Transurethral Resection of Prostate (TURP)
Summary
Dose: 2 ml 0.5% hyperbaric (or isobaric) bupivacaine + 15 mcg fentanyl.
Position: Sitting, then immediately supine. Wait for block to reach T10 then lithotomy.
Expectation: Surgical block for up to 120 minutes post-spinal.
Evidence
A number of studies have found that 15 mg bupivacaine (isobaric or hyperbaric 0.5%), injected in either the sitting or lateral position, is sufficient for TURP [1,2,3,4,5,6].
10 mg of both hyperbaric and isobaric bupivacaine (sitting, lithotomy within 3 min), in concentrations ranging from 0.5% to 0.1%, have been studied in TURP/TURBT patients [7]. Average surgical duration varied from 32-51 minutes in the groups, but only one out of ninety patients (1.1%) required general anaesthesia. All groups achieved a median pinprick level of T10 or above.
Another investigator reviewed 10 mg and 7.5 mg of both isobaric and hyperbaric bupivacaine [1,2].
Isobaric (sitting, set 2 min, then lithotomy) resulted in levels of T10 for both 7.5 mg and 10 mg. 10-20% of patients required general anaesthesia in each group.
Hyperbaric (sitting, then lithotomy) resulted in levels of L2-L4 and T12 for 7.5 mg and 10 mg respectively. Interestingly, 10-20% in each group required general anaesthesia or intravenous analgesics.
10 mg isobaric bupivacaine (sitting, set 2 min, supine for 2 min, then lithotomy) reached a peak level of T8, however 15% need intravenous fentanyl +/- light general anaesthesia [8].
7.5 mg hyperbaric bupivacaine (patient lateral, supine for 15-20 minutes, then lithotomy) maintained a block to T10 for 30 minutes and T12 for 45 minutes [4]. Surgical duration was ~36 minutes. Two patients experienced apprehension and two patients felt pain, despite not requiring analgesics.
7.5 mg isobaric 0.5% bupivacaine resulted in an average T10 level and no failures, with average surgical duration of 60 minutes [9].
7.5 mg isobaric bupivacaine with 15 mcg fentanyl (sitting, immediately supine) achieved a median height of T6 and was successful for TURP duration ~75 minutes [10].
A dose of only 4 mg hyperbaric bupivacaine with 25 mcg fentanyl was found to be successful in 97% of patients (~ 70 years) for TURP duration of ~ 40 minutes [11]. Patients remained sitting for 5 minutes after injection, before being placed supine. The mean block height was only L1.
A combination of 4 mg isobaric bupivacaine with 25 mcg fentanyl (made up to 1.5 ml with sterile water) was successful for TURP [9]. Initial injection details (sitting or lateral) were omitted. However, for surgical duration ~ 60 minutes, this dose achieved an average block level to T10, with no documented failures.
References
Axelsson et al. Spinal Anaethesia with Hyperbaric 0.5% bupivacaine: Effects of volume. Acta Anaesth Scand 1982;26:439-445.
Axelsson et al. Spinal anaesthesia with glucose-free 0.5% bupivacaine: effects of different volumes. BJA 1984;56:271-278
Nielsen et al. Plain bupivacaine: 0.5% or 0.25% for spinal analgesia? BJA 1989;62:164-167
Sundes et al. Spinal analgesia with hyperbaric bupivacaine: Effects of volume of solution. BJA 1982;54(1):69-74
Alston et al. Spinal anaesthesia with 0.5% bupivacaine 3 ml: comparison of plain and hyperbaric solutions administered to seated patients. BJA 1988;61:385-389.
Mukkada et al. Effects of dose, volume, and concentration of glucose-free bupivacaine in spinal anesthesia 1986;11(2):98-101
Malinovsky et al. Intrathecal anesthesia: ropivacaine v bupivacaine. Anesth Analg 2000;91:1457-60.
Sheskey et al. A dose-response study of bupivacaine for spinal anaesthesia. Anesth Analg 1983;62:931-5.
Karamaz et al. Low-dose bupivacaine-fentanyl spinal anaesthesia for transurethral prostatectomy. Anaesthesia 2003;58:526-530
Erdil et al. The effects of intrathecal levobupivacaine and bupivacaine in the elderly. Anaesthesia 2009;64:942-946
Kim SY et al. Comparison of intrathecal fentanyl and sufentanil in low-dose dilute bupivacaine spinal anaesthesia for transurethral prostatectomy. BJA 2009;103(5):750-4.