Comparison Of Different Anesthetic Techniques Used For Geriatric Patients Who Underwent TUR-P Operation: Single Center Experience

To investigate impacts that effect entrance to intensive care unit, mortality, and cost; according to demographical and clinical parameters of patients, and different anesthetic techniques performed on patients who underwent TUR-P operation. Methods Data of 234 patients aged 60 years and older who underwent TUR-P operations was evaluated retrospectively. The patients were examined in two groups as neuroaxial and general anesthesia groups. Charlson Comorbidity Index, preoperative laboratory parameters, presence of comorbidity, preoperative intensive care requirement, operation duration were obtained from hospital records. The cost calculation was based on the length of the patient's stay in hospital and intensive care unit.


Introduction
Along with the aging population, the number of older people with urinary system diseases is also increasing. Benign prostatic hypertrophy (BPH) can cause progressive and chronic lower urinary tract symptoms in older men (1,2) . The incidence of BPH is approximately 50% in men aged 50-60 (3) . In patients with BPH, voiding and storage symptoms can be often observed, and these symptoms can have adverse effects on quality of life (4) . Transurethral prostate resection (TUR-P) operations used for the treatment of BPH, contribute to the improvement of moderate to severe symptoms signi cantly (5,6) .
The annual cost of BPH treatment was reported in the United States in 2006, an estimated $ 4 billion. In Europe, it causes a signi cant economic burden with a treatment cost of 858 Euros per patient. Due to the demographic shift towards the elderly population, the cost resulting from lower urinary tract symptoms associated with BPH is predicted to increase substantially (7,8) .
Transurethral prostate resection may be associated with serious morbidity and even mortality (9) . Therefore, the most appropriate anesthetic technique should be selected for each patient individually.
Considering the bene ts and risks of these methods, various preoperative indices have been developed. The most commonly used indexes are Charlson Comorbidity Index (CCI), age adjusted CCI, and the American Society of Anesthesiologists Pysical Status Classi cation (ASA). These indexes reveal the risk of mortality in the preoperative evaluation of the patient (10) .
In our study, we aimed to show impacts that effect entrance to intensive care units, mortality, and cost; according to demographical and clinical parameters of patients, and different anesthetic techniques performed on patients who underwent TUR-P operation.

Material & Methods
The study was carried out according to the Helsinki Declaration Records of 311 patients aged 60 years and older, who underwent neuroaxial anesthesia (NA) and general anesthesia (GA) were analyzed retrospectively, from the intensive care unit les and hospital administration management system.
Patients with insu cient records, the patients who were under 60 years old, in whom general and neuroaxial anesthesia were performed together, patients who were followed up in intensive care in preoperative period, and who were evaluated as ASA IV-V were excluded from the study. Retrospective 234 cases who met the study criteria were evaluated within the scope of the study. Spinal and epidural anesthesia are handled together under the head of neuroaxial anesthesia, and patients were Demographic data, history of smoking, American Society of Anesthesiologist (ASA) score, examined in two groups as NA, and GA groups. Charlson Comorbidity Index (CCI), preoperative laboratory parameters, presence of comorbidity, preoperative intensive care requirement, operation times were obtained from hospital records. Duration of stay in intensive care unit, length of hospital stay, mortality rates, and cost evaluation were noted. CCI score was calculated from the preoperative information in the hospital information management system ( Table 1). The cost calculation was made on the average dollar (USD) rate at the time the patient was hospitalized. The cost calculation was based on the length of the patient's stay in the hospital and intensive care unit. GA is preferred in cases where NA is contraindicated, such as patients' refusal, receiving anticoagulant therapy, coagulopathies, and skin infection at the injection site.

Statistical Analysis
Descriptive properties of the data obtained are given as mean and standard deviation for quantitative variables, and as frequency and percentage distribution for qualitative variables. While chi-square analysis was used for comparisons of mortality status and intensive care follow-up rate according to the type of anesthesia; One-Way Analysis of Variance was used to compare cost, length of hospital stay, and intensive care unit according to the type of anesthesia. According to ASA score and CCI, independent samples t test was used for comparison of hospital stay, duration of surgery, duration of intensive care unit stay. The analyzes were carried out with the help of SPSS for Windows program.

Results
It was determined that 83 (35.4%) of 234 patients who met the study criteria were underwent GA, and 151 (64.5%) patients were underwent NA. According to age (P = 0.28), history of smoking (P = 0.731), body mass index (BMI) (P = 0.672), ASA (P = 0.36) and CCI (P = 0.586) parameters; there was no statistically signi cant difference between GA and NA groups. Demographic data of the patients is demonstrated in Table 2.
Among the parameters studied, the duration of surgery (P = 0.14), the number of the patients who were followed up in intensive care unit (P = 0.879), the duration of intensive care unit stay (P = 0.914), the length of hospital stay (P = 0.08), mortality (p = 0.759), and cost (P = 0.685), there was no statistically signi cant difference between the two groups according to the type of anesthesia (Table 3).
According to ASA score, no signi cant difference was observed among operation time (p = 0.153), hospital stay (P = 0.217) and intensive care unit stay (P = 0.313). According to the CCI scor, there was no signi cant difference among the operation time; however, when the patient's CCI was 3 and above 3, the duration of intensive care stay (P = 0.001) and hospital stay (P = 0.06) were signi cantly longer (Table 4).
In 34 (40.9%) of 83 patients who received GA, intensive care unit hospitalization was envisaged, but 2 (5.8%) patients were admitted to intensive care unit; Hospitalization in the intensive care unit was envisaged for 44 (29.1%) of 151 patients who received NA, but total 3 patients (6.8%) were hospitalized in the intensive care unit. There was no statistically signi cant difference between the type of anesthesia, and the rate of hospitalizations in intensive care unit (P = 0.879). Cost increased signi cantly when CCI was 3 and above 3 (P = 0.872), but did not change according to the ASA score (P = 0.001). When CCI is below 3, the cost was 461.3 ± 173.1 dollars; when CCI is above 3, the cost was calculated as 1033.7 ± 1225.3 dollars (P = 0.001).

Discussion
The aging population results in an increased number of surgical procedures in elderly patients. Several risk factors for morbidity and mortality after surgery increase with aging. However, increasing age itself is an important risk factor for postoperative morbidity and mortality (11) . The most important factor affecting perioperative morbidity and mortality in elderly patients are concomitant diseases originating from organs and systems, especially cardiovascular, pulmonary, endocrine, and neurological systems (12,13) .
More than 75% of TUR-P operations are performed under regional anesthesia. Spinal anesthesia is generally accepted as the technique of choice (14) . Regional anesthesia provides early detection of complications such as TUR-P syndrome and bladder perforation. It also potentially reduces blood loss, provides analgesia in the early postoperative period, and reduces the incidence of deep venous thrombosis. Increased blood ow from sympathetic blockage can help reduce thrombosis and prevent mental or cognitive dysfunction in elderly patients (14) . However GA is performed in cases such as the patient's refusal to accept spinal anesthesia, coagulopathy, taking anticoagulant therapy, infection at the injection site or aortic stenosis.
Kaufman et al. (15) reported that intraoperative NA administration could reduce the need for intensive care unit after orthopedic surgery, especially in high-risk patients (GA; n = 38 and NA; n = 45) In addition, it has been shown that NA could reduce the need for postoperative mechanical ventilation even in high-risk patients such as elderly and myasthenia graves (16) . In our study, the need for preoperative intensive care was seen in a large number of patients, since the elderly patients with comorbidities were examined. However, due to the fact that the duration of surgery was short and the form of anesthesia was mostly NA, the intensive care unit need was low. Although different anesthesia methods were performed, there was no statistically signi cant relationship between the cases for the intensive care requirement.
ASA and CCI are commonly used as preoperative evaluation scales. In these evaluations, each methodology was found to be related to the rate of operative complications (17) . In a prospective study by Valerio et al. (18) ASA grade was noted as an important and independent predictor of early morbidity after transurethral procedures. The use of ASA can assist clinicians in the decision-making process to determine the bene t and harm of the procedure to be performed on the patient In a recent analysis by Mandal et al. (17) 722 patients who underwent TUR-P showed that men with higher CCI scores had a higher morbidity rate than men with low scores; and that CCI was a fast, simple and reproducible score. It was emphasized that it was a system that could accurately predict operative complications after TUR-P.
Guo et al. (19) found that surgical complications in male patients with CCI 0, 1 and ≥ 2 were 10.6%, 10.0% and 13.1%, respectively. The authors reported that although there was no signi cant difference in patients with ASA ≥ 3 or CCI ≥ 2, the rate of operative complications tended to be higher than those with low scores (P = 0.183 and P = 0.593, respectively). Therefore, they reported that they could not predict higher complications in patients with higher ASA grades or CCI scores. In our study, length of hospital stay and intensive care unit stay were statistically analyzed according to ASA, no signi cant difference was observed. However, when the patient's CCI score was 3 and above 3, it was seen that the length of stay in the intensive care unit (ICU) and hospital were statistically signi cantly longer (P = 0.001).
Treatment of BPH in the geriatric population creates an economic burden. Since BPH is a disease seen in older ages, it increases factors affecting the treatment costs of these patients. We did not nd any study calculating the cost of TUR-P operations according to the type of anesthesia in geriatric patients. In our study, the reasons that increase the cost of TUR-P surgeries were investigated. Retrospectively, the relationship between costs and preoperative values of patients, comorbidity indices, duration of surgery, forms of anesthesia, and duration of intensive care unit stay were examined. Accordingly, the number of additional diseases of the patient was three and over three, and the CCI index 3 and above 3 signi cantly increased the cost. In our study, since there were only 5 patients who went to intensive care unit, a signi cant relationship could not be established between the duration of intensive care unit and the cost. However, the cost of patients staying in intensive care unit was found to be higher. Although costs of anesthesia change hospital costs, the propotion of anesthesia cost is small because intraoperative anesthesia costs are less than 6% of total hospital costs (20) . In a study, evidence was presented that the probability of reducing total hospital costs is low according to different anesthetic techniques (21) . In our study, no signi cant difference was found between the technique of anesthesia and its cost (p = 0.685).
This study has certain limitations. Our study was retrospective nature, and because of this, we could not perform randomization. Our results should be supported by prospective, and randomized trials.

Conclusion
In our study, in which we aimed to evaluate choosing an anesthetic method to reduce the need for intensive care, mortality and cost in patients undergoing TUR-P due to the increase in the geriatric population; it was observed that the type of anesthesia did not affect the duration of surgery, rate of entrance to intensive care unit, duration of intensive care stay, length of hospital stay, mortality and cost. However, it was observed that the duration of hospitalization and intensive care unit entrance increased in patients with CCI 3 and above, therefore the cost was increased. It was concluded that ASA scoring was not as signi cant as CCI for predicting rate of ICU entrance and length of hospitalization. Tables