• Rezūm is a short, minimally invasive procedure for BPH that avoids major risks of TURP (fluid overload, TUR syndrome, bleeding).
• In elderly, anticoagulated patients with AF and comorbidities, neuraxial anesthesia may be contraindicated; short general anesthesia with spontaneous ventilation is a safe alternative.
• Careful titration of propofol and sevoflurane with adjuncts (fentanyl, dexmedetomidine, glycopyrrolate) minimizes hemodynamic swings and movement.
• Lithotomy positioning, risk of patient movement, and the surgical learning curve demand vigilance from the anesthesia team.
• Anticoagulation resumption and catheter care remain essential parts of postoperative planning.

References

1. McVary KT, Roehrborn CG, et al. Rezūm water vapor thermal therapy for lower urinary tract symptoms secondary to BPH: 2-year results. J Urol. 2019;202(3):601-609.
2. Gilling PJ, Barber N, Bidair M, Anderson P, Sutton M, Roehrborn C. Rezūm water vapor thermal therapy: 4-year results and safety profile. Urology. 2021;147:154-161.

Case Description

Patient: An 89-year-old male with recurrent UTIs and indwelling catheter due to obstructive BPH was scheduled for Rezūm therapy.

Comorbidities:

• Chronic atrial fibrillation on apixaban 5 mg, stopped 48 h prior.
• Recovered from left frontoparietal acute infarct.
• Hypertension on nebivolol 2.5 mg BD, sacubitril-valsartan 50 mg OD, rosuvastatin 10 mg HS.
• ECHO: Bilateral atrial enlargement, EF 55%, pulmonary artery pressure 44 mmHg.
• Renal function: Creatinine 1.6 mg/dL.
• Vitals: HR 88/min (irregular), BP 140/90 mmHg.

References

3. Yates J, Barham CP, Perry M. Perioperative risk assessment in the elderly patient. Anaesthesia. 2020;75(S1):e83-e92.

4. Weitz JI, Pollack CV. Practical management of anticoagulation in patients with atrial fibrillation. Circulation. 2017;135(7):648-651.

Anesthetic ManagementPreoperative Considerations

• High-risk profile due to advanced age, anticoagulation, AF with pulmonary hypertension, and prior stroke.
• Spinal anesthesia avoided because apixaban was stopped only 48 h earlier and renal clearance was impaired.
• Planned for short GA with spontaneous breathing to maintain safety, hemodynamic stability, and airway control.

References

5. Narouze SN, Benzon HT, Provenzano DA, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications (ASRA guidelines). Reg Anesth Pain Med. 2018;43(3):225–262.

6. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC guidelines for the management of atrial fibrillation. Eur Heart J. 2016;37(38):2893-2962.

Intraoperative Course

• Premedication/Induction:
• Fentanyl 100 mcg IV
• Glycopyrrolate 0.2 mg IV
• Dexmedetomidine 25 mcg IV over 15 min
• Propofol 40 mg IV
• Airway: Mask ventilation with oxygen and air.
• Maintenance: Sevoflurane in oxygen-air mixture, spontaneous breathing.
• Duration: 10 minutes.
• Course: Hemodynamically stable, no adverse airway or cardiovascular events.

References

7. Weerink MAS, Struys MMRF, Hannivoort LN, et al. Clinical pharmacokinetics and pharmacodynamics of dexmedetomidine. Clin Pharmacokinet. 2017;56(8):893–913.

8. Miller RD, Eriksson LI, Fleisher LA, Wiener-Kronish JP, Cohen NH, Young WL. Miller’s Anesthesia. 9th ed. Philadelphia: Elsevier; 2020.

Postoperative

• Aldrete score 10 at 15 minutes. Pain score <3. Stable vitals, no desaturation or arrhythmia.
• Catheter left in situ.
• Pain managed with paracetamol; NSAIDs avoided due to CKD.
• Apixaban resumption planned after 24–48 h based on surgical advice.

References

9. Polderman JAW, Farhang-Razi V, Van Dieren S, et al. Adverse side effects of dexamethasone in surgical patients. Cochrane Database Syst Rev. 2018;2018(8):CD011940.

10. Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, et al. Perioperative management of antithrombotic therapy. Chest. 2022;162(5):e207-e243.

DiscussionNeurophysiology of Pain in Rezūm

The prostate and prostatic urethra receive innervation via pelvic splanchnic nerves (parasympathetic S2–S4) and sympathetic fibers via the hypogastric plexus. Transurethral manipulation stimulates these afferents, producing visceral pain. Systemic sedation/GA blunts this; peri-prostatic infiltration can also block local nociceptive transmission.

References

11. Lang RJ, Tonta MA, Zolfaghari P, Hashitani H, Parkington HC. Contractile and electrical properties of smooth muscle in the prostate. BJU Int. 2006;97(6):1144–1153.

Pulmonary Hypertension Physiology

In this patient, pulmonary artery systolic pressure 44 mmHg indicates moderate PH. Hypoxia, hypercarbia, and acidosis all increase pulmonary vascular resistance, risking RV strain. Hence, sevoflurane was chosen for smooth control, with careful ventilation to maintain normoxia/normocapnia.

References

12. Muñoz R, Gómez-Ruiz M, et al. Anesthetic management of elderly patients with pulmonary hypertension. Curr Opin Anaesthesiol. 2021;34(1):43-50.

13. Ghofrani HA, Humbert M. The role of combination therapy in managing pulmonary arterial hypertension. Eur Respir Rev. 2014;23(134):469–475.

Pharmacology Rationale

• Fentanyl 100 mcg: Short-acting, synergistic with sevoflurane, minimal renal excretion.
• Glycopyrrolate 0.2 mg: Reduces vagal tone, prevents bradycardia in AF, decreases airway secretions.
• Dexmedetomidine 25 mcg: Provides anxiolysis, analgesia, and stable hemodynamics in frail elderly.
• Propofol 40 mg: Low-dose induction, minimizing hypotension, used in conjunction with sevoflurane.

References

14. Shafer SL, Flood P. Pharmacology of anesthetic drugs. In: Miller RD, ed. Miller’s Anesthesia. 9th ed. Philadelphia: Elsevier; 2020.

15. Fragen RJ. Pharmacology of fentanyl and its derivatives. Br J Anaesth. 1984;56(Suppl 1):3S–14S.

Clinical Relevance

Positioning Risks: Lithotomy in elderly can precipitate hip pain, neuropathy (peroneal nerve), DVT, and pressure sores. Padding and short duration reduce risks.

Risk of Movement: Even under GA, movement may compromise probe placement, risking urethral/bladder trauma. Hence titration of volatile anesthetic was critical.

Surgical Learning Curve: Early Rezūm procedures may last 20–25 min. Anesthesiologists should anticipate this variability and avoid under-dosing sedation or volatile agents.

References

16. Warner MA, Martin JT, Schroeder DR, Offord KP, Chute CG. Lower-extremity motor neuropathy associated with lithotomy positions. Anesthesiology. 1994;81(1):6–12.

17. Gilling PJ, Barber N, Bidair M, Anderson P, Sutton M, Roehrborn C. Rezūm therapy outcomes in a multi-institutional cohort. Urology. 2021;147:154–161.

Box 1: Clinical Pearls

• Short GA with mask ventilation is safe in frail elderly Rezūm patients when neuraxial is contraindicated.
• Always anticipate movement; titrate sevoflurane carefully.
• Lithotomy positioning risks increase with age—pad carefully, minimize duration.
• Early learning curve may prolong procedures → anticipate anesthetic adjustments.
• Resume anticoagulation cautiously post-procedure in collaboration with urology.