LOCAL ANESTHESIA WITH SEDATION FOR TRANS-VAGINAL CORRECTION OF ADVANCED GENITAL PROLAPSE

G.M. Buchsbaum, E. Duecy

University of Rochester, Rochester, NY

OBJECTIVE: To evaluate local anesthesia with sedation for vaginal surgery to correct advanced genital prolapse

MATERIALS AND METHODS: A total of 27 bilateral sacrospinous ligament fixation (SSLF) and vaginal paravaginal defect repairs (PVDR) performed between 1/2004 and 9/2004 were identified for this case series from a complete listing of all vaginal surgeries for correction of pelvic organ prolapse. Excluded were 10 patients who concomitantly had procedures that were not attempted under local anesthesia (8 vaginal hysterectomies and 2 abdominal procedures). Medical records including pre-operative evaluation, operative note, anesthesia record, post-operative chart entries and patient satisfaction questionnaire were reviewed as were patient demographic data, sites and degree of genital prolapse, duration of surgery, amount of local used, estimated blood loss, hospital stay and patients’ responses to an anesthesia satisfaction questionnaire.

RESULTS: 17 patients fulfilling inclusion criteria (5 bilateral SSLF, 12 vaginal PVDR) opted to undergo surgery under local anesthesia with sedation. All repairs incorporated placement of dermal allograft. Procedures performed concomitantly included: 12 posterior colporrhaphies, 4 enterocele repairs, and 9 perineoplasties. TVTs were placed in 6 of the cases. One patient received periurethral collagen injections. The mean age of patients was 66.1 (+/- 9.4) years, range 50-79 years. Bilateral SSLF and PVDR were performed for prolapse of the apex or the anterior wall of > grade 3 respectively. Posterior repairs were performed for > grade 2 rectocele. Mean OR time was 132 (+/- 37) minutes, range 85-213 minutes. Average use of local was 31.7 (+/- 10.8) cc, range 18.5-54 cc. Mean estimated blood loss (EBL) was 150 (+/-118) cc. One in three patients bypassed the post-anesthesia care unit. Average hospital stay was 1.2 days (range 1-3 days). Fourteen of 17 (83%) patients were discharged within 24 hours of surgery. None of the patients needed to be converted to general anesthesia. All 17 patients were "very satisfied" with their surgical experience, and all would recommend local anesthesia with sedation for this type of surgery to their friend.

DISCUSSION: We have previously reported on 87 patients, who underwent vaginal surgery performed under local anesthesia (J Pelvic Med Surg 2004;10:S45). In that series we excluded SSLF and PVDR, procedures reported on here. Our experience supports that local anesthesia with sedation can be successfully employed for most vaginal reconstructive surgeries, even those with complex and advanced genital prolapse. Patients are accepting of this anesthetic technique and report a high level of satisfaction. The advantages of this type of anesthesia include minimal interference with homeostatic mechanisms and speedy recovery with patients often bypassing the recovery unit. The duration of surgery has not been a limiting factor, even in advanced reconstructive cases.

Disclosure - Grant/Research: G.M. Buchsbaum, Watson, Pfizer; Speakers Bureau: G.M. Buchsbaum, Pfizer.