Anesthesia for Prostate Surgery

Prostate surgery can be carried out to treat prostate cancer, an enlarged prostate or benign prostatic hyperplasia (BPH), urinary continence, or erectile dysfunction in some cases ¹. The goal of anesthesia for prostate surgery is to minimize pain before, during, and after surgery.  

There are multiple different approaches for prostate surgery, depending on the goal, which will require different anesthesia approaches. In a traditional open surgery or open approach, a surgeon will make an incision through the skin to excise out the prostate and nearby tissues. Either a radical retropubic or a radical perineal approach can be used during open prostate surgery. For both approaches, a patient can be under general anesthesia or spinal or epidural anesthesia.

Regional anesthesia and analgesia may favor minimal residual disease following removal of a primary tumor due to how it affects the body. A retrospective review of patient medical records looked at records from patients receiving open prostatectomy with general anesthesia. This study identified that, after adjusting for tumor size and date of surgery, among other factors,  using epidural analgesia with general anesthesia instead of postoperative opioids with general anesthesia was linked to a substantially lower risk of biochemical cancer recurrence after prostate surgery ².  

A recent retrospective study revealed that combined spinal epidural anesthesia seems to be suitable and efficient for patients undergoing open radical retropubic prostatectomy. This specific approach reduces the average time in the operating unit and the length of the hospital stay ³. 

Laparoscopic surgery is a minimally invasive prostate surgery method that has become more widespread due to advancing technology and techniques. Two main approaches can be used tfor laparascopic prostate surgery. A laparoscopic radical prostatectomy requires multiple small cuts for the insertion of small surgical instruments, after which a surgical camera is inserted. In a robotic-assisted laparoscopic radical prostatectomy, a surgeon directs a robotic arm while viewing a computer monitor, providing maneuverability and precision. 

While any induction agent can be used for anesthesia, anesthetic management of prostate surgery patients needs to consider medical co-morbidities and medically optimize patients prior to surgery. Research has found that side effects remain minimal with robotic-assisted laparoscopic prostatectomy: Anesthetic and perioperative complications are rare. However, these do include a 1.3% incidence of postoperative anemia, postoperative pulmonary emboli, and, seemingly most commonly, corneal abrasions ⁴.  

Meanwhile, prostate laser surgery, endoscopic surgery, transurethral resection of the prostate (TURP), or transurethral incision of the prostate are additional surgical approaches that can help with urine flow. While TURP remains the surgical gold standard to treat benign prostatic hyperplasia, perioperative-associated morbidity remains high, ranging from 18% and 26%. In addition, between 1% and 8% of TURP procedures are complicated by TURP syndrome ⁵. The symptoms of TURP syndrome and bladder perforation may be masked under sedation and general anesthesia ⁶, and regional anesthesia may be warranted ⁷. 

Research has found that open prostatectomy may incur fewer complications if the prostate is very large (>100 g); prostatic size may be preemptively assessed by transrectal ultrasound scanning, endoscopic inspection, or manual examination ⁸. 

In any case, it is important after the surgery to keep the surgical wound clean, not drive, not do any high-energy activity, avoid sitting for more than 45 minutes, and take pain medications as prescribed. 

Additional research is required in order to validate and elucidate the links between anesthesia for prostate surgery and certain clinical outcomes. For example, prospective randomized trials to assess the link between substituting epidural analgesia for postoperative opioids and the substantially lower risk of cancer recurrence are required. This research will continue to help select the best anesthesia approach depending on clinical context. 

 
References 

1. What You Need to Know About Prostate Surgery. Available at: https://www.healthline.com/health/prostate-surgery. (Accessed: 3rd February 2023) 

2. Biki, B. et al. Anesthetic technique for radical prostatectomy surgery affects cancer recurrence: A retrospective analysis. Anesthesiology (2008). doi:10.1097/ALN.0b013e31817f5b73 

3. Kofler, O. et al. Anesthesia for Open Radical Retropubic Prostatectomy: A Comparison between Combined Spinal Epidural Anesthesia and Combined General Epidural Anesthesia. Prostate Cancer (2019). doi:10.1155/2019/4921620 

4. Danic, M. J. et al. Anesthesia considerations for robotic-assisted laparoscopic prostatectomy: A review of 1,500 cases. in Journal of Robotic Surgery (2007). doi:10.1007/s11701-007-0024-z 

5. Hahn, R. G. Fluid absorption in endoscopic surgery. British Journal of Anaesthesia (2006). doi:10.1093/bja/aei279 

6. Demirel, I., Ozer, A. B., Bayar, M. K. & Erhan, O. L. TURP syndrome and severe hyponatremia under general anaesthesia. BMJ Case Rep. (2012). doi:10.1136/bcr-2012-006899 

7. Mebust, W. K. et al. Transurethral prostatectomy: Immediate and postoperative complications. Cooperative study of 13 participating institutions evaluating 3,885 patients. J. Urol. (2002). doi:10.1016/S0022-5347(05)65370-0 

8. O’Donnell, A. M. & Foo, I. T. H. Anaesthesia for transurethral resection of the prostate. Contin. Educ. Anaesthesia, Crit. Care Pain (2009). doi:10.1093/bjaceaccp/mkp012