spinal for TURBT

[GaseousClay]

do most of you do the TURBT under GA because of the obturator reflex or are you guys doing spinal + obturator blocks or just spinal?

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[Ipassgas]

I just do GA. Not because of any reflex, but because of PACU time and space.
The case usually takes 15 minutes, but can take an hour. I don't have a 15 minute spinal that I can instantly turn into an hour spinal.
I also can't have ten people waiting around for sensation to return, thus General Anesthesia.

Edit: if I have a compelling reason to do a spinal vs general, I have no problem doing a spinal. It's just that in most comers, General is equally safe and speeds throughput (mainly due to PACU).

 

[psychbender]

GA, as well. In residency, most of these were under SAB, but my current Urologists all want GA, because of the obturator reflex (although, was never an issue in residency), and because they all think they will be really quick and a spinal will be overkill. They do not seem to realize that I've been watching the clock, and the usual induction to end of procedure time is regularly an hour or so, very rarely faster. They also don't leave the PACU any faster with GA, because of nursing issues. Occasionally, a patient with have moderate or severe COPD, and the Urologist is concerned about our ability to extubate afterwards, so they ask for a spinal. Jokes on them, because so far I have never been concerned about my ability to extubate, and I love doing spinals.

 

[Southpaw]

i do a spinal if i feel it's appropriate for the patient, or a general if not. i prefer a general as these cases are usually short. i only have one urologist who openly whines when i do a spinal, and since i have clear reasons for doing what i do, i just ignore him and move on with my day. and the case goes just fine....

 

[BuzzPhreed]

Always GA. Any bladder surgery. Even prostates. Most urologists in our area are doing TUVPs instead of the classic TURPs, which uses NS instead of glycine. A good GA with an LMA is faster. Doesn't matter that they're in lithotomy. I typically use a Supreme LMA. Unless they are huge then they get an ETT.

In PP, it's all about turnover. Learn that in residency. Practice it. Get good at it.

 

[Oggg]

Hmm. Now I'm confused. We do LMA for 99% of our TURBTs. One old urologist always demands spinal anesthesia to avoid the obturator reflex. One time I did GA and obturator blocks bilaterally, but it took me longer than I wanted, and then it turned out to be a ditzel TURBT, so I have no idea if it worked. I suppose you'd have to use sux to really abolish the reflex under GA.

 

[Arch Guillotti]

Hmm. Now I'm confused. We do LMA for 99% of our TURBTs. One old urologist always demands spinal anesthesia to avoid the obturator reflex. One time I did GA and obturator blocks bilaterally, but it took me longer than I wanted, and then it turned out to be a ditzel TURBT, so I have no idea if it worked. I suppose you'd have to use sux to really abolish the reflex under GA.

Spinal shouldn't block the obturator reflex.

 

[BuzzPhreed]

I've personally done or supervised probably close to 300 of these since I became a fully fledged consultant anesthesiologist in 2007 (we work with a large urology group that sees a lot of pathology... partial nephrectomies are almost a weekly occurrence... at least three DaVinci prostates per week, and I'm not in a huge practice or huge city... and not at even the biggest hospital in my city).

I've never personally seen nor heard of this mythical obturator reflex, even with significant lateral wall disease in some of these patients... other than reading about it in case reports. Spinal won't obliterate direct distal nerve stimulation which is supposedly the root cause of this. Most patients would not like an obturator block, I'd imagine.

Not terribly inclined to change my practice at this point. Hope I don't get burned.

 

[Oggg]

Makes sense that the spinal would not obliterate that response. I always thought it was weird that that urologist asked for SAB all the time.

 

[Arch Guillotti]

I've never personally seen nor heard of this mythical obturator reflex, even with significant lateral wall disease in some of these patients... other than reading about it in case reports.

I have seen it before and it's pretty impressive.

 

[BuzzPhreed]

I have seen it before and it's pretty impressive.

Oh, I believe it happens. Did it perf the bladder in your case?