Evaluation of optimal epidural insertion site for catheter-related bladder discomfort after transurethral resection of prostate

Evaluation of optimal epidural insertion site for catheter-related bladder discomfort after transurethral resection of prostate | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of optimal epidural insertion site for catheter-related bladder discomfort after transurethral resection of prostate Toru Matsuoka, Tadahiko Ishiyama, Takuya Akiyama, Takamune Tanikawa, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6273987/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose In transurethral resection of the prostate (TURP), catheter-related bladder discomfort (CRBD) frequently occurs after TURP. The purpose of the present study was to investigate the effective epidural insertion site to prevent CRBD after TURP. Methods Thirty patients, who were scheduled to undergo TURP under general anesthesia combined with epidural anesthesia were divided into two groups (caudal or thoracic epidural anesthesia). Caudal or thoracic epidural catheter was placed before induction of anesthesia. Ten minutes before the start of surgery, 6 ml of 0.25% ropivacaine was injected through the epidural catheter. Patient-controlled epidural analgesia (PCEA) including fentanyl, ropivacaine, and droperidol was initiated 1 hour after the start of surgery and continued for 24 hours postoperatively. The severity of CRBD was assessed at 6, 12, and 24 hours after surgery by four point scale. The 24-hour doses of PCEA solution, number of requests, and number of boluses were also evaluated. Results Severity of CRBD was not different between the two groups at the three observation time points. Over the 24-hour period, the amount of drug solution used in PCEA was similar in both groups. The number of PCEA demand and bolus in 24 hours was also not different between the two groups. Conclusions The suppression of CRBD after TURP surgery was comparable between caudal and thoracic epidural anesthesia. Because caudal epidural anesthesia is difficult to catheterize without the use of an ultrasound device, it may be simpler to use a thoracic epidural with fentanyl for PCEA to prevent CRBD. Trial registration the full name of the registry;University Hospital Medical Information Network(UMIN),the trial registration number;UMIN000041625,the date of registration is August 31,2020. Caudal epidural Thoracic epidural TURP Figures Figure 1 Figure 2 Figure 3 Introduction Benign prostatic hyperplasia causes frequent urination and straining to void in the elderly and reducing the quality of life (QOL). Transurethral resection of the prostate (TURP) is the common treatment for benign prostatic hyperplasia. The indwelling urinary catheter is placed for bleeding monitoring and preventing urinary retention after TURP. [ 1 ] However, the catheter-related bladder discomfort (CRBD) develops at a high rate postoperatively, [ 2 ] and it contributes to lower postoperative satisfaction. We have used patient-controlled epidural analgesia (PCEA) postoperatively for TURP to prevent CRBD. However, the most effective epidural puncture site for CRBD after TURP has not yet been investigated. The innervation of the bladder involves the sympathetic hypogastric nerves (T10-L2), the parasympathetic pelvic splanchnic nerves (S2-4), and the pudendal nerves (S2-4). Bladder perception involves mainly the parasympathetic pelvic splanchnic nerves. Therefore, blockade of the pelvic splanchnic nerves may reduce the occurrence of CRBD. Nevertheless, the pudendal nerves and the sympathetic hypogastric nerves are also involved in some aspects of bladder perception. The pudendal nerves and the hypogastric nerves might contribute to CRBD. Placement of an epidural catheter at T12/L1, the hypogastric nerves should be mainly blocked, but the pelvic splanchnic nerves and the pudendal nerves may not be blocked. On the other hand, caudal epidural anesthesia strongly blocks the pelvic splanchnic nerves and the pudendal nerves, which may effectively prevent CRBD. However, little or no blockade of the hypogastric nerves are expected. In the present study, we sought to clarify the effective epidural insertion site (Th12/L1 versus sacral hiatus) to prevent catheter-related bladder discomfort after TURP. Our hypothesis was that caudal epidural anesthesia, which directly blocks the pelvic splanchnic nerves and the pudendal nerves, was superior to thoracic epidural anesthesia for prevention of CRBD after TURP. The primary outcome of the present study was the severity of CRBD. The secondary outcomes included cumulative fentanyl consumption, total dose of fentanyl, and number of PCEA demand. Methods This study was approved by the institutional review board of the University of Yamanashi Hospital on August 26, 2020 (approval number: 2299). It was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) under the study number UMIN000041625. Written informed consent was obtained from all patients. Name of the ethics committee: The Ethics Review Board of the University of Yamanashi Hospital. Reference number: 2299. Thirty-seven adult patients, who were scheduled to undergo TURP for benign prostatic hyperplasia under general anesthesia combined with epidural anesthesia were included in the study. All patients were scheduled to receive postoperative analgesia with PCEA. Exclusion criteria were age over 90 years, American Society of Anesthesiologists Physical Status of four or higher, heart failure of New York Heart Association 3 or higher, patients with respiratory failure of Hugh-Jones 3 or higher, psychiatric disorders, and having chronic pain. Patients were assigned to the caudal epidural anesthesia (caudal group) or thoracic epidural anesthesia (thoracic group) according to the preference of each anesthesiologist. (Fig. 1 ) Premedication was not given to all patients. Before induction of general anesthesia, an epidural catheter was inserted at the caudal epidural space through the sacral hiatus (caudal group) or at the T12/L1 (thoracic group) interspace. Caudal epidural anesthesia was conducted using ultrasound to allow accurate placement of the catheter within the epidural caudal canal. Thoracic epidural anesthesia was performed by the conventional loss-of-resistance method. 2% mepivacaine 4 ml was injected through the catheter as a test dose. General anesthesia was induced by intravenous administration of remifentanil at 0.5 µg/kg /min and propofol at 3 µg/ml as plasma target concentration. Tracheal intubation was facilitated with 0.6 mg/kg of rocuronium. Anesthesia was maintained with intravenous infusion of remifentanil and propofol. The dose of remifentanil was adjusted accordingly at the discretion of the anesthesiologist. The dose of propofol adjusted to maintain bispectral index between 40 and 60. Rocuronium was given as required. Approximately 10 min before the start of operation, 0.25% ropivacaine 6 ml was injected through the epidural catheter. Sixty minutes after the start of surgery, PCEA was initiated. PCEA was continued for 24 hours after completion of surgery. The composition of PCEA solution was fentanyl 4 µg/ml, ropivacaine 0.06%, and droperidol 20 µg/ml. PCEA pump (i-Fusor plus, JMS, Japan) was set for a first loading dose at 8 mL, a bolus dose of 2 mL, with a 10-min lockout interval, and a background infusion of 4 ml/h. At the end of operation, urinary catheterization was made with a 22 French 3 way Foley catheter and its balloon was inflated with 20–30 ml distilled water. After the operation, neuromuscular blockade was reversed with sugammadex 2–4 mg/kg. The trachea was extubated and the patient was moved to the ward. Non-steroidal anti-inflammatory drugs were not used perioperatively. Data collection was made at 1–6 hr after the completion of operation, in the first postoperative morning (9:00–12:00) (12 hr after the operation), and in the afternoon (13:00–17:00) (24 hr after the operation). The severity of CRBD was assessed by four point scale; 0 = none, 1 = mild (reported by the patient only on questioning), 2 = moderate (reported voluntarily by the patient without behavioral responses), and 3 = severe (reported voluntarily by the patient accompanied by behavioral responses). [ 3 ]Behavioral responses observed were flailing limbs, strong vocal response, and attempts to remove the catheter [ 4 ]. The 24-hour doses of PCEA solution, number of requests, and number of boluses were obtained from the PCEA pump. Blood pressure, heart rate, percutaneous oxygen saturation, state of consciousness, nausea and vomiting, pruritus, lower extremity sensory disturbance, and lower extremity motor disturbance were also assessed. State of consciousness was estimated by Japan coma scale, Glasgow Coma Scale, and Richmond Agitation Sedation Scale. Nausea and vomiting, pruritus, lower extremity sensory disturbance, and lower extremity motor disturbance were evaluated as present or absent. Blood pressure, heart rate, and percutaneous oxygen saturation were also assessed. Statistics We used Stat Flex version 6.0 (Artec, Osaka, Japan) for statistical analysis. Power analysis revealed that the sample size of 15 patients was sufficient to provided 80% power with an α level of 0.05 to detect mean differences of 30% in CRBD. The differences in severity of CRBD was analyzed by Mann-Whitney U test. Age, height, weight, the 24-hour doses of PCEA solution, number of requests, number of boluses, blood pressure, heart rate, and percutaneous oxygen saturation were compared using Welch’s t test. Chi square test was applied for state of consciousness, nausea and vomiting, pruritus, lower extremity sensory disturbance, and lower extremity motor disturbance. Results 37 consecutive patients were screened for eligibility, and 7 patients were excluded from the study. Of 7 excluded patients, 2 did not meet inclusion criteria, 2 were converted to spinal anesthesia or combined spinal and epidural anesthesia, 2 were not adaptable for epidural anesthesia, and one was protocol violation. Therefore, 30 patients were included in the analyses. There were no differences between the groups in age, height, weight, duration of surgery, and duration of anesthesia ( Table 1 ). Blood pressure, heart rate, percutaneous oxygen saturation, and state of consciousness were not different between the two groups. During the observational period, one patient in the caudal group complained of nausea and one patient in the thoracic group suffered pruritus. Neither lower extremity sensory disturbance nor lower extremity motor disturbance were admitted in patients in either group. Severity of CRBD was not significantly different between the two groups at the three observation time points (Fig. 2 ). Only one patient in the thoracic group complained of severe CRBD. Over the 24-hour period, the amount of drug solution used in PCEA was similar in both groups (Fig. 3 A). The number of PCEA demand and bolus in 24 hours were also not significantly different between the two groups (Fig. 3 B). Discussion We found in the present study that caudal epidural anesthesia and thoracic epidural anesthesia suppressed CRBD equally. Cumulative fentanyl consumption, total dose of fentanyl, and number of PCA demand were also comparable between caudal epidural anesthesia and thoracic epidural anesthesia. After the TURP, urinary catheterization is necessary to observe bleeding and detain for prevention blood clot. [ 1 ] However, indwelling urinary catheters cause discomfort that is known as CRBD. The incidence of CRBD is very high, reported to be 50–90%. [ 5 ] Furthermore, CRBD produces several adverse events such as postoperative pain exaggeration, agitation after the operation, decreases quality of post-operative recovery, the extension of hospital stay, and increased workload for medical staff. [ 6 – 7 ] Therefore, it is important to reduce the incidence and severity of postoperative CRBD. Non-pharmacological and pharmacological methods for prevention and improvement for CRBD have been proposed including transcutaneous electrical acupoint stimulation, [ 9 ] preoperative education, [ 8 ] gabapentin, [ 5 ] parecoxib, [ 10 ] etc. These methods are beneficial because the pathophysiological mechanism about CRBD is reported to be the stimulation of bladder smooth muscle muscarinic receptors, up-regulation of C-afferent neuronal activity, and rising the prostaglandin by the stimulation of Cyclooxygenas2. [ 5 , 11 – 16 ] Stimulations of the abdominal (Th10-L2) or pelvic (S2-4) nerves produce discomfort in the upper pubic region and symptoms similar to overactive bladder due to involuntary contractions of bladder smooth muscle. [ 17 ] Therefore, sacral nerve block and public nerve block are also effective. However, complete suppression of CRBD has not yet been achieved. Previously, in L2/3 or L3/4 interspace epidural anesthesia, a loading dose of 24 ml of 0.5% bupivacaine produced T4 to S5 analgesia, but a subsequent epidural infusion of 8 ml/hr of 0.5% bupivacaine produced regression in analgesia. [ 18 ] In this study, 0.25% ropivacaine 6 ml was injected 70 min before the loading dose of PCEA with 0.06% ropivacaine 8 ml. The dose of ropivacaine should be less than in Mogensen's study using bupivacaine. In the thoracic group, epidural catheter insertion site was T12/L1 interspace. Furthermore, continuous infusion was performed at 4 ml/h. In the thoracic group, it is unlikely that the pelvic splenic or pudendal nerves were blocked. On the other hand, when 17.6 ml of lidocaine was administered into the sacral epidural space, the analgesic spread was reported to be 6.8 segments. The analgesic range in the sacral group was presumed to be limited in the sacral nerve area. Therefore, the hypogastric nerves should be mainly blocked in the thoracic group and the pelvic splanchnic nerves and the pudendal nerves should be blocked in the caudal group. Usually, a urinary catheter is placed in the lower part of the bladder. According to Grant's Atlas of Anatomy, afferent sensation in the lower bladder is transmitted to the sacral spinal cord primarily via the pelvic splenic nerves. Therefore, we hypothesized that caudal epidural anesthesia, which directly blocks the pelvic splanchnic nerves and the pudendal nerves, was superior to thoracic epidural anesthesia for prevention of CRBD after TURP. Contrary to our expectation, caudal and thoracic epidural anesthesia were comparable in terms of CRBD suppression. In this study, not only ropivacaine but also fentanyl was used as an analgesic for PCEA. It has been reported that fentanyl was rapidly absorbed across the dura mater following lumbar epidural administration and provided significant fentanyl concentration in the cerebrospinal fluid (CSF), and the concentration rises to a level sufficient for nerve blockade. [19] The sacral cord lies beneath the T12 and L1 vertebral body. Once fentanyl administered epidurally, it should cross the dura mater to reach the sacral cord of the subarachnoid space. to interact with opioid receptors in the sacral spinal dorsal horn. Fentanyl in CSF would interact with opioid receptors in the dorsal horn region of the sacral spinal cord and would block the pelvic splenic and pudendal nerves. Therefore, thoracic epidural anesthesia may have suppressed CRBD as much as caudal epidural anesthesia. It has also been reported that fentanyl in the lumbosacral spinal fluid migrates only slightly cephalad as a result of passive spinal fluid flow. [19] Cerebrospinal fluid is hydrophilic, and the lipophilic fentanyl is unlikely to migrate to the cephalic side. It is inferred that fentanyl administered through a caudal epidural catheter rarely migrates to the thoracic spinal cord through the CSF. In the caudal epidural group, only the pelvic splenic and the pudendal nerves derived from S2-4 were presumably blocked by ropivacaine and fentanyl, but not the hypogastric nerves. In the present study, caudal epidural anesthesia effectively suppressed CRBD. Thus, CRBD is thought to occur primarily via the pelvic splenic and the pudendal nerves, with less involvement of the hypogastric nerves. This study has some limitations. It was left to the individual anesthesiologist to decide whether to perform caudal epidural anesthesia or thoracic epidural anesthesia. Anesthesiologists tended to avoid caudal epidural anesthesia in heavier patients. There was no significant difference in weight between the two groups, but there may have been differences in the patients assigned to them. Second, this study was conducted at the single institution. Multicenter studies would be beneficial to increase the validity of the results. Third, the follow-up period of this study was limited to 24 hours after the surgery. The long-term impact of epidural anesthesia on CRBD and other postoperative complications has not been assessed. Nevertheless, the Foley catheter was removed in 24 hours after surgery in most cases. Conclusions This study compared the position of postoperative epidural catheter placement for prevention of CRBD. The suppression of CRBD after TURP surgery was comparable between caudal epidural anesthesia and thoracic epidural anesthesia. Contrary to our hypothesis, the similar CRBD suppression effect in caudal epidural anesthesia and thoracic epidural anesthesia was presumably due to the use of fentanyl in PCEA. Because caudal epidural anesthesia is difficult to catheterize without the use of an ultrasound device, it may be simpler to use a thoracic epidural with fentanyl for PCEA to prevent CRBD. Abbreviations TURP: Transurethral resection of the prostate;CRBD: Catheter-related bladder discomfort; PCEA: Patient-controlled epidural analgesia;QOL: Quolity of life;CSF: Cerebrospinal fluid Declarations Ethics approval and consent to participate: Ethical approval for this study (No. 2299) was provided by the Institutional Review Board of the University of Yamanashi, Chuo, Yamanashi, Japan (Chairperson: Prof. Zentaro Yamagata) on August 26, 2020. All authors contributed to the design and concept of the study. Written informed consent was obtained from all the patients. This study was conducted in accordance with the Declaration of Helsinki. Consent for publication: Not applicable. Availability of data and materials: The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. T Matsuoka email: [email protected] Competing Interests: The authors declare no competing interests. Funding: The authors declare no funding source for this study. Authors' contributions: All authors were involved in obtaining consent from patients, conducting the study, and collecting data. Data analysis was performed by Toru Matsuoka and Tadahiko Ishiyama. The draft of the manuscript was written by Toru Matsuoka. All authors commented on the manuscript. All authors have read and agreed to submit the final version of the manuscript. Acknowledgements: We would like to thank Editage (www.editage.com) for English language editing. Reporting guidelines: This study was reported in accordance with the CONSORT 2025 Guidelines. References Zhang N, Zhang P, Zhang X, Yang Y. The efficacy of resiniferatoxin in prevention of catheter related bladder discomfort in patients after TURP - a pilot, randomized, open study. Translational Androl Urol. 2012;1:14–8. Sabetian G, Zand F, Asadpour E, Ghorbani M, Adibi P, Hosseini MM, Zeyghami S, Masihi F. Evaluation of hyoscine N-butyl bromide efficacy on the prevention of catheter-related bladder discomfort after transurethral resection of prostate: a randomized, double-blind control trial. Int Urol Nephrol. 2017;49:1907–13. Singh TK, Sahu S, Agarwal A, Gupta D, Mishra P. Dexmedetomidine for prevention of early postoperative catheter-related bladder discomfort in voluntary kidney donors: Prospective, randomized, double-blind, placebo-controlled trial. J Anaesthesiol Clin Pharmacol. 2018;34:211–5. Bala I, Bharti N, Chaubey VK, Mandal AK. Efficacy of gabapentin for prevention of postoperative catheter-related bladder discomfort in patients undergoing transurethral resection of bladder tumor. Urology. 2012;79:853–7. Bai Y, Wang X, Li X, Pu C, Yuan H, Tang Y, Li J, Wei Q, Han P. Management of Catheter-Related Bladder Discomfort in Patients Who Underwent Elective Surgery. J Endourol. 2015;29:640–9. Park JY, Hong JH, Kim DH, Yu J, Hwang JH, Kim YK. Magnesium and Bladder Discomfort after Transurethral Resection of Bladder Tumor: A Randomized, Double-blind, Placebo-controlled Study. Anesthesiology. 2020;133:64–77. Zhou L, Zhou L, Tian L, Zhu D, Chen Z, Zheng C, Zhou T, Zeng X, Jiang X, Jiang C, Bo L. Preoperative education with image illustrations enhances the effect of tetracaine mucilage in alleviating postoperative catheter-related bladder discomfort: a prospective, randomized, controlled study. BMC Anesthesiol. 2018;18:204. Tu Q, Gan J, Shi J, Yu H, He S, Zhang J. Effect of transcutaneous electrical acupoint stimulation on postoperative analgesia after ureteroscopic lithotripsy: a randomized controlled trial. Urolithiasis. 2019;47:279–87. Jendoubi A, Aissi W, Abbes A, Bouzouita A, Fourati S, Necib H, Ghedira S, Houissa M. Efficacy and safety of Parecoxib for prevention of catheter-related bladder discomfort in patients undergoing transurethral resection of bladder tumor: Prospective randomised trial. Indian J Anaesth. 2018;62:461–5. Agarwal A, Dhiraaj S, Pawar S, Kapoor R, Gupta D, Singh PK. An evaluation of the efficacy of gabapentin for prevention of catheter-related bladder discomfort: a prospective, randomized, placebo-controlled, double-blind study. Anesth Analg. 2007;105:1454–7. table of contents. Kim HC, Hong WP, Lim YJ, Park HP. The effect of sevoflurane versus desflurane on postoperative catheter-related bladder discomfort in patients undergoing transurethral excision of a bladder tumour: a randomized controlled trial. Can J Anaesth. 2016;63:596–602. Li JY, Liao R. Dorsal penile nerve block with ropivacaine versus intravenous tramadol for the prevention of catheter-related bladder discomfort: study protocol for a randomized controlled trial. Trials [Electronic Resource]. 2015;16:596. Mu L, Geng LC, Xu H, Luo M, Geng JM, Li L. Lidocaine-prilocaine cream reduces catheter-related bladder discomfort in male patients during the general anesthesia recovery period: A prospective, randomized, case-control STROBE study. Medicine. 2017;96:e6494. Zhao Yun Y, Jun Mei X, Rong Z, Ru Ping D, Lei L. Dexmedetomidine reduces Catheter-Related Bladder Discomfort: A Prospective, Randomized, Placebo- Controlled, Double-Blind Study. P R Health Sci J. 2016;35:191–6. Zugail AS, Pinar U, Irani J. Evaluation of pain and catheter-related bladder discomfort relative to balloon volumes of indwelling urinary catheters: A prospective study. Invest Clin Urol. 2019;60:35–9. Anderson KE. Pharmacology of lower urinary tract smooth muscles and penile erectile tissues. Pharmacol Rev. 1993;45:253–308. Mogensen T, Hjortso NC, Bigler D, Lund C, Kehlet H. Unpredictability of regression of analgesia during the continuous postoperative extradural infusion of bupivacaine. Br J Anaesth. 1988;60:515–9. Gourlay GK, Murphy TM, Plummer JL, Kowalski SR, Cherry DA, Cousins MJ. Pharmacokinetics of fentanyl in lumbar and cervical CSF following lumbar epidural and intravenous administration. Pain. 1989;38:253–9. Tables Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.jpg CONSORT2025editablechecklist.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6273987","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":469508814,"identity":"2e46ce1e-a109-49b9-a5b8-0d045c6f1112","order_by":0,"name":"Toru Matsuoka","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFElEQVRIiWNgGAWjYBADAwb2BihTghHMYsallIeBAazCgIHnAMlaJBJgWgg4yF7s8POHP9tsjPlnvjH8dKPmjrz87OYGhh81DOzmuGyRTjNs5m1LM5O4nWMsnXPsmeGGOwcbGHuOMTBbNuDSkmDYzNh22Ibhdo6BdA7bYcYNEokNDLwNDMwGB3BpSf/Y+BOoRf7mGePfOf8O28+fkdjA+BevlhzDBt62w2YGN3jMpHPbDic23EhsYMZry+2cwtk859KMDc+klVnn9h1O3gDUcljmmAROv7DPTt/w8UeZjeG844c33875dth2/oz0hw/f1Ngk4woxJMBhAGcCnSSRbIBbKdzCByhcOyK0jIJRMApGwcgAAITFXoa3MbVBAAAAAElFTkSuQmCC","orcid":"","institution":"University of Yamanashi","correspondingAuthor":true,"prefix":"","firstName":"Toru","middleName":"","lastName":"Matsuoka","suffix":""},{"id":469508817,"identity":"5f9037cb-101a-42f0-9928-fca808d9b5d7","order_by":1,"name":"Tadahiko Ishiyama","email":"","orcid":"","institution":"University of Yamanashi","correspondingAuthor":false,"prefix":"","firstName":"Tadahiko","middleName":"","lastName":"Ishiyama","suffix":""},{"id":469508818,"identity":"41614133-7ba7-4514-89ad-fb222a0e53d4","order_by":2,"name":"Takuya Akiyama","email":"","orcid":"","institution":"University of Yamanashi","correspondingAuthor":false,"prefix":"","firstName":"Takuya","middleName":"","lastName":"Akiyama","suffix":""},{"id":469508819,"identity":"562b2632-69fb-4e44-b214-dad56d5994f3","order_by":3,"name":"Takamune Tanikawa","email":"","orcid":"","institution":"University of Yamanashi","correspondingAuthor":false,"prefix":"","firstName":"Takamune","middleName":"","lastName":"Tanikawa","suffix":""},{"id":469508820,"identity":"e0af4291-c273-4c36-b4f8-1412d8e083ad","order_by":4,"name":"Takashi Matsukawa","email":"","orcid":"","institution":"University of Yamanashi","correspondingAuthor":false,"prefix":"","firstName":"Takashi","middleName":"","lastName":"Matsukawa","suffix":""}],"badges":[],"createdAt":"2025-03-21 04:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6273987/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6273987/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84669481,"identity":"17eceadb-4864-444b-936e-373a1d70eaa8","added_by":"auto","created_at":"2025-06-16 06:28:53","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":263788,"visible":true,"origin":"","legend":"\u003cp\u003eA consort flow chart of the study.\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6273987/v1/c5783a7de169b838c6411b4b.jpg"},{"id":84669475,"identity":"08a0ebd8-5a3a-49c2-a524-8396d908a31a","added_by":"auto","created_at":"2025-06-16 06:28:52","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":121282,"visible":true,"origin":"","legend":"\u003cp\u003eSeverity of CRBD in the two groups at the three observation time points. There were no significant differences between the two groups at any observation points. Values are median, quartiles, and range. The thick line indicates the median. Black circle indicates average value.\u003c/p\u003e","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6273987/v1/55caa244a7f2aa153fb9a647.jpg"},{"id":84670326,"identity":"122e8ae3-8394-4d5b-b3a0-8f0379931eb3","added_by":"auto","created_at":"2025-06-16 06:36:52","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":163788,"visible":true,"origin":"","legend":"\u003cp\u003eAmount of PCEA solution consumed (A) and number of PCEA demand and bolus (B). The number of PCEA demand and bolus in 24 hours were not different between the two groups. Values are mean and standard deviation.\u003c/p\u003e","description":"","filename":"Fig3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6273987/v1/b520ef552cdacb3df113d4c8.jpg"},{"id":109508765,"identity":"df701d05-fd7a-4fd5-9fe6-908c38f17f9b","added_by":"auto","created_at":"2026-05-19 03:11:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":677154,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6273987/v1/29ffa4b3-0f9d-4bff-960f-2e4b0e48a5ca.pdf"},{"id":84669477,"identity":"3a2f5011-d39b-4c11-9221-befce94b9a94","added_by":"auto","created_at":"2025-06-16 06:28:52","extension":"jpg","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":166688,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6273987/v1/ca21b80b4c4700ffa3b2ea42.jpg"},{"id":84669474,"identity":"9320622f-c7f9-489d-ba8d-00e12f9312c1","added_by":"auto","created_at":"2025-06-16 06:28:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":34794,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORT2025editablechecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-6273987/v1/c5c070b6a9f14e3fc45921be.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of optimal epidural insertion site for catheter-related bladder discomfort after transurethral resection of prostate","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBenign prostatic hyperplasia causes frequent urination and straining to void in the elderly and reducing the quality of life (QOL). Transurethral resection of the prostate (TURP) is the common treatment for benign prostatic hyperplasia. The indwelling urinary catheter is placed for bleeding monitoring and preventing urinary retention after TURP. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] However, the catheter-related bladder discomfort (CRBD) develops at a high rate postoperatively, [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and it contributes to lower postoperative satisfaction. We have used patient-controlled epidural analgesia (PCEA) postoperatively for TURP to prevent CRBD. However, the most effective epidural puncture site for CRBD after TURP has not yet been investigated.\u003c/p\u003e \u003cp\u003eThe innervation of the bladder involves the sympathetic hypogastric nerves (T10-L2), the parasympathetic pelvic splanchnic nerves (S2-4), and the pudendal nerves (S2-4). Bladder perception involves mainly the parasympathetic pelvic splanchnic nerves. Therefore, blockade of the pelvic splanchnic nerves may reduce the occurrence of CRBD. Nevertheless, the pudendal nerves and the sympathetic hypogastric nerves are also involved in some aspects of bladder perception. The pudendal nerves and the hypogastric nerves might contribute to CRBD.\u003c/p\u003e \u003cp\u003ePlacement of an epidural catheter at T12/L1, the hypogastric nerves should be mainly blocked, but the pelvic splanchnic nerves and the pudendal nerves may not be blocked. On the other hand, caudal epidural anesthesia strongly blocks the pelvic splanchnic nerves and the pudendal nerves, which may effectively prevent CRBD. However, little or no blockade of the hypogastric nerves are expected.\u003c/p\u003e \u003cp\u003eIn the present study, we sought to clarify the effective epidural insertion site (Th12/L1 versus sacral hiatus) to prevent catheter-related bladder discomfort after TURP. Our hypothesis was that caudal epidural anesthesia, which directly blocks the pelvic splanchnic nerves and the pudendal nerves, was superior to thoracic epidural anesthesia for prevention of CRBD after TURP. The primary outcome of the present study was the severity of CRBD. The secondary outcomes included cumulative fentanyl consumption, total dose of fentanyl, and number of PCEA demand.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This study was approved by the institutional review board of the University of Yamanashi Hospital on August 26, 2020 (approval number: 2299). It was registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) under the study number UMIN000041625. Written informed consent was obtained from all patients. Name of the ethics committee: The Ethics Review Board of the University of Yamanashi Hospital. Reference number: 2299.\u003c/p\u003e \u003cp\u003eThirty-seven adult patients, who were scheduled to undergo TURP for benign prostatic hyperplasia under general anesthesia combined with epidural anesthesia were included in the study. All patients were scheduled to receive postoperative analgesia with PCEA. Exclusion criteria were age over 90 years, American Society of Anesthesiologists Physical Status of four or higher, heart failure of New York Heart Association 3 or higher, patients with respiratory failure of Hugh-Jones 3 or higher, psychiatric disorders, and having chronic pain.\u003c/p\u003e \u003cp\u003ePatients were assigned to the caudal epidural anesthesia (caudal group) or thoracic epidural anesthesia (thoracic group) according to the preference of each anesthesiologist. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePremedication was not given to all patients. Before induction of general anesthesia, an epidural catheter was inserted at the caudal epidural space through the sacral hiatus (caudal group) or at the T12/L1 (thoracic group) interspace. Caudal epidural anesthesia was conducted using ultrasound to allow accurate placement of the catheter within the epidural caudal canal. Thoracic epidural anesthesia was performed by the conventional loss-of-resistance method. 2% mepivacaine 4 ml was injected through the catheter as a test dose. General anesthesia was induced by intravenous administration of remifentanil at 0.5 \u0026micro;g/kg /min and propofol at 3 \u0026micro;g/ml as plasma target concentration. Tracheal intubation was facilitated with 0.6 mg/kg of rocuronium. Anesthesia was maintained with intravenous infusion of remifentanil and propofol. The dose of remifentanil was adjusted accordingly at the discretion of the anesthesiologist. The dose of propofol adjusted to maintain bispectral index between 40 and 60. Rocuronium was given as required. Approximately 10 min before the start of operation, 0.25% ropivacaine 6 ml was injected through the epidural catheter. Sixty minutes after the start of surgery, PCEA was initiated. PCEA was continued for 24 hours after completion of surgery. The composition of PCEA solution was fentanyl 4 \u0026micro;g/ml, ropivacaine 0.06%, and droperidol 20 \u0026micro;g/ml. PCEA pump (i-Fusor plus, JMS, Japan) was set for a first loading dose at 8 mL, a bolus dose of 2 mL, with a 10-min lockout interval, and a background infusion of 4 ml/h. At the end of operation, urinary catheterization was made with a 22 French 3 way Foley catheter and its balloon was inflated with 20\u0026ndash;30 ml distilled water. After the operation, neuromuscular blockade was reversed with sugammadex 2\u0026ndash;4 mg/kg. The trachea was extubated and the patient was moved to the ward. Non-steroidal anti-inflammatory drugs were not used perioperatively.\u003c/p\u003e \u003cp\u003eData collection was made at 1\u0026ndash;6 hr after the completion of operation, in the first postoperative morning (9:00\u0026ndash;12:00) (12 hr after the operation), and in the afternoon (13:00\u0026ndash;17:00) (24 hr after the operation). The severity of CRBD was assessed by four point scale; 0\u0026thinsp;=\u0026thinsp;none, 1\u0026thinsp;=\u0026thinsp;mild (reported by the patient only on questioning), 2\u0026thinsp;=\u0026thinsp;moderate (reported voluntarily by the patient without behavioral responses), and 3\u0026thinsp;=\u0026thinsp;severe (reported voluntarily by the patient accompanied by behavioral responses). [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]Behavioral responses observed were flailing limbs, strong vocal response, and attempts to remove the catheter [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The 24-hour doses of PCEA solution, number of requests, and number of boluses were obtained from the PCEA pump. Blood pressure, heart rate, percutaneous oxygen saturation, state of consciousness, nausea and vomiting, pruritus, lower extremity sensory disturbance, and lower extremity motor disturbance were also assessed. State of consciousness was estimated by Japan coma scale, Glasgow Coma Scale, and Richmond Agitation Sedation Scale. Nausea and vomiting, pruritus, lower extremity sensory disturbance, and lower extremity motor disturbance were evaluated as present or absent. Blood pressure, heart rate, and percutaneous oxygen saturation were also assessed.\u003c/p\u003e \u003cp\u003e \u003cb\u003eStatistics\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWe used Stat Flex version 6.0 (Artec, Osaka, Japan) for statistical analysis. Power analysis revealed that the sample size of 15 patients was sufficient to provided 80% power with an α level of 0.05 to detect mean differences of 30% in CRBD. The differences in severity of CRBD was analyzed by Mann-Whitney U test. Age, height, weight, the 24-hour doses of PCEA solution, number of requests, number of boluses, blood pressure, heart rate, and percutaneous oxygen saturation were compared using Welch\u0026rsquo;s t test. Chi square test was applied for state of consciousness, nausea and vomiting, pruritus, lower extremity sensory disturbance, and lower extremity motor disturbance.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e37 consecutive patients were screened for eligibility, and 7 patients were excluded from the study. Of 7 excluded patients, 2 did not meet inclusion criteria, 2 were converted to spinal anesthesia or combined spinal and epidural anesthesia, 2 were not adaptable for epidural anesthesia, and one was protocol violation. Therefore, 30 patients were included in the analyses. There were no differences between the groups in age, height, weight, duration of surgery, and duration of anesthesia (\u003cb\u003eTable\u0026nbsp;1\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eBlood pressure, heart rate, percutaneous oxygen saturation, and state of consciousness were not different between the two groups. During the observational period, one patient in the caudal group complained of nausea and one patient in the thoracic group suffered pruritus. Neither lower extremity sensory disturbance nor lower extremity motor disturbance were admitted in patients in either group.\u003c/p\u003e \u003cp\u003eSeverity of CRBD was not significantly different between the two groups at the three observation time points (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Only one patient in the thoracic group complained of severe CRBD.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOver the 24-hour period, the amount of drug solution used in PCEA was similar in both groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). The number of PCEA demand and bolus in 24 hours were also not significantly different between the two groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe found in the present study that caudal epidural anesthesia and thoracic epidural anesthesia suppressed CRBD equally. Cumulative fentanyl consumption, total dose of fentanyl, and number of PCA demand were also comparable between caudal epidural anesthesia and thoracic epidural anesthesia.\u003c/p\u003e \u003cp\u003eAfter the TURP, urinary catheterization is necessary to observe bleeding and detain for prevention blood clot. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] However, indwelling urinary catheters cause discomfort that is known as CRBD. The incidence of CRBD is very high, reported to be 50\u0026ndash;90%. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Furthermore, CRBD produces several adverse events such as postoperative pain exaggeration, agitation after the operation, decreases quality of post-operative recovery, the extension of hospital stay, and increased workload for medical staff. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] Therefore, it is important to reduce the incidence and severity of postoperative CRBD. Non-pharmacological and pharmacological methods for prevention and improvement for CRBD have been proposed including transcutaneous electrical acupoint stimulation, [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] preoperative education, [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] gabapentin, [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] parecoxib, [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] etc. These methods are beneficial because the pathophysiological mechanism about CRBD is reported to be the stimulation of bladder smooth muscle muscarinic receptors, up-regulation of C-afferent neuronal activity, and rising the prostaglandin by the stimulation of Cyclooxygenas2. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12 CR13 CR14 CR15\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] Stimulations of the abdominal (Th10-L2) or pelvic (S2-4) nerves produce discomfort in the upper pubic region and symptoms similar to overactive bladder due to involuntary contractions of bladder smooth muscle. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] Therefore, sacral nerve block and public nerve block are also effective. However, complete suppression of CRBD has not yet been achieved.\u003c/p\u003e \u003cp\u003ePreviously, in L2/3 or L3/4 interspace epidural anesthesia, a loading dose of 24 ml of 0.5% bupivacaine produced T4 to S5 analgesia, but a subsequent epidural infusion of 8 ml/hr of 0.5% bupivacaine produced regression in analgesia. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] In this study, 0.25% ropivacaine 6 ml was injected 70 min before the loading dose of PCEA with 0.06% ropivacaine 8 ml. The dose of ropivacaine should be less than in Mogensen's study using bupivacaine. In the thoracic group, epidural catheter insertion site was T12/L1 interspace. Furthermore, continuous infusion was performed at 4 ml/h. In the thoracic group, it is unlikely that the pelvic splenic or pudendal nerves were blocked. On the other hand, when 17.6 ml of lidocaine was administered into the sacral epidural space, the analgesic spread was reported to be 6.8 segments. The analgesic range in the sacral group was presumed to be limited in the sacral nerve area. Therefore, the hypogastric nerves should be mainly blocked in the thoracic group and the pelvic splanchnic nerves and the pudendal nerves should be blocked in the caudal group. Usually, a urinary catheter is placed in the lower part of the bladder. According to Grant's Atlas of Anatomy, afferent sensation in the lower bladder is transmitted to the sacral spinal cord primarily via the pelvic splenic nerves. Therefore, we hypothesized that caudal epidural anesthesia, which directly blocks the pelvic splanchnic nerves and the pudendal nerves, was superior to thoracic epidural anesthesia for prevention of CRBD after TURP.\u003c/p\u003e \u003cp\u003eContrary to our expectation, caudal and thoracic epidural anesthesia were comparable in terms of CRBD suppression. In this study, not only ropivacaine but also fentanyl was used as an analgesic for PCEA. It has been reported that fentanyl was rapidly absorbed across the dura mater following lumbar epidural administration and provided significant fentanyl concentration in the cerebrospinal fluid (CSF), and the concentration rises to a level sufficient for nerve blockade. [19] The sacral cord lies beneath the T12 and L1 vertebral body. Once fentanyl administered epidurally, it should cross the dura mater to reach the sacral cord of the subarachnoid space. to interact with opioid receptors in the sacral spinal dorsal horn. Fentanyl in CSF would interact with opioid receptors in the dorsal horn region of the sacral spinal cord and would block the pelvic splenic and pudendal nerves. Therefore, thoracic epidural anesthesia may have suppressed CRBD as much as caudal epidural anesthesia.\u003c/p\u003e \u003cp\u003eIt has also been reported that fentanyl in the lumbosacral spinal fluid migrates only slightly cephalad as a result of passive spinal fluid flow. [19] Cerebrospinal fluid is hydrophilic, and the lipophilic fentanyl is unlikely to migrate to the cephalic side. It is inferred that fentanyl administered through a caudal epidural catheter rarely migrates to the thoracic spinal cord through the CSF. In the caudal epidural group, only the pelvic splenic and the pudendal nerves derived from S2-4 were presumably blocked by ropivacaine and fentanyl, but not the hypogastric nerves. In the present study, caudal epidural anesthesia effectively suppressed CRBD. Thus, CRBD is thought to occur primarily via the pelvic splenic and the pudendal nerves, with less involvement of the hypogastric nerves.\u003c/p\u003e \u003cp\u003eThis study has some limitations. It was left to the individual anesthesiologist to decide whether to perform caudal epidural anesthesia or thoracic epidural anesthesia. Anesthesiologists tended to avoid caudal epidural anesthesia in heavier patients. There was no significant difference in weight between the two groups, but there may have been differences in the patients assigned to them. Second, this study was conducted at the single institution. Multicenter studies would be beneficial to increase the validity of the results. Third, the follow-up period of this study was limited to 24 hours after the surgery. The long-term impact of epidural anesthesia on CRBD and other postoperative complications has not been assessed. Nevertheless, the Foley catheter was removed in 24 hours after surgery in most cases.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study compared the position of postoperative epidural catheter placement for prevention of CRBD. The suppression of CRBD after TURP surgery was comparable between caudal epidural anesthesia and thoracic epidural anesthesia. Contrary to our hypothesis, the similar CRBD suppression effect in caudal epidural anesthesia and thoracic epidural anesthesia was presumably due to the use of fentanyl in PCEA. Because caudal epidural anesthesia is difficult to catheterize without the use of an ultrasound device, it may be simpler to use a thoracic epidural with fentanyl for PCEA to prevent CRBD.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTURP: Transurethral resection of the prostate;CRBD: Catheter-related bladder discomfort;\u003c/p\u003e\n\u003cp\u003ePCEA: Patient-controlled epidural analgesia;QOL: Quolity of life;CSF: Cerebrospinal fluid\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: Ethical approval for this study (No. 2299) was provided by the Institutional Review Board of the University of Yamanashi, Chuo, Yamanashi, Japan (Chairperson: Prof. Zentaro Yamagata) on August 26, 2020. All authors contributed to the design and concept of the study. Written informed consent was obtained from all the patients. This study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. T Matsuoka email: [email protected]\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Competing Interests: The authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding: The authors declare no funding source for this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthors\u0026apos; contributions: All authors were involved in obtaining consent from patients, conducting the study, and collecting data. Data analysis was performed by Toru Matsuoka and Tadahiko Ishiyama. The draft of the manuscript was written by Toru Matsuoka. All authors commented on the manuscript. All authors have read and agreed to submit the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgements: We would like to thank Editage (www.editage.com) for English language editing.\u003c/p\u003e\n\u003cp\u003eReporting guidelines: This study was reported in accordance with the CONSORT 2025 Guidelines.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZhang N, Zhang P, Zhang X, Yang Y. The efficacy of resiniferatoxin in prevention of catheter related bladder discomfort in patients after TURP - a pilot, randomized, open study. Translational Androl Urol. 2012;1:14\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSabetian G, Zand F, Asadpour E, Ghorbani M, Adibi P, Hosseini MM, Zeyghami S, Masihi F. Evaluation of hyoscine N-butyl bromide efficacy on the prevention of catheter-related bladder discomfort after transurethral resection of prostate: a randomized, double-blind control trial. Int Urol Nephrol. 2017;49:1907\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSingh TK, Sahu S, Agarwal A, Gupta D, Mishra P. Dexmedetomidine for prevention of early postoperative catheter-related bladder discomfort in voluntary kidney donors: Prospective, randomized, double-blind, placebo-controlled trial. J Anaesthesiol Clin Pharmacol. 2018;34:211\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBala I, Bharti N, Chaubey VK, Mandal AK. Efficacy of gabapentin for prevention of postoperative catheter-related bladder discomfort in patients undergoing transurethral resection of bladder tumor. Urology. 2012;79:853\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBai Y, Wang X, Li X, Pu C, Yuan H, Tang Y, Li J, Wei Q, Han P. Management of Catheter-Related Bladder Discomfort in Patients Who Underwent Elective Surgery. J Endourol. 2015;29:640\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePark JY, Hong JH, Kim DH, Yu J, Hwang JH, Kim YK. Magnesium and Bladder Discomfort after Transurethral Resection of Bladder Tumor: A Randomized, Double-blind, Placebo-controlled Study. Anesthesiology. 2020;133:64\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhou L, Zhou L, Tian L, Zhu D, Chen Z, Zheng C, Zhou T, Zeng X, Jiang X, Jiang C, Bo L. Preoperative education with image illustrations enhances the effect of tetracaine mucilage in alleviating postoperative catheter-related bladder discomfort: a prospective, randomized, controlled study. BMC Anesthesiol. 2018;18:204.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTu Q, Gan J, Shi J, Yu H, He S, Zhang J. Effect of transcutaneous electrical acupoint stimulation on postoperative analgesia after ureteroscopic lithotripsy: a randomized controlled trial. Urolithiasis. 2019;47:279\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJendoubi A, Aissi W, Abbes A, Bouzouita A, Fourati S, Necib H, Ghedira S, Houissa M. Efficacy and safety of Parecoxib for prevention of catheter-related bladder discomfort in patients undergoing transurethral resection of bladder tumor: Prospective randomised trial. Indian J Anaesth. 2018;62:461\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAgarwal A, Dhiraaj S, Pawar S, Kapoor R, Gupta D, Singh PK. An evaluation of the efficacy of gabapentin for prevention of catheter-related bladder discomfort: a prospective, randomized, placebo-controlled, double-blind study. Anesth Analg. 2007;105:1454\u0026ndash;7. table of contents.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim HC, Hong WP, Lim YJ, Park HP. The effect of sevoflurane versus desflurane on postoperative catheter-related bladder discomfort in patients undergoing transurethral excision of a bladder tumour: a randomized controlled trial. Can J Anaesth. 2016;63:596\u0026ndash;602.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi JY, Liao R. Dorsal penile nerve block with ropivacaine versus intravenous tramadol for the prevention of catheter-related bladder discomfort: study protocol for a randomized controlled trial. Trials [Electronic Resource]. 2015;16:596.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMu L, Geng LC, Xu H, Luo M, Geng JM, Li L. Lidocaine-prilocaine cream reduces catheter-related bladder discomfort in male patients during the general anesthesia recovery period: A prospective, randomized, case-control STROBE study. Medicine. 2017;96:e6494.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhao Yun Y, Jun Mei X, Rong Z, Ru Ping D, Lei L. Dexmedetomidine reduces Catheter-Related Bladder Discomfort: A Prospective, Randomized, Placebo- Controlled, Double-Blind Study. P R Health Sci J. 2016;35:191\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZugail AS, Pinar U, Irani J. Evaluation of pain and catheter-related bladder discomfort relative to balloon volumes of indwelling urinary catheters: A prospective study. Invest Clin Urol. 2019;60:35\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAnderson KE. Pharmacology of lower urinary tract smooth muscles and penile erectile tissues. Pharmacol Rev. 1993;45:253\u0026ndash;308.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMogensen T, Hjortso NC, Bigler D, Lund C, Kehlet H. Unpredictability of regression of analgesia during the continuous postoperative extradural infusion of bupivacaine. Br J Anaesth. 1988;60:515\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGourlay GK, Murphy TM, Plummer JL, Kowalski SR, Cherry DA, Cousins MJ. Pharmacokinetics of fentanyl in lumbar and cervical CSF following lumbar epidural and intravenous administration. Pain. 1989;38:253\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Caudal epidural, Thoracic epidural, TURP","lastPublishedDoi":"10.21203/rs.3.rs-6273987/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6273987/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eIn transurethral resection of the prostate (TURP), catheter-related bladder discomfort (CRBD) frequently occurs after TURP. The purpose of the present study was to investigate the effective epidural insertion site to prevent CRBD after TURP.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThirty patients, who were scheduled to undergo TURP under general anesthesia combined with epidural anesthesia were divided into two groups (caudal or thoracic epidural anesthesia). Caudal or thoracic epidural catheter was placed before induction of anesthesia. Ten minutes before the start of surgery, 6 ml of 0.25% ropivacaine was injected through the epidural catheter. Patient-controlled epidural analgesia (PCEA) including fentanyl, ropivacaine, and droperidol was initiated 1 hour after the start of surgery and continued for 24 hours postoperatively. The severity of CRBD was assessed at 6, 12, and 24 hours after surgery by four point scale. The 24-hour doses of PCEA solution, number of requests, and number of boluses were also evaluated.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSeverity of CRBD was not different between the two groups at the three observation time points. Over the 24-hour period, the amount of drug solution used in PCEA was similar in both groups. The number of PCEA demand and bolus in 24 hours was also not different between the two groups.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe suppression of CRBD after TURP surgery was comparable between caudal and thoracic epidural anesthesia. Because caudal epidural anesthesia is difficult to catheterize without the use of an ultrasound device, it may be simpler to use a thoracic epidural with fentanyl for PCEA to prevent CRBD.\u003c/p\u003e\u003ch2\u003eTrial registration\u003c/h2\u003e \u003cp\u003ethe full name of the registry;University Hospital Medical Information Network(UMIN),the trial registration number;UMIN000041625,the date of registration is August 31,2020.\u003c/p\u003e","manuscriptTitle":"Evaluation of optimal epidural insertion site for catheter-related bladder discomfort after transurethral resection of prostate","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-16 06:28:48","doi":"10.21203/rs.3.rs-6273987/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"88a0d140-b7ab-4d99-a6c7-afd937acd8a7","owner":[],"postedDate":"June 16th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-19T02:59:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-04T17:16:41+00:00","index":93,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-19T03:10:00+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-16 06:28:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6273987","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6273987","identity":"rs-6273987","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}