Effects of Thoracic Epidural Administered Ropivacaine Versus Bupivacaine on Bladder Function

Effects of Thoracic Epidural Administered Ropivacaine Versus Bupivacaine on Lower Urinary Tract Function: A Randomized, Controlled Study

Acute urinary retention is one of the most common complications after surgery and anesthesia. Micturition depends on coordinated actions between the detrusor muscle and the external urethral sphincter. Under the influence of epidural analgesia, patients may not feel the sensation of bladder filling, which can result in urinary retention and bladder overdistension. Overfilling of the bladder can stretch and in some cases permanently damage the detrusor muscle. Because epidural anesthesia can be performed at various levels of the spinal cord, it is possible to block only a portion of the spinal cord (segmental blockade). Thoracic epidural analgesia with bupivacaine significantly inhibits the detrusor muscle during voiding, resulting in clinically relevant post void residuals which required monitoring or transurethral catheterisation. This bladder muscle inhibition is comparable to a motor blockade. The epidural administration of ropivacaine during labour results in a clinically relevant reduction of motor blocks.

The hypothesis is that thoracic epidural analgesia with the local anesthetics ropivacaine leads to less significant changes in bladder function than bupivacaine as a control group, in patients undergoing lumbotomy incision for renal surgery.

Study Overview

• Status: Completed
• Conditions: Post Operative Urinary Retention
• Intervention / Treatment: Drug: Ropivacaine 2mg/ml; Device: 6 French transurethral dual channel catheter (Gaeltec, Dunvegan, Scotland); Device: 14 French rectal balloon catheter (Gaeltec, Dunvegan, Scotland); Drug: Bupivacaine

Detailed Description

Background

Acute urinary retention is one of the most common complications after surgery and anesthesia. It can occur in patients of both sexes and all age groups and after all types of surgical procedures. It is linked to several factors including increased intravenous fluids, postoperative pain and type of anaesthesia.

Micturition depends on coordinated actions between the detrusor muscle and the external urethral sphincter. Motorneurons of both muscles are located in the sacral spinal cord and coordination between them occurs in the pontine tegmentum of the caudal brain stem. Motorneurons innervating the external urethral sphincter are located in the nucleus of Onuf, extending from segment S1 to S3. The detrusor smooth muscle is innervated by parasympathetic fibers, which reside in the sacral intermediolateral cell group and are located in S2-4. Sympathetic fibers innervating the bladder and urethra play an important role in promoting continence and are located in the intermediolateral cell group of the lumbar cord (L1-L4). Most afferent fibers from the bladder enter the sacral cord through the pelvic nerve at segments L4-S2 and the majority are thin myelinated or unmyelinated.

There are few studies on the urodynamic effects of various anaesthetic agents, which mainly focused on lumbar epidural anaesthesia. Under the influence of epidural analgesia, patients may not feel the sensation of bladder filling, which can result in urinary retention and bladder overdistension. Overfilling of the bladder can stretch and in some cases permanently damage the detrusor muscle.

Because epidural anesthesia can be performed at various levels of the spinal cord, it is possible to block only a portion of the spinal cord (segmental blockade). Based on knowledge of the bladder innervations, it can be assumed that epidural analgesia within segments T4-6 to T10-12 has no or minimal influences on lower urinary tract function.

In a previous study, the investigators found, against their expectations, that thoracic epidural analgesia (TEA) with bupivacaine significantly inhibits the detrusor muscle during voiding, resulting in clinically relevant post void residuals which required monitoring or transurethral catheterisation 11. This detrusor inhibition is comparable to a motor blockade.

In addition, it is known that the epidural administration of ropivacaine during labour results in a clinically relevant reduction of motor blocks. However, the analgesic potency of ropivacaine is approximately 60% that of bupivacaine.

Objective

The main objectives of this investigator initiated trial are:

• To analyse if a TEA with the local anesthetics ropivacaine leads to less detrusor atony and thus resulting to lower incidence of postvoid residual urine volume resulting in postoperative urinary retention.
• To compare urodynamic parameters (storage and voiding phases) during TEA with ropivacaine versus bupivacaine.

Methods

Assessments of bladder function:

International Prostate Symptom Score (IPSS) will be used for assessment of lower urinary tract symptoms preoperatively.

Urodynamic investigations will be performed: The first investigation will be done as baseline data before attempted surgery.

Urodynamic investigations will be performed according to good urodynamic practice. After placement of a 6 French transurethral dual channel catheter and a 14 French rectal balloon catheter (Gaeltec, Dunvegan, Scotland), the bladder will be filled at a rate of 25 to 50 ml/min with Ringer's lactate solution at room temperature. Parameters of both the storage phase (maximum cystometric capacity, bladder compliance) and voiding phase (detrusor pressure at maximum flow rate (PdetQmax), maximum flow rate (Qmax) and PVR will be recorded. All methods, definitions and units will be in accordance with the standards recommended by the International Continence Society.

• Study Type: Interventional
• Enrollment (Actual): 42
• Phase: Phase 4

Contacts and Locations

Study Locations

• Switzerland
  • BE
    • Bern, BE, Switzerland, 3010
      • Patrick Wuethrich, Department of Anaesthesiology and Pain Therapy, University Hospital Bern Inselspital Bern

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Written informed consent
• Kidney surgery
• Thoracic epidural analgesia

Exclusion Criteria

• Contraindications to epidural analgesia or refusal
• Preoperative postvoid residual urine volume > 100ml
• International Prostate Symptom Score (IPSS) > 7
• Pregnancy (pregnancy test in all women who are not in menopause, exclusion for surgery per se)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Ropivacaine; Ropivacaine 2mg/ml (ROPIVACAIN Sintetica 2 mg/ml ™, Sintetica-Bioren, Couvet, Schweiz)	Drug: Ropivacaine 2mg/ml; local anesthetics, which will epidurally administered; Device: 6 French transurethral dual channel catheter (Gaeltec, Dunvegan, Scotland); Device: 14 French rectal balloon catheter (Gaeltec, Dunvegan, Scotland)
Active Comparator: Bupivacaine; Bupivicaine 1.25mg/ml (BUPIVACAIN Sintetica 0.125 % ™ (Bupivacain 1,25 mg/ml), Sintetica-Bioren, Couvet, Schweiz)	Device: 6 French transurethral dual channel catheter (Gaeltec, Dunvegan, Scotland); Device: 14 French rectal balloon catheter (Gaeltec, Dunvegan, Scotland); Drug: Bupivacaine; local anesthetics, which will epidurally administered

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Post void residual urine volume: Change between postvoid residual urine volume before surgery versus during thoracic epidural analgesia for postoperative analgesia	before surgery/TEA (baseline), during TEA (expected to be on average ca. 5 days)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Bladder volume at first desire to void (mL)	Change of the parameters of the storage and voiding phases from baseline (preoperative) to postoperative day 2 or 3, depending on patient's mobility.	before surgery/TEA (baseline), during TEA (expected to be on average ca. 5 days)
Maximum cystometric capacity (mL)	Change of the parameters of the storage and voiding phases from baseline (preoperative) to postoperative day 2 or 3, depending on patient's mobility.	before surgery/TEA (baseline), during TEA (expected to be on average ca. 5 days)
Bladder compliance (mL/cmH2O)	Change of the parameters of the storage and voiding phases from baseline (preoperative) to postoperative day 2 or 3, depending on patient's mobility.	before surgery/TEA (baseline), during TEA (expected to be on average ca. 5 days)
Urethral pressure profile (cmH2O)	Change of the parameters of the storage and voiding phases from baseline (preoperative) to postoperative day 2 or 3, depending on patient's mobility.	before surgery/TEA (baseline), during TEA (expected to be on average ca. 5 days)
Maximum detrusor pressure (cmH2O)	Change of the parameters of the storage and voiding phases from baseline (preoperative) to postoperative day 2 or 3, depending on patient's mobility.	before surgery/TEA (baseline), during TEA (expected to be on average ca. 5 days)
Detrusor pressure at maximum flow rate(cmH2O)	Change of the parameters of the storage and voiding phases from baseline (preoperative) to postoperative day 2 or 3, depending on patient's mobility.	before surgery/TEA (baseline), during TEA (expected to be on average ca. 5 days)
Maximum flow rate (mL/sec)	Change of the parameters of the storage and voiding phases from baseline (preoperative) to postoperative day 2 or 3, depending on patient's mobility.	before surgery/TEA (baseline), during TEA (expected to be on average ca. 5 days)

Collaborators and Investigators

• Sponsor: University Hospital Inselspital, Berne
• Investigators: Principal Investigator: Patrick Y Wuethrich, MD, Department of Anaesthesiology and Pain Therapy, University Hospital Bern Inselspital Bern, 3010 Bern

Study record dates

Study Major Dates

• Study Start (Actual): April 1, 2015
• Primary Completion (Actual): May 15, 2017
• Study Completion (Actual): May 15, 2017

Study Registration Dates

• First Submitted: March 26, 2015
• First Submitted That Met QC Criteria: April 9, 2015
• First Posted (Estimate): April 10, 2015

Study Record Updates

• Last Update Posted (Actual): May 18, 2017
• Last Update Submitted That Met QC Criteria: May 17, 2017
• Last Verified: May 1, 2017

More Information

Terms related to this study

• Keywords: local anesthetics; analgesia, epidural; urination
• Additional Relevant MeSH Terms: Urologic Diseases; Urination Disorders; Urinary Retention; Physiological Effects of Drugs; Central Nervous System Depressants; Peripheral Nervous System Agents; Sensory System Agents; Anesthetics; Anesthetics, Local; Bupivacaine; Ropivacaine
• Other Study ID Numbers: 390/14