anesthesia Vol. 9, Issue 3, July-September 2015