TNS Development After HoLEP Surgery May Be Influenced by Patient Positioning, Procedure Duration, and Patient Characteristics

A retrospective chart review found a 3.7% occurrence rate of transient neurologic symptoms (TNS) in patients receiving 1.5% mepivacaine during Holmium Laser Enucleation of the Prostate (HoLEP) surgery and suggested a possible association of TNS development with quicker procedures, smaller prostates, lithotomy positioning, and younger age. In addition, post-anesthesia care unit time was slightly shorter for patients who developed TNS than those who did not develop TNS. This finding may help clinicians and patients in shared decision-making about the choice of anesthesia used during surgery.

The study, “Transient Neurological Symptoms In Holmium Laser Enucleation of the Prostate: Patients Receiving 1.5% Mepivacaine Spinal Anesthesia,” was undertaken by researchers at the Mayo Clinic, Jacksonville, FL, in response to patients developing classic TNS symptoms after HoLEP. TNS is defined as back pain that radiates down to the buttocks and the lower extremities within 24 hours after a spinal anesthetic. For many procedures, including HoLEP, the decision to perform a spinal anesthetic compared to a general anesthetic is based on shared decision-making with the patient, considering underlying medical conditions, blood thinning medications, and evidence of surgical outcomes for specific procedures. Therefore, researchers sought to determine if particular patient characteristics, the type of spinal anesthetic medication used, or procedure-specific details were involved in developing TNS.

Of 164 patients who underwent HoLEP under 1.5% mepivacaine spinal anesthesia between July 2020 and November 2022, 3.7% developed TNS. Patient distress and discomfort occurred, but there were no permanent neurological consequences.  Individuals who developed TNS had shorter procedure durations, shorter recovery times, and smaller prostate sizes and were younger when compared to those who did not develop TNS. However, these differences were small. The occurrence rate of TNS may be less influenced by the specifics of the HoLEP procedure but more influenced by patient positioning during surgery (lithotomy), quicker procedure duration, and rapid ambulatory status after surgery.

Spinal mepivacaine for HoLEP is an attractive option because of its potentially lower rates of TNS and shorter duration of action than other agents.  Lidocaine, a commonly used intermediate-duration local anesthetic, has a higher rate of TNS development (10-33% vs. 0-7.4% for mepivacaine), and bupivacaine, a longer-duration local anesthetic option, may prolong hospital stays as it takes longer to wear off, though it has a lower rate of TNS development (0-1%).  Spinal anesthetic with 1.5% mepivacaine can be considered for use in HoLEP procedures, but patients should be educated about the risks, benefits, and alternatives to spinal anesthesia.

The abstract was selected for a Resident/Fellow Travel Award at the 48th Annual Regional Anesthesiology and Acute Pain Medicine Meeting. Lead author Asaf Gans, MD, will present the findings at a session on Friday, April 21, at 2:15 pm, at The Diplomat Beach Resort in Hollywood, FL. Co-authors are Drs. Kishan Patel, Hari Kalagara, Steven Porter, and Dora Chandler.

ASRA Pain Medicine is a membership society of more than 5,000 healthcare professionals devoted to advancing evidence-based practice of pain medicine across the pain continuum, from acute pain to chronic pain. Our mission is to advance the science and practice of regional anesthesia and pain medicine to improve patient outcomes through research, education, and advocacy. Our vision is to relieve the global burden of pain. We are committed to integrity, innovation, inclusiveness, service, compassion, and wellness. Learn more at www.asra.com.