Safety and efficacy of transurethral resection of bladder tumour comparing spinal anaesthesia to spinal anaesthesia with an obturator nerve block: A systematic review and meta-analysis

Krishan, A.; Bruce, A.; Khashaba, S.; Abouelela, M.; Ehsanullah, S. A.

Introduction: To investigate whether spinal anaesthesia with an obturator nerve block (SA+ONB) can be effectively employed for transurethral resection of bladder tumours (TURBT) during the COVID-19 pandemic to improve patient outcomes whilst also avoiding aerosolgenerating procedures (AGPs). We aimed to compare outcomes of TURBT using spinal anaesthesia (SA) alone versus SA+ONB in terms of rates of obturator reflex, bladder perforation, incomplete tumour resection, tumour recurrence and local anaesthetic toxicity. Methods: We conducted a comprehensive search of electronic databases, identifying studies comparing the outcomes of TURBT using SA versus SA+ONB. The Cochrane risk-of-bias tool for RCTs and the Newcastle- Ottawa scale for observational studies were used to assess the studies. Random effects modelling was used to calculate pooled outcome data. Results: Four randomised control trials (RCTs) and three cohort studies were identified, enrolling a total of 448 patients. The use of SA+ONB was associated with a significantly reduced risk of obturator reflex(P<0.00001), bladder perforation(P=0.02), incomplete resection(P<0.0001) and 12-month tumour recurrence(P=0.005). Obturator nerve block was not associated with an increased risk of local anaesthetic toxicity(0/159). Conclusions: Our meta-analysis suggests that TURBT employing SA+ONB is superior to the use of SA alone. During the COVID-19 pandemic, where avoidance of AGPs such as general anaesthesia is paramount, the use of SA+ONB is essential for the safety of both patients and staff without compromising care. Further high-quality RCTs with adequate sample sizes are required to compare the different techniques of obturator nerve block as well as comparing this method to general anaesthesia with complete neuromuscular blockade.