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CLINICAL INVESTIGATION
Year : 2007  |  Volume : 51  |  Issue : 2  |  Page : 121 Table of Contents     

Haemodynamic and central venous pressure changes in transurethral resection of prostate during general, spinal and epidural anaesthesia: A comparative study


1 M.D., Asst. Prof., Department of Anaesthesiology, India
2 M.D., Assoc Prof., Department of Anaesthesiology, India
3 M.D., DA, Prof. and Head, Department of Anaesthesiology, India
4 M.D., Prof., Department of Anaesthesiology, India
5 M.D., DA Asst. Prof., Department of Anaesthesiology, India
6 M.ch., MS, Prof. and Head, Department of Urology, India

Date of Acceptance22-Jan-2007
Date of Web Publication20-Mar-2010

Correspondence Address:
Parul Jindal
Pain Management & ICU, Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun
India
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Source of Support: None, Conflict of Interest: None


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During transurethral resection of prostate (TURP) both intravascular and extra vascular absorption of irrigating fluid may lead to adverse cardiovascular effects and myocardial damage. This prospective study is aimed to compare central venous pressure and haemodynamic changes with different techniques of anaesthesia and to find the best possible technique. We randomly allocated 90 elderly patients (ASA I, II III) into three equal groups receiving either general anaesthesia (Group A), spinal anaesthesia (Group B) or epidural anaesthesia (Group C) for transurethral resection of prostate (TURP). It was observed that the MAP increased by 11% from preinduction values to the completion of surgery in group A while a decrease of 11.2% was observed in group B but only minimal changes in group C. There was decrease in heart rate of 14% and 17% in group A& C respectively but maximum decrease was in group B of 21%. CVP was raised from basal value up to 77%, 44% and 42% and in group A, B and C respectively. Thus, patients who received epidural anaesthesia had minimal changes in haemodynamics.

Keywords: TURP, General anaesthesia, Spinal anaesthesia, Epidural anaesthesia, CVP, Hemodynamic


How to cite this article:
Jindal P, Khurana G, Sharma U C, Sharma J P, Chopra G, Lal S. Haemodynamic and central venous pressure changes in transurethral resection of prostate during general, spinal and epidural anaesthesia: A comparative study. Indian J Anaesth 2007;51:121

How to cite this URL:
Jindal P, Khurana G, Sharma U C, Sharma J P, Chopra G, Lal S. Haemodynamic and central venous pressure changes in transurethral resection of prostate during general, spinal and epidural anaesthesia: A comparative study. Indian J Anaesth [serial online] 2007 [cited 2019 Sep 20];51:121. Available from: http://www.ijaweb.org/text.asp?2007/51/2/121/61126


   Introduction Top


Benign prostatic hypertrophy comprises 70% of the total disease conditions necessitating prostatectomy with the remainder equally shared between the bladder neck contracture and carcinoma of the prostate. Approximately 20% of the men over the age of 60 years require intervention of this type and 80% of obstructions are relieved by transurethral resection of prostate (TURP). [1]

Despite great advances in medical therapeutics, nutrition, and concept of fitness, a large percentage of our aging population will continue to have chronic disease. Surgical intervention, the need for perioperative care and pain control will become even more common place in the elderly than it is now. [2] Ischemic heart disease, chronic airway obstruction, diabetes and cardiac failure are common in this age group. Co-existing renal dysfunction may complicate treatment. In addition the elderly may be on continuous medication for the above or any other conditions. Although most of the commonly used drugs for cardiac or respiratory disease pose no particular problem, certain medications such as aspirin and oral anticoagulants invite caution. [3]

Anaesthetic management should involve proper knowledge of expected complications, adequate preoperative preparation, the use of a technique that will not obscure complications and that will produce minimal physiological disturbances, and allows prompt treatment of adverse reactions, and should they supervene.


   Aim Top


To evaluate and compare CVP and haemodynamic changes during general, spinal and epidural anaesthesia for TURP. To evaluate the choice of anaesthesia less likely to produce haemodynamic changes and to understand any unwanted complications during the course of study.


   Material and Methods Top


After approval from hospital Ethics Committee and fully informed consent from the patient ,this prospective double blind randomized study was carried out on 90 elderly male patients in the age group of 50-85 years undergoing elective TURP at HIMS from 1st May 2003 to 31st Dec 2004. As these patients were in the elderly age group, patients with pre-existing cardiovascular, respiratory or endocrine diseases were not specifically excluded.

Patients with preoperative anaemia, deranged serum electrolytes, coagulopathy and on antiplatelet or anticoagulant therapy were excluded from the study.

After a detailed history, general and systemic examination and necessary investigations patients were graded for ASA status. They were randomly allocated to receive. General anaesthesia (Group A); subarachnoid block (Group B); epidural anaesthesia (Group C). All the patients were premedicated with diazepam 10 mg oral HS and xylocaine sensitivity was done in all. After establishing I.V. line and monitoring patients in different groups was induced accordingly. A peripheral line was established. Central line was inserted through either basilic or cephalic vein. Group B and C were preloaded with 10-12mlkg-10of Ringer lactate. In group A Inj morphine 1.5ìgkg-1. IV was given.

Group A: Patients received in injection glycopyrrolate 0.2-0.4mg at least 30 minutes prior to surgery. Anaesthesia was induced with sleep dose of thiopentone (4-7mgkg-1) I.V. followed by inj succinylcholine 1-2 mgkg- 1 IV for intubation with appropriate sized cuffed endotracheal tube. Anaesthesia was maintained by using 33% oxygen in nitrous oxide, 0.5-1.0% halothane and Inj vecuronium 0.1 mgkg-1I.V. At the end of surgery muscle relaxant was reversed with Inj neostigmine 0.05 mgkg-1with Inj atropine 0.02 mgkg-1 I.V.

In both group B, C after explaining the procedure and instructing the patient not to move while performing the procedure, patients were placed in the sitting position. In group B in L3-4 space 0.5% hyperbaric bupivacaine 2.5-3 ml via a 23-gauge LP Quincke Babcock needle was given. All injections were made at a rate approximately 0.3-0.5 ml/sec. Immediately after injection, needle was withdrawn, the patient was laid supine. Level of block, was judged by the loss of pinprick sensation.

In group C under all aseptic precautions at the L2-3 or L3-4 intervertebral spaces. Epidural space was identified using 17 gauge Tuohy's needle. After negative aspiration for cerebrospinal fluid, patient received 12-16 ml of 0.5% isobaric bupivacaine. Catheter was not introduced in any patient. The patient was laid supine until the block had established.

After the block onset in both groups B, C all the patients were placed in lithotomy position for surgery, eyes were covered and oxygen at 4L/min was given by face mask. Intravenous sedation was not used in both group B and group C.

Fluid input during study period was determined by the anaesthetist based on clinical criteria (arterial pressure, heart rate and observation of the patient).

For prostate resection an Olympus 24 resectoscope, supra pubic trocar used in some cases and a continuous irrigation with a 1.5% glycine solution, warmed to body temperature were employed. The liquid surface was maintained at the height of about 60-70 cms above the operating table, measured from the level of pubic symphysis of the patient on the operating table.

At least three measurements were obtained to determine the baseline.

Heart Rate : Bradycardia was defined as heart rate less than 50 per minute and treated with intravenous injection atropine 0.3 mg, and was repeated again, if required.

Arterial blood pressure : Hypotension was defined as a decrease in systolic arterial pressure more than 30% from the baseline. Treatment of hypotension consisted of: increasing the infusion rate, inj atropine if associated with bradycardia, continuing oxygenation, vasopressor like mephentermine, if not responding to fluids and oxygen.


   ECG : monitored from lead II. Top


CVP monitoring : CAVAFIX (B.Braun), placed through either cephalic or basilic vein. The position was checked by fluoroscopy and the CVP was recorded by the manometer.

Variables were recorded before induction, immediately before and after intubation in the group A, at 5 min after injection in the group B and C, and immediately after the patients were placed in the lithotomy position in all the groups. The time of surgery was defined as the time when resection was started and not the time when the resectoscope was introduced and removed. The start of resection was taken as time zero and measurements were then recorded every 10 min. from time zero throughout the resection period. The weight of the prostate resected, volume of intravenous (including the loading dose) and irrigating fluid administered up to the end of surgery, and duration of operation were recorded. The prostatic chippings were weighed on an electronic scale immediately post operatively.

Complications like shivering, discomfort; nausea and vomiting or allergic reaction were noted and managed accordingly.

Data were analyzed looking at the variations in standard deviation of means of mean arterial pressure, heart rate and central venous pressure. Data analyzed with paired t test (p<0.05 was considered significant and p<0.001 was considered highly significant) and ANOVA test.


   Observations & Results Top


There was no significant difference in all the three groups in age, height, weight ASA grade and associated disease. There was no significant difference in the weight of the prostate and the weight of the prostate resected. Most of the patients belonged to ASA grade II. [Table 1] and [Table 2]

Most of the patients in our study had associated disease; most common was hypertension (28%) and diabetes mellitus (18.8%).

It was noted that the resection time was not the same in all the patients and did not last upto 60 minutes in all the patients. In group A it lasted upto 30 minutes in 6.67%, 40 minutes in 23.33%, 50 min in 30%, 60 min in 23.33% and > 60 min. in 16.67% patients. In group B it lasted upto 40 min in 3.33% and upto 50min in 33.33%, upto 60 min in 40% and more than 60 min in 23.33% patients. In group C the surgery lasted upto 40 min. in 3.33%, 50 min. in 16.67%, 60 min in 26.67% and more than >60 min. in 53.33% patients.

In group C the surgery lasted longer than group A and B because of large prostate and difference in the operator skill but there was statistically no significant difference in duration of surgery in all the three groups because large variations in standard deviation were present both in group A and B.

Among all the groups the IV fluids given were maximum in group B, and irrigating fluid used was more in group C than in group A and B. [Table 2]

There was decrease in heart rate in group A of 14% and about 17% in group C but maximum decrease in group B of 21%.

(P1 = Pre Induction, IND = Induction, INT = Intubation, L = Lithotomy, A0 = Start of resection, A10 = After 10 Min, A20 = After 20 Min, A30 = After 30 Min, A40 = After 40 Min, A50 = After 50 Min, A60 = After 60 Min, COM = At the end of surgery).

The subsequent changes in the MAP show an increase of 11% at the time of completion from basal value in group A but in group B there was a decrease of 11.2% but only minimal changes in group C.

(P1 = Pre Induction, IND = Induction, INT = Intubation, L = Lithotomy, A0 = Start of resection, A10 = After 10 Min, A20 = After 20 Min, A30 = After 30 Min, A40 = After 40 Min, A50 = After 50 Min, A60 = After 60 Min, COM = At the end of surgery).

In group A the CVP is raised from basal value upto 77% and in group B and C, there is again an increase in CVP of 44% and 42% respectively.

(P1 = Pre Induction, IND = Induction, INT = Intubation, L = Lithotomy, A0 = Start of resection, A10 = After 10 Min, A20 = After 20 Min, A30 = After 30 Min, A40 = After 40 Min, A50 = After 50 Min, A60 = After 60 Min, COM = At the end of surgery).


   Discussion Top


Any operation produces a stress response. [4]

Although several modalities of treatment are available for benign enlargement of prostate, TURP is still the gold standard and is one of the commonest surgeries performed on elderly. [5]

The ideal anaesthetic technique for TURP should provide adequate analgesia, minimal physiological disturbances, uncompromised compensatory mechanism, adequate muscle relaxation to enable good irrigating flow into bladder, relaxation of pelvic floor, minimal blood loss and permits early recognition of over hydration, perforation and hemolysis. [6],[7]

In a large retrospective study Lange R [8] concluded that regional anaesthesia up to the level of T10 is an ideal choice as it is associated with minimal physiological changes, respiratory exchange is little affected and it does not mask the signs of dilutional hyponatremia [9] while Walsh KH et al [10] demonstrated that limiting the spread of block does not improve haemodynamic or pulmonary function. Reeves, [11] Hosking MP [12] reported that while spinal anaesthesia was not associated with improved outcome GA was associated with higher incidence of minor side effects. But Mebust [13] suggested that a patient's anaesthetic requirement should be tailored according to his requirements.

All anaesthetic techniques have their own sets of advantages and disadvantages.

Epidural anaesthesia is technically difficult to perform and has a slower onset of action where as spinal anaesthesia is easy to perform, has rapid onset of action and shorter recovery time but it may lead to sudden hypotension. [14] GA has usually been described for TURP if patient requires ventilatory and haemodynamic support and where regional anaesthesia is contraindicated. [15] GA obtunds the symptoms of TURP syndrome which makes central neuraxial blockade a preferable choice. Central neuraxial blockade is less forgiving than general anaesthesia of anything less than perfection.

In a spontaneously breathing patient venous pressure may be raised by other means including shivering, straining, coughing. The combination of vasodilatation induced by the spinal anaesthesia, dependent positioning of the operative area and the assumption of the lithotomy position tends to favour pooling of blood and raised venous pressure in the pelvis and the prostatic venous sinuses. [16],[17]

In the elderly the ventricular compliance decreases, relatively small changes in the intravascular volume or venous capacitance become increasingly important determinants of the circulatory stability. Circulatory overload either due to absorption of irrigating fluid or due to iatrogenic over transfusion of blood or other fluids increase the bleeding by raising venous pressure. [18],[19] Cardiovascular changes are usually limited to a fall in the mean arterial pressure in the regional anaesthesia as sympathetic block is established. This can be minimized by prophylactic overloading; a patient with borderline heart function may develop congestive heart failure when the block dissipates and the normal sympathetic tone returns. [20]

In our study, there was no significant difference in all the groups in age, weight, height, ASA grade of the patients. Most of our patients had associated disease; commonest being hypertension (28.8%) and diabetes mellitus (18.8%). There was no significant difference in the weight of the prostate evaluated preoperatively and the weight of the prostate resected. Intravenous fluids were given more in group B (1.25± 0.33 L) than in other two groups. Irrigating fluids were used more in group C.

11.4 ± 3.45 L as the surgery was prolonged, with varying operator skill. The mean arterial pressure varies from pre induction to the completion of the surgery in all the three groups but in epidural group there were least variations in the MAP. Statistically there is a highly significant difference in MAP between group A and B (p<0.001). There is highly significant difference in MAP between group B and C (p<0.001). Incidentally, there was no significant difference in MAP in patients of group A and C (p> 0.05). There is no significant difference in heart rate between group A and Group B (p>0.05). There is significant difference between group B and C (p<0.05) while there is significant difference between Group A and C (p= 0.0056 less than p<0.05). Hence changes in heart rate are minimal in group C.

In our study we noted that decrease in mean arterial pressure (4%) and heart rate from baseline to the time of induction in group A may be due to decrease in venous return secondary to manual IPPV. The subsequent changes in mean arterial pressure (increases about 7%) and heart rate after intubation were of typical pressor response as no measures were taken to curtail this response. In our study there was no bradycardia between the intubation and lithotomy position Dobson et al [21] had a significant decrease in heart rate (mean 32%) which occurred between intubation and lithotomy may be due to loss of positive chronotropic response to induction and intubation and also to a change in depth of anaesthesia.

We observed 15% decreases in heart rate from baseline during the resection period unlike Lawson and Dobson [22],[21] who observed decrease in MAP and heart rate at the time of induction in their respective study but no change during the resection period. This difference in observation could be because they performed surgery in Trendelenberg position, which supports cardiac output, and not in lithotomy position as done in our study. Dobson [21] induced with etomidate, fentanyl, vecuronium and enflurane. Etomidate when combined with fentanyl causes significant decrease in heart rate.

Evan [23] et al in their study observed a reduction in the heart rate it could be because they used large amount of irrigating fluid >11 L/patient at room temperature of 20°C and not body temperature and this could have resulted in a decrease in core temperature.

In group B and C there was a decrease in MAP of 9% and 8% respectively at the time of effect of block, which was due to sympathetic block and a physiological response to the anaesthetic technique used. There was no major fall in blood pressure as patient in both groups were preloaded with 10 mlkg-1 of lactated Ringer 10 minutes prior to shifting the patient to operation theatre. There were no signs of fluid overload in any patient. The level of block reached was T8-10 i.e. mid thoracic block thus vasoconstriction of vessels supplied by unaffected sympathetic nerves would counteract vasodilatation of vessels supplied by blocked sympathetic nerves. During the resection time there was a decrease in MAP of 12% in group B but in group C, there were minimal changes in the MAP, throughout the resection period event though few surgeries lasted longer than 60 minutes. Similar findings were observed by Aromaa U et al. [24]

In a recent study Togal T et al [25] demonstrated that low dose bupivacaine with ketamine provide shorter motor and sensory block onset, shorter duration of action and less motor block

CVP was observed in all the patients. The central venous pressure was 12.41±2.29, 9.18±1.4 and 8.00±0.461 cms of H2O in patients of group A, B& C respectively. Statistically there is a significant difference between patients of group A& B (p<0.001). The p value between group B & C and between group A& C is significant.

Tolksdorf W et al [26] observed that during general anaesthesia BP and CVP reached their maximum 10 minutes later and were significantly higher than was the case in regional anaesthesia and recommended routine recording of the central venous pressure in GA. In general anaesthesia because of positive pressure ventilation, which such patients receive the venous return is reduced and the central venous pressure is raised. The less severe reaction during regional anaesthesia on the circulation is probably attributable to a sympatholytic effect and peripheral pooling.

In their study Gehring et al [27] showed that the intravascular absorption of the irrigating fluid is inhibited in general anaesthesia in ventilated patient as compared to the spontaneously breathing spinally anaesthetized patient. Correspondingly both the absorption rate and the quantity of irrigating fluid are higher in spinal group patients. They concluded that the low central venous absorption support direct intravascular fluid absorption and that degree of absorption in spinal anaesthesia patient. Gadzhimuradov KN [28] reported significant fall of CVP and stated that this low central venous pressure resulted from the epidural block and contributed much to development of hyponatremia in these patients.

In our study there were no changes in SpO2 in any of the group at any time of observation. In group B early manifestation like nausea, vomiting (6.67%) and bradycardia (10%) were observed in a small number of patients, in these patients the duration of surgery was more than 60 min and the prostate was more than 50 grams. In group A, bradycardia was the earliest manifestation in 26.67% patients. In group C there were frequent episodes of hypotension in 23.33% patients which could be because of blood loss. None of the patients in our study showed signs of full-blown TURP syndrome.


   Conclusion : Top


We can conclude that epidural anaesthesia is less likely to produce haemodynamic changes.[Figure 1] [Figure 2] [Figure 3]

 
   References Top

1.Korth VH. Anaesthesia for transurethral prostatectomy. A review of two hundred cases at Sunny brook Hospital .Med Serv J Can 1965; 21: 398-405.   Back to cited text no. 1  [PUBMED]    
2.Schneider EL, Reed JD Jr. Life extension. N Engl J Med. 1985; 312: 1159.   Back to cited text no. 2  [PUBMED]    
3.Jensen V. The TURP syndrome. Can J Anaesth1991 (38); 1: 90-97.   Back to cited text no. 3      
4.Malhotra V. Transurethral resection of the prostate. Anesthesiol Clin North America 2000; 18(4): 883-97.   Back to cited text no. 4      
5.Russel RCG, Williams NS, Bulstrode CJK. Prostate and seminal vesicles. In Bailey and Love's: The short practice of surgery. 23 rd ed London, Arnold 2000; 1245.   Back to cited text no. 5      
6.Mc Gowan JW, Smith GFN. Anaesthesia for TURP. Anaesthesia 1980; 35: 847-53.   Back to cited text no. 6      
7.Denison B, Wildsmith JAW, Notley RG, Schweitzeerr FAW, Mc Gowan SW, Smith GFN. Anaesthesia for transurethral prostatectomy 1981; 36: 218-21.   Back to cited text no. 7      
8.Lange R, Rupieper N, Ringert RH. Anesthesia in transurethral surgery Urologe A 1988; 27(2): 86-88.   Back to cited text no. 8      
9.Evans TI. Regional analgesia for transurethral resection of prostate-which method and which segment? Anaesth Intensive Care 1974; 2: 240-42. E   Back to cited text no. 9  [PUBMED]    
10.Walsh KH, Murphy C, Iohom C, Cooney C, Mc Adoo J. Comparison of the effects of two intrathecal anaesthetic techniques for transurethral prostatectomy on hemodynamic and pulmonary function. Eur J Anaesthesiol 2003; 20: 560-64.   Back to cited text no. 10      
11.Reeves MDS, Myles PS. Does anesthetic technique affect the outcome after trans urethral resection of the prostate? BJU International 1999; 84: 982-86.   Back to cited text no. 11      
12.Hosking MP, Lobdell CM, Warner MA, Offord KP, Melton LJ. Anaesthesia for patients over the 90 years of age. Outcomes after regional and general anaesthetic techniques for two common surgical procedures. Anaesthesia 1989; 44(8): 697-98.   Back to cited text no. 12      
13.Mebust WK, Holtgrewe HL, Cocktt ATK, Peters PC, and Writing Committee: Transurethral prostatectomy : immediate and postoperative complications. A Cooperative study of thirteen participating institutions evaluating 3885 patients. J. Urol 1989; 144: 243-47.   Back to cited text no. 13      
14.Reisli R, Celik J, Tuncer S, Yosunkaya A, Otelcioglu S. Anaesthetic and hemodynamic effects of continuous spinal versus continuous epidural anaesthesia with prilocaine. Eur J Anaesthesiol 2003; 20: 26-30.   Back to cited text no. 14  [PUBMED]    
15.Lim EK. Anaesthesia for transurethral prostatectomy - a review of the problems, complications and their management. Singapore Med J 1979; 20: 330-34.   Back to cited text no. 15  [PUBMED]    
16.Desmond J. Complications of transurethral prostatic surgery. Can Anaesth Soc J 1970; 17: 25-36.   Back to cited text no. 16  [PUBMED]    
17.Hatch PD . Surgical and anaesthetic considerations in transurethral resection of prostate. Anaesthesia Intensive care 1987; 15: 203-11.   Back to cited text no. 17      
18.Sunderrajan S, Bauer JH, Vopal RL, Wanner-Barjenbrush P, Hayes A. Post transurethral prostatic resection hyponatremic syndrome: Case report and review of the literature. Am J Kid Dis 1984; 4: 80-84.   Back to cited text no. 18      
19.Gravenstein D. Transurethral resection of prostate (TURP) syndrome: a review of pathophysiology and management. Anesth Analg 1997; 84: 438-44.   Back to cited text no. 19  [PUBMED]  [FULLTEXT]  
20.Minuck M. Complications arising during transurethral resection of prostate. Can Anaesth Soc J 1954; 1: 59.   Back to cited text no. 20      
21.Dobson PMS, Caldicott LD, Gerrish SP, Foex P, Millet SV, Howell SJ. Changes in hemodynamic variables during transurethral resection of prostate: comparison of general and spinal anaesthesia. Br J Anaesth 1994; 72: 267-71.   Back to cited text no. 21      
22.Lawson RA, Turner WH, Reeder MK, Sear JW, Smith JC. Haemodynamic effects of Trans urethral prostatectomy. Br J Urol 1993; 72: 74-79.   Back to cited text no. 22  [PUBMED]    
23.Evans JW, Singer M, Chapple CR, McCartney N, Coppinger SW, Milroy EJ. Hemodynamic evidence for per-operative cardiac stress during transurethral prostatectomy. Preliminary communication. Br J Urol 1991; 67(4): 376-80.   Back to cited text no. 23      
24.Aromaa U, Linko K, Nieminen MT. Comparison of epidural and spinal blockade with 0.5% bupivacaine for transurethral surgery. Eur J Anaesthesiol 1986; 3(3): 241-46.   Back to cited text no. 24      
25.Togal T, Demirbilek S, Koroflu A, Yapici E, Ersov O. Effects of S(+) Ketamine added to bupivacaine for spinal anaesthesia for prostate surgery in elderly patients. Eur J Anaesthesiol 2004; 21: 193-97.   Back to cited text no. 25      
26.Tolksdorf W, Ditterich G, Hartung HJ, Klose R, Lutz H. The effects of various anaesthetic techniques on central venous pressure during transurethral prostatectomy Prakt Anaesthesia 1979; 14(1): 35-41.   Back to cited text no. 26      
27.Gehring H, Nahm W, Baerwald J et al. Irrigation fluid absorption during transurethral resection of prostate: Spinal vs General anaesthesia. Acta Anaesthesiol Scand 1999; 43: 458-63.   Back to cited text no. 27      
28.Gadzhimuradov KN. Changes in central haemodynamics in Trans urethral resection prostate under epidural anaesthesia. Urol Nefrol (Mosk) 1998; (3): 12-15.  Back to cited text no. 28  [PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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