An evaluation of conscious sedation using propofol and remifentanil for tension‐free vaginal tape insertion

Abstract

Tension-free vaginal tape insertion is a recommended treatment for stress incontinence. There is evidence that intra-operative testing of continence by asking patients to cough may improve outcomes, but an optimal sedation regimen has not been determined. We prospectively evaluated the effectiveness of propofol and remifentanil infusions in 25 patients using pre-and postsedation peak cough pressures and pain scores. Patient satisfaction was assessed using the Iowa Satisfaction with Anaesthesia Score (ISAS). Post-sedation cough pressures were improved compared to baseline, with a mean peak pressure increase of 24 mmHg (95% CI 15.5-32.5; p < 0.001). Tension-free vaginal tape (TVT) insertion is a surgical treatment for genuine stress incontinence. It involves insertion of a prolene tape (Ethicon TVT, Ethicon, Edinburgh, UK) using 7-mm needles attached at either end. The tape is positioned to form a U-shaped sling at the level of the mid-urethra and is brought out behind the pubis symphysis through two small abdominal incisions. In the original description of the procedure, after the tape is positioned, the bladder is filled via a cystoscope which is then removed, and the patient asked to cough forcibly. This allows the tape to be adjusted until continence is just achieved.In traditional suspension procedures, or with a TVT performed under general or regional anaesthesia, the surgeon must estimate the degree of suspension required to relieve incontinence. This can lead to increased postoperative complications including failure to relieve incontinence or urinary retention. There have been no prospective studies comparing incontinence outcomes following TVT insertion performed under general anaesthesia versus sedation, though one paper did report improved results with local anaesthesia [1]. Published data has shown rates of urinary retention following TVT insertion under general anaesthesia to be high. One study quoted 56% of patients required an indwelling catheter for more than 24 h postoperatively [2].There are few published descriptions of sedation for TVT insertion. An optimal regimen would provide complete analgesia and anxiolysis during insertion of the tape, and an orientated patient able to co-operate with incontinence testing. It would also aim to minimise effects on urodynamics, with minimal respiratory depression and impairment of cough effectiveness. The authors previously described a method using a midazolam and fentanyl combination [3], which provided good analgesia and anxiolysis, but further improvement in emergence and cooperation with continence testing was proposed with a combination of propofol and remifentanil. The aim of this study was to evaluate the efficacy of a propofol and remifentanil regimen in terms of patient acceptance, co-operation with continence testing and cough effectiveness.

Alfentanil and patient‐controlled propofol sedation – facilitate gynaecological outpatient surgery with increased risk of respiratory events

“…The propofol/alfentanil regimen that we used impair safety, which also was confirmed for incontinence surgery in which target-controlled infusion of propofol and remifentanil resulted in apneic episodes, reduced respiratory rate, oxygen desaturation, and the need for close monitoring. 2 Our use of the same mixtures for gynecological treatment as for burn care 19 , display problems with generalizability, and to ensure safety, tuning of the PCS system is needed. 8 Usually surveys describe a preset loading dose that is infused before the patient uses the PCS.…”

“…Local anesthesia is widely used, sometimes combined with propofol alone, 1 or propofol and remifentanil. 2 The need to improve effectiveness and quality has led to the more extensive use of propofol. Moderate sedation has also been claimed to be an alternative to general anesthesia.…”

A prospective observational cohort study of the Ajust® single incision sling performed under conscious sedation with local infiltration

“…We chose to add sedation compared to local para urethral infiltration only, since this has been widely accepted as an effective type of anesthesia in terms of analgesia and patient satisfaction. It also allows for the ability to create an effective cough during surgery . Furthermore, Abdel‐Fattah reported that 29% of the patients did not accept an Ajust® procedure solely under local anesthesia.…”

Dexmedetomidine: an alternative for epidural anesthesia in tension-free vaginal-tape surgery

“…This a 2 -adrenergic receptor agonist offers a unique ''cooperative sedation,'' anxiolysis, and analgesia, with no respiratory depression [14,15]. Dexmedetomidine is usually administered as a continuous infusion, which makes it easy to titrate, and it is associated with a predictable and stable hemodynamic response [6,7]. However, care and precautions should be taken when it is administered to patients who are volumedepleted, vasoconstricted, or have severe heart block [14], as dexmedetomidine can cause severe hypotension and bradycardia.…”

“…Later, epidural anesthesia gained popularity and seemed to be the right choice, as it allowed patients to cough and be pain free at the same time. An optimal regimen would provide complete analgesia and sedation during tape insertion and an orientated patient able to cooperate with incontinence testing [6].…”