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.