Perioperative anxiety and depression in patients undergoing transurethral urological surgeries: The role of anesthetic management

Abstract

BACKGROUND

Perioperative anxiety and depression are common, yet often underestimated psychological comorbidities in patients undergoing transurethral urological surgery. These emotional disturbances can negatively affect anesthesia induction, hemodynamic stability, postoperative pain, and recovery. The choice of anesthetic technique and adjunctive psychological intervention may have influenced these outcomes.

AIM

To evaluate the prevalence and clinical impact of perioperative anxiety and depression in patients undergoing transurethral surgeries and compare the effectiveness of different anesthetic and psychological management strategies.

METHODS

A retrospective observational analysis was conducted in 120 patients who underwent transurethral resection between January 2022 and December 2023. Preoperative anxiety and depression were assessed using the State-Trait Anxiety Inventory (STAI) and Beck Depression Inventory-II. Patients receiving general anesthesia or spinal anesthesia (SA) were compared and subgroup analyses were performed to examine the effects of pharmacological interventions (dexmedetomidine vs midazolam) and nonpharmacological methods (music therapy and structured education). The primary outcomes were perioperative changes in STAI and Beck Depression Inventory-II scores, and the secondary outcomes included hemodynamic stability, postoperative complications, pain control, and recovery parameters.

RESULTS

Preoperative anxiety and depression were present in 68.3% and 35.8% of the patients, respectively. SA significantly reduced postoperative anxiety compared with general anesthesia (ΔSTAI -12.3 ± 8.4 vs -8.1 ± 7.2; mean difference -4.2;P = 0.004) and was associated with better intraoperative hemodynamic stability. Dexmedetomidine provided superior anxiolysis and reduced postoperative delirium (6.7% vs 20.0%; risk difference -13.3%; P = 0.02), although mild bradycardia occurred more frequently (16.7% vs 3.3%). Music therapy and structured preoperative education effectively reduced anxiety and improved patient satisfaction (P < 0.001). Patients with moderate to severe preoperative anxiety exhibited higher postoperative complication rates (32.5% vs 15.3%; risk difference +17.2%; P = 0.008) and longer hospital stays (3.8 ± 1.6 days vs 2.9 ± 1.1 days; P = 0.002). Persistent depressive symptoms were observed in 23.3% of the patients at 30 days.

CONCLUSION

Perioperative anxiety and depression are highly prevalent in patients undergoing transurethral urological surgery and are associated with worse postoperative outcomes. SA, dexmedetomidine, music therapy, and structured education are associated with better psychological stability and clinical recovery. Integrating routine screening and multimodal psychological management appears beneficial in perioperative care.

Key Words: Transurethral surgery; Perioperative anxiety; Depression; Anesthetic management; Dexmedetomidine; Music therapy; Spinal anesthesia; Retrospective study

Core Tip: This study highlights the high prevalence of perioperative anxiety and depression among patients undergoing transurethral urological surgery and their significant impact on postoperative outcomes. In this retrospective analysis of 120 cases, spinal anesthesia combined with music therapy and structured education effectively reduced anxiety and improved satisfaction. Dexmedetomidine demonstrated superior anxiolytic effects compared with midazolam, with fewer postoperative complications. These findings emphasize the need for routine psychological screening and multimodal management that integrates anesthetic, pharmacological, and psychological strategies to enhance recovery and overall patient well-being.

INTRODUCTION

Transurethral urological surgeries, including transurethral resection of the prostate (TURP) and transurethral resection of bladder tumors (TURBT), are cornerstone procedures in modern urological practice. These minimally invasive techniques have revolutionized the management of benign prostatic hyperplasia and bladder cancer, offering reduced morbidity compared with open surgical approaches[1]. Despite the technological advances and improved surgical techniques, the psychological burden associated with these procedures remains a significant challenge for healthcare providers.

Perioperative anxiety affects up to 48% of surgical patients globally, with rates varying significantly according to the surgical type, patient demographics, and healthcare settings[2]. Psychological distress is particularly pronounced in urological procedures owing to the intimate nature of surgery and concerns about postoperative sexual and urinary function. Preoperative anxiety can adversely affect multiple aspects of patient care, including anesthetic requirements, postoperative pain perception, and the overall recovery trajectory[3]. The pathophysiology of perioperative anxiety involves complex interactions between psychological stressors and physiological responses. Activation of the hypothalamic-pituitary-adrenal axis causes elevated cortisol levels, activates the sympathetic nervous system and initiates inflammatory signaling cascades[4]. These changes can manifest as hemodynamic instability during anesthesia induction, increased analgesic requirements, and a prolonged hospital stay. Furthermore, sustained anxiety is associated with impaired wound healing, increased infection rates, and development of chronic postoperative pain syndromes[5].

Depression, which often coexists with anxiety, presents additional perioperative challenges. The bidirectional relationship between depression and surgical outcomes is well documented - preoperative depression is associated with worse postoperative outcomes, including a higher risk of complications, prolonged recovery, and persistent psychological symptoms, and surgical stress can exacerbate depressive symptoms[6]. In the context of transurethral surgeries, the prevalence of postoperative depression is reported to be as high as 24.9%, especially in patients undergoing TURP procedures[7]. Anesthetic management of patients with preoperative anxiety and depression, which may extend into the perioperative period, requires careful consideration of both pharmacological and non-pharmacological strategies, including structured preoperative education, reassurance, and intraoperative anxiolytic support. However, emerging evidence also supports the use of alpha-2 agonists, multimodal analgesia, and complementary therapies[8]. The choice between general and regional anesthesia also plays a crucial role in managing psychological distress. Regional anesthesia is often associated with better intraoperative hemodynamic stability and lower immediate psychological burden, whereas general anesthesia (GA) may be more appropriate for highly anxious patients who cannot tolerate awareness, although it may carry a higher risk of hemodynamic instability and postoperative delirium.

Recent advances have improved the recognition and clinical understanding of perioperative anxiety and depression, emphasizing their measurable impact on surgical recovery and postoperative outcomes. Rather than relying on complex neurobiological or imaging-based assessments, validated psychological screening tools such as the State-Trait Anxiety Inventory (STAI) and Beck Depression Inventory-II (BDI-II) provide practical and reliable approaches for identifying at-risk patients in routine clinical practice[9]. These instruments demonstrate strong psychometric performance in perioperative settings, with reported internal consistency coefficients typically ranging from 0.89 to 0.94 for the STAI and approximately 0.90-0.92 for the BDI-II, and with well-established construct and criterion validity in surgical populations[10]. Early identification using these validated tools enables anesthesiologists to implement preventive strategies and optimize perioperative management.

Non-pharmacological interventions have gained increasing recognition as essential components of perioperative care. Notably, music therapy has shown promising results in reducing preoperative anxiety and postoperative pain in diverse surgical populations[11]. Virtual reality, mindfulness-based interventions, and structured preoperative education programs represent additional non-pharmacological approaches for managing perioperative psychological distress[12]. Untreated perioperative anxiety and depression are associated with increased healthcare utilization, prolonged hospital stays, and higher readmission rates, which together contribute to greater overall healthcare costs[13]. Investment in comprehensive psychological support services and implementation of standardized screening protocols may therefore offer cost-effective strategies for improving clinical outcomes and optimizing resource allocation. Quality improvement initiatives focusing on perioperative mental health have demonstrated measurable benefits in patient satisfaction and postoperative recovery, as reported in previous studies[14,15]. Multidisciplinary approaches involving anesthesiologists, surgeons, nurses, and mental health professionals facilitate comprehensive care delivery. In this study, we sought to retrospectively evaluate the prevalence and impact of perioperative anxiety and depression on postoperative outcomes in patients undergoing transurethral urological surgeries and to assess the effectiveness of different anesthetic management strategies.

MATERIALS AND METHODS

Study design and setting

This retrospective observational study reviewed the medical records of patients treated between January 2022 and December 2023 at Second Affiliated Hospital of Jiaxing University. Perioperative psychological outcomes and anesthetic management strategies documented in patient records were retrospectively analyzed. The institutional ethics committee approved the research plan, and informed consent was obtained. The data collection and analysis adhered to the principles of the Declaration of Helsinki.

Patient selection and recruitment

This study included the medical records of adult patients aged 18-80 years who underwent elective transurethral urological procedures. The eligible procedures were as follows: (1) TURP for benign prostatic hyperplasia; (2) TURBT for suspected or confirmed bladder malignancy; (3) Transurethral incision of the prostate for smaller prostates, typically with a gland volume ≤ 30 mL as measured by transrectal ultrasound; and (4) Transurethral vaporization procedures. Patients whose records indicated an American Society of Anesthesiologists physical status classification of I-III were included. The patient medical records were required to include documented STAI and BDI-II scores and perioperative data, including baseline evaluation and postoperative follow-up records, with ≥ 80% completeness across required data fields.

Exclusion criteria encompassed the following: (1) Emergency surgical procedures; (2) Documented psychiatric hospitalization within the year prior to surgery; (3) Documented use of antipsychotic medications; (4) Substance use disorders requiring active treatment as noted in medical records; (5) Severe cardiovascular disease that precluded the safe administration of GA or neuraxial (spinal) anesthesia; (6) Documented contraindications to neuraxial anesthesia, including coagulopathy or infection at the puncture site; (7) Missing psychological assessment data or overall data completeness < 80%; and (8) Participation in other clinical trials during the study period as documented in patient records.

Psychological assessment tools

STAI: Documented anxiety assessments using the STAI, a validated 40-item self-report questionnaire, were extracted from the patient records. This instrument measures both state anxiety (temporary condition) and trait anxiety (general tendencies). Each subscale contains 20 items rated on a 4-point Likert scale ranging from “not at all” to “very much so”. The scores range from 20 to 80 for each subscale, with higher scores indicating greater anxiety. The clinical cut-off scores were defined as minimal anxiety (20-39), mild anxiety (40-54), moderate anxiety (55-69), and severe anxiety (70-80). The STAI demonstrates excellent internal consistency (Cronbach’s alpha = 0.89-0.94) and test-retest reliability in surgical populations.

BDI-II: Depression screening results recorded using the BDI-II were analyzed. This 21-item tool assesses depressive symptoms over the preceding 2 weeks. Items evaluated the cognitive, affective, and somatic symptoms of depression on a scale of 0-3. Total scores range from 0 to 63, with established cutoffs: Minimal depression (0-13), mild depression (14-19), moderate depression (20-28), and severe depression (29-63). The BDI-II shows high internal consistency (Cronbach’s alpha = 0.92) and strong convergent validity with clinician-administered depression scales in clinical patient populations.

Anesthetic management protocols

Patient grouping and analysis: Patients meeting the inclusion criteria were categorized based on the anesthetic technique they received: GA or spinal anesthesia (SA). The choice of anesthetic technique was determined by the attending anesthesiologist, based on clinical judgment and patient factors. Patients were grouped according to surgical procedure type and baseline anxiety level for comparative analysis.

GA protocol: A review of the anesthetic records revealed that the GA protocol followed standardized institutional guidelines, with modifications for patients with anxiety. Documented premedication included either midazolam (0.03-0.05 mg/kg) or dexmedetomidine (0.5-1.0 μg/kg), based on the anesthesiologist’s clinical decision. Anesthesia induction utilized propofol (1.5-2.5 mg/kg) with fentanyl (1-2 μg/kg) or remifentanil infusion (0.1-0.2 μg/kg/minute). Maintenance was documented as achieved with sevoflurane (1.0-1.5 minimum alveolar concentration) or total intravenous anesthesia using propofol infusion (4-8 mg/kg/hour). Muscle relaxation, when documented as required, was achieved using rocuronium (0.6 mg/kg), with neuromuscular blockade reversal performed using sugammadex according to clinical indication and anesthetic records. Multimodal analgesia incorporated paracetamol (1 g), ketorolac (30 mg), and regional blocks.

SA protocol: Records indicated that SA was performed at the L3-L4 or L4-L5 interspace using a 25-27 gauges pencil-point needle. Local anesthetic selection included hyperbaric bupivacaine (10-15 mg) or prilocaine (50-60 mg) for shorter procedures. Adjuvants such as fentanyl (10-25 μg) or dexmedetomidine (5-10 μg) were included based on clinical decision. Sedation during procedures utilized propofol infusion (25-50 μg/kg/minute) or dexmedetomidine (0.2-0.7 μg/kg/hour) titrated to documented Ramsay sedation scores of 2-3. Patients with documented failed SA requiring conversion to GA were excluded from the comparative analysis.

Non-pharmacological interventions

Music therapy protocol: Patients received music therapy according to individualized intervention plans developed by certified music therapists. The protocol documented in the medical records included the following: (1) Preoperative sessions (30-45 minutes) for music selection and relaxation training; (2) Intraoperative music delivery via noise-canceling headphones at 40-50 dB; and (3) Postoperative sessions in the recovery area. Music selection encompassed classical, instrumental, and nature sounds or patient-preferred genres with a tempo of 60-80 beats/minute. Effectiveness was evaluated at multiple time points using documented visual analog scales for anxiety and relaxation.

Preoperative education program: Documentation showed that structured education, when provided, consisted of: (1) Multimedia presentations about surgical procedures and anesthetic techniques; (2) Virtual operating room tours to familiarize patients with the environment; (3) Demonstrations of postoperative exercises and pain management techniques; and (4) Documented opportunities for questions and discussions with the anesthesia team. Educational materials were culturally adapted and made available in multiple languages according to the records.

Data collection

Data were extracted from medical records for the following time points: (1) Baseline assessments documented 24 hours preoperatively; (2) Preoperative evaluations recorded in the holding area; (3) Postoperative assessments documented in the post-anesthesia care unit (PACU); (4) Follow-up records at 24 hours, 48 hours, and 7 days postoperatively; and (5) Long-term follow-up documentation at 30 days and 90 days. Two independent reviewers extracted the data from electronic health records. Any discrepancies were resolved by a third reviewer to ensure data quality and accuracy. The primary outcome measures included documented changes in STAI and BDI-II scores from baseline to postoperative day 7. Secondary outcomes included the following documented items: (1) Hemodynamic stability during anesthesia; (2) Analgesic requirements in the first 48 hours; (3) Length of post-anesthesia care unit and hospital stay; (4) Postoperative complications using the Clavien-Dindo classification; (5) Patient satisfaction scores; (6) Emergence delirium incidence in GA patients; (7) Postoperative cognitive dysfunction at 30 days; and (8) Development of chronic pain at 90 days. Chronic pain was defined according to the International Association for the Study of Pain criteria as pain persisting or recurring for more than three months following surgery. Pain assessment at the 90-day follow-up utilized the Brief Pain Inventory, with chronic pain defined as a Brief Pain Inventory severity score ≥ 3 accompanied by functional interference.

Statistical analysis

Statistical analyses were performed using all available data. As this was a retrospective study, some variables were not documented for all patients. In cases where the proportion of missing values did not exceed 20% and the missingness pattern was considered missing at random, multiple imputation was applied to minimize potential bias. Continuous variables were analyzed using Student’s t-test or the Mann-Whitney U test based on distribution normality, and categorical variables were compared using the χ² or Fisher’s exact tests. Repeated-measures analysis of variance was used to evaluate longitudinal changes in psychological scores where longitudinal data were available. Multivariate logistic regression analysis was performed to identify predictors of postoperative anxiety and depression after adjusting for baseline characteristics, surgical factors, and documented interventions. Subgroup analyses examined the differential treatment effects based on baseline psychological status, age, and procedure type. Propensity score matching was applied to address potential selection bias in comparisons of anesthetic techniques, using clinically relevant covariates. All analyses were performed using SPSS version 28.0, with statistical significance set at P < 0.05.

RESULTS

Patient demographics and baseline characteristics

A total of 142 patient records from the 2-year period were screened for eligibility; among these, 120 records met the inclusion criteria and contained sufficiently complete data for analysis. The mean age was 62.4 ± 11.3 years, with 78 men (65%) and 42 women (35%). Primary surgical procedures included TURP (n = 68, 56.7%), TURBT (n = 42, 35%), and other transurethral procedures (n = 10, 8.3%). There were 58 patients (48.3%) that received GA, whereas 62 patients (51.7%) received SA. Detailed baseline demographic and clinical characteristics are presented in Table 1.

Table 1 Baseline demographic and clinical characteristics, n (%).

Characteristic	Total (n = 120)	General anesthesia (n = 58)	Spinal anesthesia (n = 62)	P value
Age (years), mean ± SD	62.4 ± 11.3	61.8 ± 12.1	63.0 ± 10.6	0.56
Male sex	78 (65.0)	38 (65.5)	40 (64.5)	0.91
BMI (kg/m2), mean ± SD	26.8 ± 4.2	27.1 ± 4.5	26.5 ± 3.9	0.43
ASA classification				0.68
I	28 (23.3)	14 (24.1)	14 (22.6)
II	68 (56.7)	31 (53.4)	37 (59.7)
III	24 (20.0)	13 (22.4)	11 (17.7)
Procedure type				0.82
TURP	68 (56.7)	32 (55.2)	36 (58.1)
TURBT	42 (35.0)	21 (36.2)	21 (33.9)
Other	10 (8.3)	5 (8.6)	5 (8.1)
Previous surgery	45 (37.5)	22 (37.9)	23 (37.1)	0.92
Comorbidities
Hypertension	52 (43.3)	25 (43.1)	27 (43.5)	0.96
Diabetes	31 (25.8)	15 (25.9)	16 (25.8)	0.99
Cardiac disease	18 (15.0)	9 (15.5)	9 (14.5)	0.88

Previous surgery refers to any prior surgical procedure documented in the medical record. BMI: Body mass index; ASA: American Society of Anesthesiologists; TURP: Transurethral resection of the prostate; TURBT: Transurethral resection of bladder tumor.

After propensity score matching, baseline demographic and clinical variables were comparable between the GA and SA groups.

Preoperative psychological assessment

A review of the documented baseline psychological assessments revealed a high prevalence of anxiety and depressive symptoms. The mean documented STAI-state score was 48.6 ± 14.2, and 82 patients (68.3%) exhibited clinically significant anxiety (STAI-state ≥ 40). Moderate-to-severe anxiety (STAI-state ≥ 55) was documented in 51 patients (42.5%). The mean BDI-II score was 12.8 ± 9.4, with 43 patients (35.8%) meeting the criteria for depression (BDI-II ≥ 14).

Trait anxiety (STAI-trait) was strongly correlated with state anxiety (r = 0.68, P < 0.001) and depression scores (r = 0.72, P < 0.001). Women demonstrated significantly higher anxiety scores compared to men (52.3 ± 13.8 vs 46.7 ± 14.1, P = 0.04). Patients who underwent TURBT exhibited higher anxiety levels than those who underwent TURP (51.4 ± 13.6 vs 47.1 ± 14.5, P = 0.03), likely reflecting cancer-related concerns.

Impact of anesthetic technique

A comparison between the anesthetic techniques revealed significant differences in the documented psychological outcomes. Patients who received SA showed greater reduction in anxiety scores from baseline to postoperative day 1 compared to those who received GA (-12.3 ± 8.4 vs -8.1 ± 7.2, P = 0.004). Postoperative day 1 was selected as the primary comparison time point as it represents the earliest period with minimal residual anesthetic effects while capturing the acute psychological response to surgery. However, this group difference was attenuated by postoperative day 7 (-14.2 ± 9.1 vs -12.8 ± 8.6, P = 0.38). A summary of psychological outcome changes stratified by anesthetic technique is shown in Table 2.

Table 2 Psychological outcomes by anesthetic technique, mean ± SD.

Outcome	General anesthesia	Spinal anesthesia	Mean difference (95%CI)	P value
STAI-state scores
Baseline	49.2 ± 14.5	48.1 ± 14.0	1.1 (-4.0 to 6.2)	0.67
Preoperative	52.8 ± 15.2	46.3 ± 13.8	6.5 (1.3-11.7)	0.02
POD 1	41.1 ± 12.3	35.8 ± 11.6	5.3 (0.9-9.7)	0.02
POD 7	36.4 ± 10.8	33.9 ± 10.2	2.5 (-1.3 to 6.3)	0.20
BDI-II scores
Baseline	13.2 ± 9.7	12.4 ± 9.2	0.8 (-2.6 to 4.2)	0.64
POD 7	11.8 ± 8.9	10.2 ± 8.3	1.6 (-1.5 to 4.7)	0.31
POD 30	10.4 ± 8.2	8.9 ± 7.6	1.5 (-1.3 to 4.3)	0.30

Baseline assessments were performed 24 hours before surgery, and preoperative assessments were conducted in the holding area immediately before anesthesia induction. Mean differences are calculated as values in the general anesthesia group minus those in the spinal anesthesia group. CI: Confidence interval; STAI: State-Trait Anxiety Inventory; POD: Postoperative day; BDI: Beck Depression Inventory.

The hemodynamic parameters showed greater stability in the SA group, with a lower documented incidence of hypertension (11.3% vs 27.6%, P = 0.02) and tachycardia (8.1% vs 22.4%, P = 0.03) during the perioperative period. Emergence delirium was documented in eight patients (13.8%) in the GA group, with a higher incidence among those with severe baseline anxiety (25% vs 8.3%, P = 0.04).

Pharmacological interventions

Analysis of the premedication subgroups revealed that dexmedetomidine demonstrated superior anxiolytic effects compared to midazolam. Patients who received dexmedetomidine showed a greater reduction in preoperative STAI-state scores (-8.4 ± 5.2 vs -5.1 ± 4.8, P = 0.02) and had a lower incidence of postoperative delirium (6.7% vs 20%, P = 0.04). However, dexmedetomidine was associated with more frequent bradycardia requiring intervention (16.7% vs 3.3%, P = 0.03).

Non-pharmacological interventions

We found that music therapy combined with standard care resulted in a significant reduction in anxiety compared to standard care alone. The music therapy group (n = 40) demonstrated a greater decrease in STAI-state scores from baseline to the preoperative holding area assessment conducted within 30-60 minutes before anesthesia induction (-10.2 ± 6.8 vs -4.3 ± 5.1, P < 0.001). Patient satisfaction scores were significantly higher in the music therapy group compared with the standard care group (8.9 ± 1.2 vs 7.6 ± 1.8 on a 10-point scale, P < 0.001). Analysis of patients who received structured preoperative education (n = 38) revealed reduced preoperative anxiety compared with those who received routine preparation (STAI-state: 44.2 ± 12.6 vs 51.3 ± 14.8, P = 0.01). Patients in the education group also reported a better understanding of the procedure (92.1% vs 68.3%, P = 0.006) and a lower fear of anesthesia (28.9% vs 52.4%, P = 0.02).

Postoperative outcomes and complications

The analysis revealed that patients with documented moderate-to-severe preoperative anxiety had significantly higher postoperative complication rates. The detailed distribution of postoperative complications according to baseline anxiety levels is shown in Table 3. The overall complication rate was 32.5% in the high-anxiety group compared to 15.3% in the low-anxiety group [odds ratio (OR) = 2.67, 95% confidence interval (CI): 1.28-5.58, P = 0.008]. Specific complications included higher documented incidence of postoperative urinary retention (17.5% vs 7.1%, P = 0.04), prolonged catheterization time (4.2 ± 1.8 days vs 3.1 ± 1.2 days, P = 0.001), and increased analgesic requirements (morphine equivalent: 42.3 ± 18.6 mg vs 28.7 ± 14.2 mg, P < 0.001).

Table 3 Postoperative complications by baseline anxiety level, n (%).

Complication	Low anxiety (n = 38)	Moderate anxiety (n = 31)	Severe anxiety (n = 51)	P value
Any complication	6 (15.8)	9 (29.0)	17 (33.3)	0.04
Clavien-Dindo grade				0.02
Grade I	4 (10.5)	5 (16.1)	9 (17.6)
Grade II	2 (5.3)	3 (9.7)	6 (11.8)
Urinary retention	2 (5.3)	4 (12.9)	9 (17.6)	0.04
Bleeding requiring transfusion	1 (2.6)	2 (6.5)	3 (5.9)	0.68
UTI	2 (5.3)	3 (9.7)	5 (9.8)	0.71
Readmission within 30 days	1 (2.6)	2 (6.5)	4 (7.8)	0.58

Anxiety severity was categorized based on State-Trait Anxiety Inventory-state scores as follows: Low anxiety (20-39), moderate anxiety (40-54), and severe anxiety (≥ 55). Postoperative complications were graded according to the Clavien-Dindo classification. UTI: Urinary tract infection.

The length of hospital stay was significantly longer in patients with high baseline anxiety (3.8 ± 1.6 days vs 2.9 ± 1.1 days, P = 0.002). Recovery room time was also prolonged (142 ± 48 minutes vs 98 ± 32 minutes, P < 0.001), primarily attributed to increased analgesic requirements and hemodynamic instability based on nursing documentation.

Long-term psychological outcomes

At the 30-day follow-up, 28 patients (23.3%) met criteria for persistent depression (BDI-II ≥ 14), with higher rates among those with preoperative depression (51.2% vs 9.1%, P < 0.001). New-onset depression was documented in seven patients (7.8%) without baseline depression. Analysis revealed risk factors for persistent depression included severe preoperative anxiety (OR = 3.45, 95%CI: 1.52-7.82), postoperative complications (OR = 2.89, 95%CI: 1.21-6.91), and inadequate pain control (OR = 2.34, 95%CI: 1.03-5.31).

Chronic pain at 90 days was documented in 18 patients (15%), and was significantly associated with baseline anxiety (r = 0.42,P < 0.001) and depression scores (r = 0.38, P < 0.001). Patients who received multimodal interventions (combined pharmacological and non-pharmacological approaches) had a lower incidence of documented chronic pain (8.3% vs 21.3%, P = 0.04).

DISCUSSION

This study provides important insights into the complex relationship among perioperative anxiety, depression, and surgical outcomes based on real-world clinical data from patients who underwent transurethral urological procedures. We found a remarkably high prevalence of psychological distress in this population, with over two-thirds of the patients experiencing clinically significant anxiety and more than one-third meeting the criteria for depression. The rates of anxiety and depression observed in this study exceed those reported in the general surgical population, highlighting the unique psychological challenges associated with urological procedures[16].

The elevated anxiety levels observed in our cohort likely reflect multiple contributing factors specific to transurethral surgeries. The intimate nature of urological procedures, concerns about postoperative sexual and urinary function, and fear of cancer diagnosis in patients undergoing TURBT all contribute to heightened psychological distress[17]. Our finding that women and those undergoing TURBT experienced higher anxiety levels aligns with previous research that identified sex- and cancer-related surgery as significant risk factors for perioperative anxiety. These observations underscore the importance of targeted screening and intervention strategies for high-risk subgroups[18].

Our comparative analysis of anesthetic techniques revealed superior anxiety reduction with SA compared with GA, particularly in the immediate postoperative period. This finding corroborates recent evidence suggesting that maintaining consciousness during surgery, when combined with appropriate sedation and anxiolysis, may paradoxically reduce anxiety by allowing patients to maintain a sense of control[19]. Additionally, SA prevents the direct effects of general anesthetic agents on the central nervous system, potentially reducing the risk of postoperative cognitive dysfunction, which is particularly relevant in elderly patients undergoing transurethral procedures. The ability to communicate with the surgical team and the absence of concerns about “not waking up” from GA may have contributed to these psychological benefits. However, it is important to note that these advantages were most pronounced in patients who received adequate preoperative preparation and intraoperative sedation[20]. Importantly, the choice of anesthetic technique should be individualized based on a comprehensive patient assessment. For patients with severe anxiety who cannot tolerate awake surgery, GA combined with effective preoperative sedation and postoperative multimodal analgesia remains a reasonable alternative. The optimal approach should be determined through shared decision-making considering the patient’s psychological state, surgical requirements, and available institutional resources.

Pharmacological comparisons of dexmedetomidine and midazolam provided important clinical insights. While both agents effectively reduced preoperative anxiety based on documented scores, the superior anxiolytic profile and lower incidence of postoperative delirium of dexmedetomidine support its preferential use in patients[21]. The unique mechanism of action of dexmedetomidine, which provides anxiolysis without respiratory depression and maintains arousable-level sedation, offers particular advantages for older patients who commonly undergo transurethral procedures. The observed bradycardia with dexmedetomidine, although statistically significant, was clinically manageable and rarely required intervention beyond glycopyrrolate administration according to chart review[22].

The striking efficacy of music therapy documented in our study adds to the growing body of evidence supporting the use of non-pharmacological interventions in perioperative care. The magnitude of anxiety reduction achieved with music therapy was comparable to that observed with pharmacological interventions and without associated side effects[23]. This mechanism likely involves multiple pathways, including distraction, relaxation response activation, and modulation of stress hormone release. The high patient satisfaction scores observed in our cohort, together with evidence from previous studies demonstrating the cost-effectiveness of music therapy, support its consideration as a useful adjunct in perioperative care for transurethral surgeries[24]. However, as a retrospective study, the standardization of these nonpharmacological interventions represents a notable challenge. Implementation standards, intervention duration, and uniformity of personnel administering music therapy and structured education may have varied across the study period. Future prospective studies should establish standardized protocols with defined session durations, certified personnel requirements, and quality control measures to ensure reproducibility and facilitate wider clinical adoption.

Our analysis of structured educational programs demonstrated significant benefits in reducing preoperative anxiety and improving patient preparedness. The use of multimedia presentations and virtual operating room tours addressed fear of the unknown, which is a primary contributor to preoperative anxiety[25]. Improved understanding of the procedures and anesthetic techniques translated into better cooperation during anesthesia induction and higher overall satisfaction scores. These findings emphasize the importance of investing time and resources in comprehensive preoperative education, particularly for patients undergoing their first surgical procedure[26].

The strong association between preoperative anxiety and postoperative complications observed in this study has important clinical implications. The observed 2.67-fold increase in complication rates among highly anxious patients likely reflects both physiological and behavioral mechanisms[27]. Anxiety-induced sympathetic activation can impair wound healing, increase the risk of infection, and exacerbate postoperative pain. In addition, patients with anxiety may demonstrate poor compliance with postoperative instructions and rehabilitation protocols. These findings support the economic argument for routine anxiety screening and treatment, as preventing complications through psychological interventions may reduce overall healthcare costs[28].

The persistence of depression in nearly one-quarter of the patients at the 30-day follow-up represents a significant concern requiring systematic attention. The bidirectional relationship between depression and surgical outcomes creates a potentially vicious cycle in which preoperative depression predicts worse outcomes, which, in turn, exacerbates depressive symptoms[29]. Our identification of modifiable risk factors, including inadequate pain control and a lack of psychological support, suggests opportunities for intervention. The implementation of routine postoperative psychological screening and referral pathways could help identify at-risk patients early and prevent their progression to chronic depression[30].

The development of chronic pain in 15% of patients at the 90-day follow-up aligns with published rates for urological surgeries but remains concerning given the impact on quality of life. The strong correlation between baseline psychological distress and chronic pain development supports the concept of centralized pain sensitization in anxious and depressed patients[16]. Our finding that multimodal interventions reduced the incidence of chronic pain by more than 50% provides compelling evidence for comprehensive perioperative psychological care. These interventions likely work through multiple mechanisms, including the reduction of central sensitization, improved coping strategies, and the prevention of catastrophizing behaviors[17].

Our study has several limitations, including its single-center retrospective design, which may limit generalizability and introduce potential selection bias, incomplete documentation, and the inability to control for all confounding variables. The reliance on documented assessments may not fully capture the psychological status, as evaluations may not have been uniformly administered. Additionally, the 90-day follow-up period may have been insufficient to capture long-term psychological sequelae. Future research should focus on developing brief, procedure-specific screening tools, investigating the optimal timing and dosing for psychological interventions, and conducting prospective randomized controlled trials to establish causal relationships. The clinical implications of our findings support fundamental changes in perioperative management, including routine anxiety and depression screening using validated instruments, implementation of multimodal interventions for high-risk patients, preferential consideration of SA for patients with anxiety when appropriate, and the integration of music therapy and structured education programs into standard care pathways. Success requires training perioperative staff to recognize and manage psychological distress, develop clear referral pathways to mental health services, and incorporate psychological outcomes into quality metrics. Although implementation of these comprehensive psychological support programs requires systematic organizational change and resource allocation, the potential benefits of improved patient outcomes, reduced complications, and enhanced satisfaction justify this investment.

CONCLUSION

This comprehensive retrospective analysis demonstrated that perioperative anxiety and depression were highly prevalent in patients who underwent transurethral urological surgery and had a significant impact on clinical outcomes. This study revealed that psychological distress correlated with increased postoperative complications, prolonged hospital stay, and the development of chronic pain. SA appeared to be advantageous for anxious patients compared to GA, whereas dexmedetomidine showed benefits over traditional benzodiazepines. Non-pharmacological interventions, particularly music therapy and structured education programs, were associated with meaningful reductions in anxiety. These findings support the implementation of multimodal perioperative psychological care by combining appropriate anesthetic techniques with evidence-based interventions. Routine screening using validated instruments should become standard practice, with clear intervention pathways for high-risk patients. Although the retrospective nature of the study limits causal inferences, the consistent patterns observed suggest clinically meaningful relationships that warrant investment in integrated psychological support services and future prospective research to optimize intervention strategies for patient-centered surgical care.