الفهرس 
Materials and methodsOnly 14 pages are availabe for public view
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Abstract
In the present study, eighty seven selected patients
with different lower urological lesions were submitted for
different urological procedures,41 open and 46 endoscopic,
under local anesthesia in the urology department of Benha
University Hospital. All patients were SUbjected to full
clinical examination, laboratory investigations, radiological
examination (when indicated) which included plain
U.T., intravenous urography and postvoiding film; ECG
(when indicated) and urethrocystoscopy (when indicated).
The age of the patients ranged from 10 to 78 years
with an average of 58.3 years. TWenty-four patients
(27.6%) were above the age of 60 years. Those elderly
patients would require special anesthetic care if they
have to be operated upon under spinal or general
anesthesia.
The incidence of associated medical diseases which
rendered the patient of a bad anesthetic risk was 10.4%.
The premedication drugs used in this study were
midazolam (dormicum) 1M and meperidine (pethidine) IV.
These two drugs were given to all patients 20-30 minutes
prior to the procedure. In endoscopic procedures lidocaine
2% Jell (xylocaine 2%) was instilled into the urethra 10-
15 minutes after premedication.
In scrotal procedures, scopolamine was given 1M with
the other two drugs.The anesthetic drug used was lidocaine
1% with adrenaline 1/400,000 for all procedures expect for
penile procedures where adrenaline was not used.
In the present study, the route of injection of local
anesthetic into the prostate was the transurethral route
alone. This route twas found to be satisfactory if the
resected tissue was around 15 grams. If more tissue needs
to be resected, further injection of local anesthetic was
needed.
The procedure was successfully performed in 17 out of
20 cases of TURP. In two cases the procedure was converted
to general anesthe~ia because the patients became unduly
irritable and apprehensive, although the two patients
accepted the idea prior to the procedure.In the third case
the procedure was terminated. This patients had a chest
problem and developed respiratory distress from prolonged
lying supine during resection.
The weight of prostatic adenomatous tissues removed
from 17 patients ranged from 5 to 25 grams with an average
of 11.7 grams. The operative time ranged between 40 and 90
minutes including the time consumed for injection. The
average time was 58.5 minutes.
There was no operative mortality and no adverse
reactions attributable to the local anesthesia. Only one
patient developed transient rise of blood pressure above
his own previous level (150/110) the blood pressure
reached (220/130). This rise of blood pressure was
controlled by administration of sublingual capsule of
epilate and intravenous ampoule of lasix. It was suggested
that the rise of blood pressure was related to stress
related to the procedure itself.
The subjective pain assessment in the 17 patients
was, no pain in 8 patients (47.1%), mild tolerable pain in
5 patients (29.4%), severe intolerable pain in 4 patients
(23.5%). The pain tolerance was improved after injection
of additional dose of local anesthetic at painful sites as
well as supplemental dose of midazolam.
Twelve patients underwent visual internal urethrotomy
under local anesthesia. The most common site of stricture
was the bulbomembranous, 5 cases. The length of stricture
ranged from 0.5 to 2 em. Only one patient had a recurrent
stricture.
out of these 12 cases the procedure was successfully
performed in 8 patients. It was discontinued in two cases
in whom urethrotomy resulted in false passage.In the other
two cases the procedure was terminated because of bleeding
at the site of injection. It was felt that further
injection will make bleeding worse particularly that the
guide catheter did not pass. Both cases were submitted to
general anesthesia to give room for maneuverability.
The subjective pain assessment in the 12 cases was,
no pain in 9 cases (75%) including the two cases complicated
by false passage and the two cases who were converted
to general anesthesia due to bleeding at site of injection
of local anesthetic. Mild tolerable pain occurred in one
patient (8%) while severe pain occurred in two patients
(17%). This severe pain disappeared after injection of an
extra dose of local anesthetic into the stricture.
Two cases ~f midline bladder neck incision and one
case of bladder neck resection for bladder neck contracture
were successfully performed under local anesthesia.
In the three cases the procedure was painless and no
complications were reported.
Transurethral resection of bladder~tumors was performed
successfully in 4 out of 6 cases. The other two cases
were converted to spinal anesthesia prior to completion of
injection. In one of these two cases the tumor was located
in the lateral bladder wall, while the other was located
in the anterior bladder wall with subsequent difficulty to
infiltrate both tumors circumferentially and the resection
was suspected tOibe painful, therefore,both were converted
to spinal anesthesia from the beginning.
The tumor size in the 4 successful cases ranged from
1.5 to 3.5 cm; three of these tumors were papillary with
narrow pedicle; while the fourth was nodular.
The resection was painless in 3 cases (75%) where the
tumor was papillary with narrow pedicle, and the tumors
were excised completely. In the fourth case (25%), nodular
tumor,the pain was severe and developed on deep resection.
This was explained by insufficient infiltration with local
anesthetic. However, the pain Qisappeared after injection
of an extradose of local anesthetic.
Transurethral resection of chronic bilharzial bladder
ulcer was perfo~ed successfully in 5 cases. The size of
resected ulcer ranged from 0.5 to 1.5 em. The site of all
ulcers was posterodomal, while the shape of these ulcers
was stellate (3 case~) and fissure ulcer (2 cases).
The first two cases in our series experienced severe
pain (40%). This, was due to inexperience with the
technique. These 2 patients probably were infiltrated with
insufficient amount of local anesthetic solution.
However, pain disappeared after injection of an extradose
of local anesthetic.
Twenty one cases of scrotal procedures,hydroce1ectomy
(14 cases), testicular biopsy (5 cases) and epidedemectomy
(2 cases), were performed under local anesthesia. The
procedure was performed successfully in all patients
except one in whom exploration of the distal cord
structures lead to severe pain (4.8%) which did not
disappear after injection of extradose of local anesthetic
and the procedure was completed under general anesthesia.
This was a case of congenital hydrocele where the sac had
to be followed high up in the cord above the site of
injection.
There were no complications attributed to local
anesthetic and no vasovagal episodes.Only in some patients
extensive traction on the cord lead to transient abdominal
discomfort which disappeared
traction.
after release of such
Twenty cases of different penile procedures,circumcision
(8 cases), frenu10p1asty (7,cases), veno1igation (2
cases), drainage of periurethral abscess (2 cases) and
repair of fracture penis (one case), were performed under
local anesthesia. The procedure was successful with no
pain in 19 cases (95%) while in one case (5%) it was
converted to general anesthesia. This was a case of
fracture penis. The patient experienced no pain on
performance of circumferential incision at the dorsal
aspect of the penis but on completing such incision onto
the ventral aspect, he felt severe pain. Injecting an
extradose of local anesthetic did not relieve such pain.
This may be explained by improper injection, superficial
to Buck’s fascia, so, sparing the deep dorsal nerve
unanesthetised, as it was our first experience with such
technique.