Influence of Epidural Mixture and Surgery on Bladder Function after Open Renal Surgery A Randomized Clinical Trial
ABSTRACT BACKGROUND: In a previous observational study, thoracic epidural analgesia (TEA) after open renal surgery resulted in clinically relevant postvoid residuals (PVRs). This study aimed to investigate the individual contribution of epidurally administrated drugs and surgery in bladder dysfunction.
METHODS: In this single-center, parallel-group, randomized (computer-generated list), double-blind superiority trial, 40 patients undergoing open renal surgery were equally allocated to receive epidural bupivacaine (0.125%) alone or with fentanyl (2 µg/ml). Patients underwent urodynamic investigations before TEA and during TEA preoperatively and postoperatively. Primary outcome was the difference (Δ) in PVR between before TEA and postoperatively during TEA. Secondary outcomes were changes in detrusor pressure at maximum flow rate, bladder compliance, and ΔPVR between different time points.
RESULTS: Median ΔPVR (ml) from baseline to postoperatively was 180 (range, -85 to 645; P = 0.001) in the bupivacaine group and 235 (range, 0-580; P value less than 0.001) in the bupivacaine/fentanyl group, with no difference between groups (95% confidence interval, -167 to 103; P = 0.634). Detrusor pressure at maximum flow rate (cm H(2)O) from baseline was more pronounced in the bupivacaine/fentanyl than that in the bupivacaine group preoperatively (-10; range, -64 to -2; P value less than 0.001 vs. -3; range, -35 to 13; P = 0.397) (P = 0.045) and postoperatively (-18; range, -64 to 0; P value less than 0.001 vs. -12; range, -34 to 22; P = 0.006) (P = 0.135). Surgery did not affect PVRs, but a decreased bladder compliance was observed in both groups. No adverse events occurred.
CONCLUSIONS: Thoracic epidurally administrated bupivacaine resulted in clinically relevant PVRs based on impaired detrusor function. The addition of fentanyl enhanced this effect without generating greater PVRs. After surgery, the voiding phase was not further impaired; however, bladder compliance was decreased.
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ABSTRACT: OBJECTIVES.: Thoracic epidural analgesia (TEA) has been shown to inhibit detrusor activity in patients undergoing open renal surgery, resulting in clinically relevant post-void residuals. However, the impact of different epidural drug mixtures on urethral sphincter function is not completely elucidated. DESIGN.: Pooled analysis of an open observational study and a double-blind randomized trial. SETTING.: Single tertiary centre. SUBJECTS.: Twenty-eight women without lower urinary tract symptoms and post-void residual <100 mL, who underwent open renal surgery with TEA. METHODS.: Pooling results in three groups with different epidural regimens (7 with bupivacaine 0.125%, 8 with bupivacaine 0.125% and fentanyl 2 μg/mL, and 13 with bupivacaine 0.1% plus fentanyl 2 μg/mL and epinephrine 2 μg/mL). All women underwent urethral pressure measurements before TEA and during TEA 2-3 days postoperatively. All patients received a TEA placed at the insertion site interspace T 8-9. RESULTS.: Maximum urethral closure pressure at rest decreased significantly during TEA with bupivacaine alone (median 70 cm H2 O [interquartile range 66-76] to 43 [43-65], P = 0.031) and with bupivacaine/fentanyl/epinephrine (75 cm H2 O [68-78] to 56 [52-75], P = 0.028), whereas with bupivacaine/fentanyl, no significant change could be detected (74 [51-88] vs 67 [46-70], P = 0.156). In all groups, functional profile length at rest was not influenced during TEA. CONCLUSION.: TEA with bupivacaine and the addition of fentanyl and epinephrine appears to decrease maximum urethral closure pressure at rest in women. The addition of fentanyl alone to bupivacaine may reduce this effect. Thus, the TEA effect on urethral sphincter function seems to depend on the drug mixture administered.Pain Medicine 04/2013; 14(8). DOI:10.1111/pme.12128 · 2.24 Impact Factor
- Anesthesiology 07/2013; 119(1):237-8. DOI:10.1097/ALN.0b013e318297634a · 6.17 Impact Factor
Article: In reply.Anesthesiology 07/2013; 119(1):238-9. DOI:10.1097/ALN.0b013e3182977002 · 6.17 Impact Factor