Urolithiasis DOI 10.1007/s00240-015-0776-2
ORIGINAL PAPER
The efficacy and safety of percutaneous nephrolithotomy under general versus regional anesthesia: a systematic review and meta‑analysis Chunxiao Pu1 · Jia Wang1 · Yin Tang1 · Haichao Yuan1 · Jinhong Li1 · Yunjin Bai1 · Xiaoming Wang1 · Qiang Wei1 · Ping Han1
Received: 9 December 2014 / Accepted: 13 April 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract This meta-analysis was performed to evaluate the efficacy and safety of percutaneous nephrolithotomy (PCNL) under regional anesthesia (RA) vs. general anesthesia (GA). A systematic literature search in the electronic databases (Cochrane CENTRAL, Medline and EMBASE) was performed up to April 2014. Twelve trials, including 1954 patients, met the inclusion criteria and were included in the final analysis. Our pooled analysis showed that PCNL under RA could reduce surgical duration (MD, −2.47; 95 % CI, −3.51 to −1.44), hospitalization period (MD, −0.48; 95 % CI −0.93 to −0.04), fluoroscopy time (MD, −0.48; 95 % CI, −0.83 to −0.14), blood transfusion (OR, 0.59; 95 % CI, 0.38–0.92), postoperative pain (MD, −1.99; 95 % CI, −2.2 to −1.78), and analgesic requirements (MD, −19.14; 95 % CI, −26.64 to −11.63). However, there was no difference between RA and GA groups with regard to stone-free rate (OR, 1.09; 95 % CI, 0.86–1.37) and postoperative complications associated with PCNL (OR, 0.95; 95 % CI 0.58–1.54). Our results show that PCNL under RA offers several potential advantages over GA in terms of surgical duration, hospitalization period, fluoroscopy time, blood transfusion, postoperative pain, and analgesic requirements, but both anesthetic techniques appear to be equivalent with regard to the stone-free rate and complication rate. Along with the suggested favorable hemodynamic profile and lower cost, RA may prove a better alternative than GA. Chunxiao Pu and Jia Wang contributed equally to this work and should be considered co-first authors. * Ping Han [email protected] 1
Department of Urology, West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu 610041, Sichuan, People’s Republic of China
Keywords Anesthesia · Efficacy · Meta-analysis · Percutaneous nephrolithotomy · Safety
Introduction Urolithiasis is a major healthcare concern that affects approximately 10 % of the American population [1]. There are various accepted treatment options, such as percutaneous nephrolithotomy (PCNL), extracorporeal shock wave lithotripsy, and retrograde intrarenal surgery, to manage urinary tract stone disease. Of these, PCNL has become an established procedure for large, multiple, and complex upper urinary stones. Since the introduction of PCNL into clinical practice by Fernström and Johansson [2], several modifications, such as mini-PCNL, tubeless PCNL, and PCNL in the supine position, have been reported in an attempt to decrease morbidity, surgical duration, and length of hospitalization [3]. PCNL can be safely performed under both general anesthesia (GA) and regional anesthesia (RA), including epidural anesthesia (EA), spinal anesthesia (SA), and spinalepidural anesthesia (SEA). Typically, PCNL is performed with the patient under GA to control breathing and improve patient comfort. However, there are more complications associated with GA than RA, such as pulmonary atelectasis, intraoperative hemorrhage, vascular damage, and neurological disorders [4]. In addition, patients are considered unfit for GA due to severe comorbidities or the need to lower cost. Recent investigations have shown that PCNL under RA has some potential advantages over GA, such as cost-effectiveness, lower postoperative pain, lower requirement for analgesic drugs, and the avoidance of side effects from multiple medications during GA [5–8]. However, there is no consensus regarding which is more effective
13
Urolithiasis
and safer. Therefore, we performed a systematic review and meta-analysis to compare the efficacy and safety of RA and GA during surgery for upper urinary stones based on currently available clinical trials.
Materials and methods Literature search A literature search restricted to the English language of the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and EMBASE up to April 2014 was performed with the following search terms: “percutaneous” and (“nephrolithotomy” or “nephrostomy” or “nephrolitholapaxy”) and (“calculi” or “stone” or “nephrolithiasis” or “urolithiasis”) and (“anesthesia” or “general anesthesia” or “regional anesthesia” or “epidural anesthesia” or “spinal anesthesia” or “spinal-epidural anesthesia” or “neuraxial anesthesia”). Additional studies in the reference lists of all retrieved articles were manually searched. Inclusion and exclusion criteria All studies that met the following criteria were included: (1) randomized or non-randomized controlled trials (RCTs or non-RCTs); (2) patients with large renal pelvic calculi (>2 cm); (3) comparisons of the efficacy and safety of PCNL under RA vs. GA; (4) accurate data available for analysis; and (5) access to the full text of the study. The exclusion criteria included contraindications for RA or GA, such as irreversible coagulopathy, vertebral deformity, neuropathy, severe cardiac and respiratory insufficiency, renal failure, congenital renal anomalies. Quality assessment of the studies Two authors independently extracted data from the included studies using a standardized data collection form. Discrepancies were settled by consensus after discussion with a third author. Extracted data included author names, year of publication, country of publication, type of study design, type of intervention, sample size, body mass index, stone burden, location of renal access, and surgical position. We contacted the authors by e-mail to obtain missing information when needed. Outcome measure The following outcome variables of comparisons between the RA and GA groups across studies were collected for further meta-analysis: surgical duration, hospitalization period, fluoroscopy time, pain score, postoperative
13
analgesic requirement, blood transfusion, stone-free rate, and postoperative complications associated with PCNL. Stone-free was defined as no stone with a maximum diameter of >4 mm evaluated by radiography or ultrasonography of the kidneys, ureters, and bladder at the first postoperative day. Postoperative pain was assessed by use of the visual analog scale (VAS) for grading pain from 0 (no pain) to 10 (most severe pain). The modified Clavien classification (MCC) system was used to assess postoperative complications of PCNL ranging from MCC grade 1–5 [9]. Statistical analysis Methodological quality assessment was independently performed by two authors according to the guidelines published in the Cochrane Handbook for Systematic Reviews of Interventions (v. 5.1.0), which included randomization, allocation concealment, blinding, and description of withdrawals and dropouts [10]. Disagreements were resolved by consultation with a third party, when necessary. All analyses were performed using Review Manager, version 5.2.0 (Cochrane Collaboration, Oxford, UK). We estimated the odds ratio (OR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes, both with a 95 % confidence interval (CI). A probability (p) value
ORIGINAL PAPER
The efficacy and safety of percutaneous nephrolithotomy under general versus regional anesthesia: a systematic review and meta‑analysis Chunxiao Pu1 · Jia Wang1 · Yin Tang1 · Haichao Yuan1 · Jinhong Li1 · Yunjin Bai1 · Xiaoming Wang1 · Qiang Wei1 · Ping Han1
Received: 9 December 2014 / Accepted: 13 April 2015 © Springer-Verlag Berlin Heidelberg 2015
Abstract This meta-analysis was performed to evaluate the efficacy and safety of percutaneous nephrolithotomy (PCNL) under regional anesthesia (RA) vs. general anesthesia (GA). A systematic literature search in the electronic databases (Cochrane CENTRAL, Medline and EMBASE) was performed up to April 2014. Twelve trials, including 1954 patients, met the inclusion criteria and were included in the final analysis. Our pooled analysis showed that PCNL under RA could reduce surgical duration (MD, −2.47; 95 % CI, −3.51 to −1.44), hospitalization period (MD, −0.48; 95 % CI −0.93 to −0.04), fluoroscopy time (MD, −0.48; 95 % CI, −0.83 to −0.14), blood transfusion (OR, 0.59; 95 % CI, 0.38–0.92), postoperative pain (MD, −1.99; 95 % CI, −2.2 to −1.78), and analgesic requirements (MD, −19.14; 95 % CI, −26.64 to −11.63). However, there was no difference between RA and GA groups with regard to stone-free rate (OR, 1.09; 95 % CI, 0.86–1.37) and postoperative complications associated with PCNL (OR, 0.95; 95 % CI 0.58–1.54). Our results show that PCNL under RA offers several potential advantages over GA in terms of surgical duration, hospitalization period, fluoroscopy time, blood transfusion, postoperative pain, and analgesic requirements, but both anesthetic techniques appear to be equivalent with regard to the stone-free rate and complication rate. Along with the suggested favorable hemodynamic profile and lower cost, RA may prove a better alternative than GA. Chunxiao Pu and Jia Wang contributed equally to this work and should be considered co-first authors. * Ping Han [email protected] 1
Department of Urology, West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu 610041, Sichuan, People’s Republic of China
Keywords Anesthesia · Efficacy · Meta-analysis · Percutaneous nephrolithotomy · Safety
Introduction Urolithiasis is a major healthcare concern that affects approximately 10 % of the American population [1]. There are various accepted treatment options, such as percutaneous nephrolithotomy (PCNL), extracorporeal shock wave lithotripsy, and retrograde intrarenal surgery, to manage urinary tract stone disease. Of these, PCNL has become an established procedure for large, multiple, and complex upper urinary stones. Since the introduction of PCNL into clinical practice by Fernström and Johansson [2], several modifications, such as mini-PCNL, tubeless PCNL, and PCNL in the supine position, have been reported in an attempt to decrease morbidity, surgical duration, and length of hospitalization [3]. PCNL can be safely performed under both general anesthesia (GA) and regional anesthesia (RA), including epidural anesthesia (EA), spinal anesthesia (SA), and spinalepidural anesthesia (SEA). Typically, PCNL is performed with the patient under GA to control breathing and improve patient comfort. However, there are more complications associated with GA than RA, such as pulmonary atelectasis, intraoperative hemorrhage, vascular damage, and neurological disorders [4]. In addition, patients are considered unfit for GA due to severe comorbidities or the need to lower cost. Recent investigations have shown that PCNL under RA has some potential advantages over GA, such as cost-effectiveness, lower postoperative pain, lower requirement for analgesic drugs, and the avoidance of side effects from multiple medications during GA [5–8]. However, there is no consensus regarding which is more effective
13
Urolithiasis
and safer. Therefore, we performed a systematic review and meta-analysis to compare the efficacy and safety of RA and GA during surgery for upper urinary stones based on currently available clinical trials.
Materials and methods Literature search A literature search restricted to the English language of the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and EMBASE up to April 2014 was performed with the following search terms: “percutaneous” and (“nephrolithotomy” or “nephrostomy” or “nephrolitholapaxy”) and (“calculi” or “stone” or “nephrolithiasis” or “urolithiasis”) and (“anesthesia” or “general anesthesia” or “regional anesthesia” or “epidural anesthesia” or “spinal anesthesia” or “spinal-epidural anesthesia” or “neuraxial anesthesia”). Additional studies in the reference lists of all retrieved articles were manually searched. Inclusion and exclusion criteria All studies that met the following criteria were included: (1) randomized or non-randomized controlled trials (RCTs or non-RCTs); (2) patients with large renal pelvic calculi (>2 cm); (3) comparisons of the efficacy and safety of PCNL under RA vs. GA; (4) accurate data available for analysis; and (5) access to the full text of the study. The exclusion criteria included contraindications for RA or GA, such as irreversible coagulopathy, vertebral deformity, neuropathy, severe cardiac and respiratory insufficiency, renal failure, congenital renal anomalies. Quality assessment of the studies Two authors independently extracted data from the included studies using a standardized data collection form. Discrepancies were settled by consensus after discussion with a third author. Extracted data included author names, year of publication, country of publication, type of study design, type of intervention, sample size, body mass index, stone burden, location of renal access, and surgical position. We contacted the authors by e-mail to obtain missing information when needed. Outcome measure The following outcome variables of comparisons between the RA and GA groups across studies were collected for further meta-analysis: surgical duration, hospitalization period, fluoroscopy time, pain score, postoperative
13
analgesic requirement, blood transfusion, stone-free rate, and postoperative complications associated with PCNL. Stone-free was defined as no stone with a maximum diameter of >4 mm evaluated by radiography or ultrasonography of the kidneys, ureters, and bladder at the first postoperative day. Postoperative pain was assessed by use of the visual analog scale (VAS) for grading pain from 0 (no pain) to 10 (most severe pain). The modified Clavien classification (MCC) system was used to assess postoperative complications of PCNL ranging from MCC grade 1–5 [9]. Statistical analysis Methodological quality assessment was independently performed by two authors according to the guidelines published in the Cochrane Handbook for Systematic Reviews of Interventions (v. 5.1.0), which included randomization, allocation concealment, blinding, and description of withdrawals and dropouts [10]. Disagreements were resolved by consultation with a third party, when necessary. All analyses were performed using Review Manager, version 5.2.0 (Cochrane Collaboration, Oxford, UK). We estimated the odds ratio (OR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes, both with a 95 % confidence interval (CI). A probability (p) value
