Sir,

We report a case of stricture urethra in a 59 years male undergoing buccal mucosal graft (BMG) urethroplasty for partial segmental stricture at bulbourethral membrane, since buccal mucosa is the new gold standard for substitution urethroplasty.\[[@ref1]\] On evaluation, patient gave a history of myocardial infarction 6 years back, with angiographic findings of 100% block in left anterior descending artery and 70% block in right coronary artery 60% block in left circumflex arteryalong with ostial lesions and diffuse atherosclerosis of all vessels, suggesting of triple vessel disease.  As patient was not willing to accept the high risk associated with coronary artery bypass graft surgery as explained by the surgeons, he was not operated.  Electrocardiography revealed signs of left ventricular hypertrophy.  Patient was a known diabetic since 18 years and hypertensive since 8 years.  His echo findings were left ventricular hypertrophy, mild aortic stenosis, moderate diastolic dysfunction with ejection fraction 36% and moderate mitral regurgitation, mild pulmonary hypertension and mild tricuspid regurgitation.  Patient was instructed to discontinue antiplatelet medication 7 days prior and insulin on the day of surgery.  Pre - operative vitals and haematological parameters were within normal limits.  According to guidelines 2007 on perioperative cardiovascular evaluation and care for non - cardiac surgery, infrainguinal procedures can be performed under spinal or epidural anaesthesia with minimal hemodynamic changes if neuraxial blockade is limited to those dermatomes.  Studies have shown that combined spinal-epidural anaesthesia, using low doses of local anaesthetics with additives, is effective and reduces the incidence of hypotension in caesarean section\[[@ref2][@ref3][@ref4]\] and transurethral resection of prostrate.\[[@ref5]\] 12 lead ECG and central venous pressure monitoring was done along with all other routine protocol.  Epidural catheter was introduced at L~1~-L~2~ level and catheter was directed downward and tip was fixed at L~3~-L~4~ level.  Then spinal anaesthesia was given in L~4~-L~5~ space.  Patient received 2.5 mL of 0.25% bupivacaine (1.25 mL of 0.5% bupivacaine with 1.25 mL of 5% dextrose).  In addition, 5 mic of dexmedetomedine was added.  BMG was taken under local infiltration of 10 mL of 1% lignocaine and 100 mic of intravenous fentanyl without any hemodynamic alterations.  Neither changes in blood pressure nor ECG changes were noticed.  After 2 hours, 10 mL of 0.375% ropivacaine and 50 mic of fentanyl was given as epidural bolus.  After 1 hour of bolus dose, a continuous epidural infusion was started with 0.2% ropivacaine 2 mic/mL of fentanyl at the rate of 7 mL/hour and continued up to 48 hours postoperatively.  Low dose spinal and epidural anaesthesia in cardiac patient offer better response in-terms of maintaining hemodynamic stability, level of anaesthesia achieved would not be more than T~10~, which would be sufficient for BMG urethroplasty.