General versus spinal anesthesia in percutaneous nephrolithotomy: A systematic review and meta-analysis

Abstract

Background: Percutaneous nephrolithotomy (PCNL) is the preferred treatment for the removal of large kidney stones, sized >20 mm. However, there is still an ongoing debate concerning the best anesthesia for PCNL. This study aimed to compare the efficacy and safety between general and spinal anesthesia for PCNL. Methods: A systematic review and meta-analysis study. A systematic, electronic literature search was performed in several databases, including PubMed, Scopus, and Google Scholar until July 1 ^st, 2022. The quality of the articles was examined using Crombie's Items (for non-randomized controlled trials (RCTs)) and Jadad Scale (for RCTs). The outcomes assessed were operation time, fluoroscopy time, length of stay, stone-free rate, overall complication rate, specific postoperative complications, cost, pain score, and postoperative analgesic requirement. The article selection was reported based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. We assessed four RCTs and eight retrospective studies. Meta-analysis of selected studies was performed using the Review Manager 5.3. Results: General anesthesia resulted in fewer Clavien-Dindo grade II (OR: 0.68; 95% CI: 0.49 - 0.94; p=0.02), major complications (OR: 0.65; 95% CI: 0.45 - 0.94; p=0.02, and lower transfusion rates (OR: 0.70; 95% CI: 0.53 - 0.94; p=0.02). Whereas spinal anesthesia resulted in faster operation time (Mean Difference: -12.98; 95% CI: -20.56 - -5.41; p<0.001, fluoroscopy time (MD: -26.15; 95% CI: -42.79 - -9.50; p=0.002), reduced length of stay (MD: -0.47; 95% CI: -0.75 - 0.20; p<0.001), and lower postoperative analgesic requirement and cost. No significant difference in stone-free rate (OR: 1.08; 95% CI: 0.92 - 1.26; p=0.37). PCNL performed using either general anesthesia or spinal anesthesia is equally safe and effective. Conclusions: Each method of anesthesia has its own advantages and disadvantages. The final choice between general and spinal anesthesia should be based on the patient's condition and surgical team preference.

Keywords: Complication; General Anesthesia; PCNL; Spinal Anesthesia; Stone-free Rate.

Figure 1.. Study flow diagram.

Figure 2.. Forest plot of the study outcomes.

(A) Pooled estimate of operation time using random-effect model; (B) pooled estimate of fluoroscopy time using fixed-effect model; (C) pooled estimate of length of stay using random-effect model; (D) pooled estimate of stone-free rate using fixed-effect model.

Figure 3.. Forest plot of complication rate of the studies.

(A) Pooled estimate of overall complication rate using fixed-effect model; (B) pooled estimate of every Clavien–Dindo classification complication.

Figure 4.. Forest plot of specific complication parameters of the studies.

(A) Pooled estimate of transfusion rate using fixed-effect model; (B) pooled estimate of UTI using fixed-effect model; (C) pooled estimate of urosepsis using fixed-effect model; (D) pooled estimate of postoperative headache using random-effect model. UTI, urinary tract infection.