Intraoperative Hypotension During Photodynamic Diagnosis-Guided TURBT Under Spinal Anesthesia: A Propensity Score-Matched and Logistic Regression Analysis.

OBJECTIVES

To compare the incidence of intraoperative hypotension between oral 5-aminolevulinic acid (5-ALA)-guided photodynamic diagnosis-assisted transurethral resection of bladder tumor (PDD-TURBT) and white light transurethral resection of bladder tumor (WL-TURBT) performed under spinal anesthesia, and to identify risk factors for hypotension with a focus on spinal sensory block level.

METHODS

We retrospectively reviewed 279 consecutive patients who underwent transurethral resection of bladder tumor (TURBT) under spinal anesthesia between June 2018 and March 2023 (PDD-TURBT, n = 162; WL-TURBT, n = 117). Hyperbaric bupivacaine was used without sedation. Intraoperative hypotension was defined as mean arterial pressure < 60 mmHg and/or vasopressor use. Propensity score matching was performed, and logistic regression analyses were conducted to identify independent predictors.

RESULTS

After matching, 103 patients remained in each group. Intraoperative hypotension occurred more frequently in the PDD-TURBT group than in the WL-TURBT group (60.2% vs. 27.2%, p < 0.001), and vasopressor use was also higher (49.5% vs. 23.3%, p < 0.001). Perioperative mean arterial pressure was significantly lower in the PDD-TURBT group from anesthesia induction through postoperative day 1. In multivariable analysis of the overall cohort, oral 5-ALA use (odds ratio 3.30) and a maximum intraoperative sensory block level of T6 or higher (odds ratio 2.72) were independent predictors of hypotension. In the PDD-TURBT subgroup, a maximum intraoperative sensory block level of T6 or higher remained an independent risk factor (odds ratio 3.33).

CONCLUSIONS

Under spinal anesthesia, oral 5-ALA-guided PDD-TURBT carries a higher risk of intraoperative hypotension than WL-TURBT. Excessive cephalad spread of spinal block (levels of T6 or higher) independently increases this risk, highlighting the need for careful block level management.