E3- GU Procedures Flashcards
6 Indications for Urological Surgery
Direct visualization of urethra, bladder, ureter, kidney
* Biopsies/evaluate bleeding
* Retrograde pyelography
* Laser/retrieve stones
* Remove/treat stricture
* Resect masses
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List the structures of the genitourinary system from the top to bottom.
- Kidney
- Ureter
- Bladder
- Urethra
What position will the patient be in for Urological Surgery?
- Lithotomy
In the Lithotomy position, the stirrups can cause what type of nerve injury?
- Peroneal Nerve Injury
- Femoral Nerve Injury
What other problems can occur besides nerve injuries in the Lithotomy position?
- Skin breakdown d/t stirrup pressure
- Hip dislocation
- Back strains
- Vessel compression (DVT, Compartment Syndrome)
Remember to move both legs simultaneously to prevent torsion and injury to lower spine
What lab is the best measure of glomerular function?
- GFR
What is normal GFR?
When will patients become symptomatic?
- 125 mL/min
- Asymptomatic until a 50% drop
What will be the result of moderate GFR insufficiency?
- ↑ BUN/Creat
- Anemia
- Decreased energy
What will be the result of severe GFR insufficiency?
- Profound uremia (high levels of waste product in the blood)
- Acidemia
- Volume overload
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What is BUN?
- Blood Urea Nitrogen
- BUN measures the amount of nitrogen in the blood that comes from the waste product urea.
- Urea is produced when the body breaks down proteins from the food we eat.
- The liver then processes this nitrogen into urea, which is eventually eliminated from the body through urine.
What is a Normal BUN?
- 8-18 mg/ dL
What will influence the BUN level?
- Exercise
- Steroids
- Dehydration
BUN will not be elevated in the kidney disease until GFR is ________% of normal.
- 75%
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What is Creatinine?
- Creatinine is a waste product that comes from muscle metabolism.
- It is produced at a relatively constant rate and is filtered out of the blood by the kidneys, then excreted through urine.
What is normal Creatinine? Varies with?
- 0.8 - 1.2 mg/dL
- Varies with age and gender
- Higher in men d/t more muscle mass
What are 6 considerations during the preoperative evaluations of patients with Chronic Renal Failure?
- Hypervolemia = ↑Na, ↑H2O
- Acidosis = ↓ production of ammonia, ↑ Anion Gap
- Hyperkalemia = normally managed … precipitated by hemorrhage, met acidosis
- HTN d/t RAAS
- Cardiac/Pulmonary Symptoms = arthersclerosis, pulm edema, vent hypertrophy
- Hematologic Symptoms
What type of anemia with CRF pts have? what is abnormal?
- normochromic (color) , normocytic (size) , iron defecient anemia
- abnormal :: plt aggregation + prothrombin consumption
Because most anesthetic drugs are lipid soluble in a non-ionized state, termination doesn’t depend on _________.
- Renal Excretion
Metabolite of these drugs are excreted as water-soluble compounds
What are 7 drugs of concern for patients with Renal Insufficiency?
- Drugs that are highly ionized and eliminated unchanged in urine
- Muscle relaxants (pancuronium)
- H2 antagonists
- Cholinesterase inhibitors (neostigmine)
- Thiazide diuretics
- Digoxin
- Many antibiotics
- Active metabolites of opioids (morphine/meperidine/ketamine/midazolam)
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What is the active metabolite of morphine?
- Morphine-6-glucuronide
Renal Protection strategies
Pts w/ moderate RI - cardiac sx + AKI (sepsis, crush, burn, nsaids)
* hydration
* adequate RBF
* NOT helpful = mannitol, low dose dopamine , fenoldopam , loop d, bicacrb gtt
Only renal protection strategy proven to work
N-Acetylcysteine (dye injuries)
Mortality rate of AKI?
50%
What are examples of endoscopic evaluations (scope procedures) of the lower urinary tract?
- Through urethra = urethroscopy
- Through bladder = cystoscopy
- Through ureteral orifice = ureteroscopy
What are the two types of scopes used for urological procedures?
- Flexible
- Rigid (this scope NOT into ureter, it will stop in the bladder)
Scope hooked to irrigation system
Guid Wire is inserted through scope for catheter and instruments
Purpose of a urethroscopy/cystoscope.
- Visualize the urethra and/or bladder d/t urinary symptoms (Pain, burning, hematuria, difficult urination.)
- Diagnose and Treat a lesion or stricture (dilate stricture, treat cystitis, stent placement, resect tumors).
The procedure of choice for mid/distal ureter or bilateral stones.
- Ureteroscopy (flexible scope)
Can incorporate laser technology
What percentage of men and women lifetime will experience ureter stones?
What is the recurrence percentage?
Stones contain ______ and are _____.
- Men: 10%
- Women: 5%
- Recurrence: 50%
- Calcium ,, radiopaque
Ureter stones are diagnosed using _______, _______, and ________.
- CT
- KUB X-RAY
- IVP (Intravenous Pyelogram)
Complications of ureteroscopy are low.
What is the percentage for perforation?
What is the percentage of stricture formation?
- Perforation: 5%
- Stricture formation: <2%
What are some medical therapy for ureter stones?
- MET (Medical Expulsive Therapy)
- NSAIDs
- Aggressive Fluid intake
- CCB and alpha blockers to vasodilate - relax ureter
- Surgery
What are 3 choices for surgery for ureter stones?
- Stone basket vs. Laser (preferred) - uteroscopy
- Shock Wave Lithotripsy
- Percutaneous nephrolithotomy (least preferable)
Shock wave Lithotripsy is best suited for __________ intranephric stones.
- small/medium
What is the risk for Shock Wave Lithotripsy (SWL)?
- kidney injury (trauma from pressure)
- sub-capsular hematoma
Compare the Old SWL vs New SWL.
- Old SWL: Water baths, hypothermia, painful
- New SWL: Water-filled coupler device, focus beam, decrease pressure pulse, less painful
What are ABSOLUTE contraindications to SWL?
- Bleeding disorder/ anticoagulants
- Pregnancy
5 RELATIVE contraindications to lithotripsy
- Large calcified aortic/renal aneurysms
- Untreated UTI
- Obstruction distal to the renal calculi
- Pacemaker, ICD, neuro-stimulate
- Morbid obesity
Preoperative anesthetic considerations for SWL, stone basket, or laser therapy.
- Single PIV
- Consider anxiolytics
- Appropriate ABX within 1 hour “cut time”
- Iodine Allergy - pretreat with benadryl
Intraoperative anesthetic considerations for SWL, stone basket, or laser therapy.
- Local vs. General (most people will be general)
- LMA vs ETT
- Minimal narcotics
- Consider antiemeticc
- **Eye covering for laser **
- Lead for providers
PACU postop
What procedure will be indicated for large intranephric stone removal?
- Percutaneous Nephrolithotomy
Describe a percutaneous nephrolithotomy.
- Minimally-invasive procedure to remove stones from the kidney by a small puncture wound through the skin.
- The procedure will** require initial stent placement** of ureteral stents to prevent obstruction as the fragment passes
- Uses lg amt fluoroscopy
- Transurethral Resection syndrome possible
Preoperative anesthetic considerations for percutaneous nephrolithotomy.
- Single PIV
- Consider anxiolytics
- Appropriate ABX within 1 hour “cut time”
Intraoperative anesthetic considerations for percutaneous nephrolithotomy.
Position? NMBD?
- General ETT
- Short NMBD’s
- Lateral position (bean bag, pillows)
- Lead apron for provider
- Eye covering for laser (document!)
What is an orchiectomy?
- one or both testicles are removed.
- Almost always bilateral
- Spermatic cord is clamped, cut, and sutured
- metastatic prostate cancer
What is a Hydrocelectomy?
- remove a hydrocele.
- A hydrocele is a fluid-filled sac inside the scrotum.
- Wall of hydrocele excised and edges sutured to prevent recurrence.
Testicular torsion must be performed within ____ hours to prevent irreversible ischemia.
- 6 hours
What are the reasons for circumcision in older males?
- Phimosis (tight foreskin)
- Penile/ prostate cancer risk
What is hypospadias?
- Birth defect in boys
opening of the urethra is not located at the tip of the penis.
What is a Penectomy?
- Removal of squamous cell carcinoma on the penis or inguinal lymph node.
What population group would seek a penile prosthesis discussed in the lecture?
Special considerations?
- Diabetic patients
- Spinal cord injury patients
- Infection risk !!
Anesthetic considerations for scrotal and penile operations.
- Preop anxiolytics
- General: ETT vs LMA
- Supine
- Penile Block :: (S2-S4) = pudendal nerve
- SCIP (take care with prosthesis touching skin before insertion)
- Manipulation of genitals —vagal bradycardia, have glycopyrrolate ready
What is a Cystectomy?
- Surgical removal of all or part of the urinary bladder.
What are the indications for cystectomy?
- Simple-benign conditions (hemorrhagic cystitis, radiation cystitis)
- Radical - malignant conditions (bladder cancer, includes removal of ureters, prostate, uterus, ovaries)
- Requires ileal conduit or bladder substitution
Preoperative anesthetic considerations for cystectomy.
- Risk factors for CAD or pulmonary disease, CXR? (older patients)
- Anticoagulant use. EKG?
- Bowel prep
Intraoperative anesthetic considerations for cystectomy.
- GETA, SAB, epidural
- Supine
- SCIP
What are 3 common complications of cystectomy?
- Blood loss: up to 3L — 1-2 PIV, type and crossmatch blood
- 3rd space losses d/t open belly
- Hypothermia — prepping lg area
What is a TURP?
- Transurethral Resection of Prostate
- Surgical procedure that involves cutting away a section of the prostate using a laser or electrocautery.
- Usually done on elderly patients to treat BPH, the gold standard
What is the estimated blood loss of a TURP?
- 100-200 mL
What comorbidities will patients receiving a TURP procedure have?
- Patients are generally in their 30-50’s
- Obesity
- HTN
- Hyperparathyroidism
- Chronic Renal Insufficiency
- DM
- Paraplegia
Preoperative anesthetic considerations for TURP?
- Consider comorbidities
- Consider if the patient is on anticoagulants
- Large bore IV (18G or 16G)
Intraoperative anesthetic considerations for TURP?
- General/ SAB (textbook: perform a SAB)
- Lithotomy
- Possible transfusion
- TUR syndrome
The reason why you want to perform a SAB for a TURP is to assess for TUR Syndrome. You can assess when a patient begins to become confused versus being under general anesthesia.
What are anesthetic considerations to take into account for robotic prostatectomy?
- Insertion of an arterial line (we want to watch the blood pressure d/t to lack of fluid).
- Phenylephrine drip
- LIMIT IV fluids
What is TUR syndrome?
- Symptoms r/t hypervolemic water intoxication
- Excessive volume expansion through venous sinuses
- > > Hyponatremia
D/t Irrigating fluid!
What are CNS and EKG changes with a serum Na+ level of 120 mEq/L?
CNS changes: Confusion, Restlessness
EKG changes: Widening of QRS
What are CNS and EKG changes with a serum Na+ level of 115 mEq/L?
CNS changes: Somnolence, Sleepy, Nausea
EKG changes: Elevated ST segments, Widened QRS
What are CNS and EKG changes with a serum Na+ level of 110 mEq/L?
CNS changes: Seizure, Coma, Death
EKG changes: V-tach, V-fib
What are the types of irrigants used in TURP?
- Saline- volume overload, current dispersion with monopolar cautery
- Glycine- metabolized in liver to ammonia
- Water- intravascular hemolysis
- Sorbitol- metabolized to CO2 and fructose, volume overload
What is the irrigation rate for a TURP?
What is the absorption rate of irrigation fluid for a TURP?
- Irrigation rate: 300 ml/min
- Absorption rate: 20 to 200 ml/min
Greater than _______ (volume) of irrigation fluid absorption is usually required for TUR syndrome.
- 2 Liters
How do you prevent TUR syndrome? 3
- Limit resection time to 1 hour
- Suspend the irrigation fluid less than 30 cm above the table
- Treat hypotension for SAB with vasopressors NOT IVF
Treatment of TUR Syndrome (Mild vs Severe)
- ABC’s
- Stop the procedure
- Consider invasive lines…for cardiovascular instability
- For Mild symptoms (Na > 120): Fluid restriction and Loop diuretics
- Severe symptoms (Na < 120): 3% IV saline
What is a nephrectomy?
- Surgical removal of a kidney, performed to treat several kidney diseases.
How many nephrectomies are performed each year?
Complication rate?
- 50,000 nephrectomies/yr
- 20% post-op compilation rate: mortality, peritonitis, acute renal failure, etc.
What are the types of nephrectomy procedures?
- Simple: Irreversible non-malignant disease (autoimmune), trauma, congenital disease (Polycystic Kidney disease)
- Radical: Renal cell carcinoma, kidneys and adrenal glands removed
- Donor
Nephrectomies are commonly associated with these conditions.
- CAD
- CKD / ESRD
- HTN
Preoperative anesthetic considerations for nephrectomy.
- Anxiolytics
- SCIP
- Type/Screen or Type/Cross
- 2 large bore IV
Intraoperative anesthetic considerations for nephrectomy.
- GETA: avoid nitrous
- Consider an arterial line
- Consider a central line: Ipsilateral to the surgical site
- Consider regional anesthesia for postop pain
- Have these items available: Colloids, Blood, Rapid transfusion set up, mannitol, furosemide
Which kidney has a long ureter and longer vascular supply?
- Left Kidney
What arteries and veins do transplanted kidneys attach to?
- Transplanted kidneys are attached to the common iliac vein and artery
Do you re-anastomose the vein, artery, or ureter first in a kidney transplant?
- Re-anastomose :: Vein»_space; artery»_space; ureter
What fraction of all nephrectomies are living donor nephrectomies?
- 1/3
What are the benefits of receiving a kidney from a living donor?
- No physiological alterations compared to Donations after brain death or cardiac death donor.
- Waiting times avoided
- Decreases cold ischemic times
What are the parameters of being a living donor?
- Healthy
- Two Kidneys
- No DM, HIV, Liver Disease, Cancer
Anesthesia Considerations for the Living Kidney Transplantation.
- Similar to simple nephrectomy (anesthesia-wise)
- Starts a couple of hours before recipient
- Left kidney preferred
- Aggressive isotonic hydration (10-20 ml/kg/hr)
- Kidney needs low-level anticoagulation (5000 U of heparin)
- Furosemide, mannitol to maintain 2 ml/kg/hr
- Protamine reversal (50 mg)
What neurological instability will occur with brain death? 2
- Cushing’s sign: HTN, bradycardia, wide pulse pressure
- Catastrophic ICP elevation
What cardiac instability will occur with brain death? 3
- Massive release of catecholamines
- Acute MI
- Cardiovascular collapse (catecholamines run out, massive dilation)
What pulmonary instability will occur with brain death? 2
- Neurogenic pulmonary edema
- SIRS
What metabolic instability will occur with brain death?
- Dysfunction of the hypothalamus and pituitary systems
- Thermoregulation, hormones, insulin, electrolytes, DIC
Anesthesia Considerations for the Cadaver Donors.
- Don’t need anesthetic….need stabilization until retrieval
- Maintain hemodynamics with short-acting agents (cardene, esmolol, volatiles)
- Significant bradycardia not responsive to anticholinergics…use isuprel
- Fluid resuscitation with crystalloids and PRBC’s
- Avoid glucose-containing solutions, can metabolize and become a hypotonic solution
- PEEP/lung protective ventilation: 6-8 ml/kg of ideal body weight and 5-10cm PEEP
- Steroids to attenuate immune response (in recipient)
Donor Management Goals:
CVP
- 4-10 mmHg
- 6-8 mmHg for lung transplant
Donor Management Goals:
MAP
- 60-120 mmHg
Donor Management Goals:
PaO2
- > 300 mmHg on 5cm PEEP on 100% O2
Donor Management Goals:
PaCO2
- 35-45 mmHg
Donor Management Goals:
ABG pH
- 7.35-7.45
Donor Management Goals:
Urine Output
- Greater than 1 mL/kg/hr
Donor Management Goals:
Sodium
- 135-160 mEq/L
Donor Management Goals:
Glucose
- < 150
Donor Management Goals:
Ejection Fraction
- > 50%
Donor Management Goals:
Hemoglobin
- > 9
Ischemic time for kidney
- 48-72 hours
What happens to the donor kidney during ischemia?
- Lack of O2
- Depletion of ATP/glycogen
- Failure of Na/K Pump
- Increase intracellular sodium….edema
What are preop evaluations for the kidney recipient?
- Need to know last dialysis and K+ level
- Diabetic (blood sugar, insulin)
- 40% have CAD, and most have HTN (EKG, Heart Cath)
- If PCKD, is nephrectomy concurrent? (Consider positioning)
Intraoperative consideration for kidney transplantation.
- GETA, may use Anectine if K+ appropriate
- Consider cisatracurium
- Supine; watch AV access
- CVP/art line…..STERILE
- Donor anastomoses to recipient (vein, artery, ureter)
- Steroids, mannitol, lasix, bumex, antithymocyte, albumin
- Extubate on table…to ICU (D/C next day)
What is an anti-thymocyte?
- Infusion of rabbit-derived antibodies against human T cells to prevent/treat acute rejection
What is the side effect of an anti-thymocyte?
Treatment?
- Cytokine release syndrome: high-grade fevers (over 39C), chills, and possibly rigors.
- Treatment: steroids (normally methylprednisolone), diphenhydramine 25–50 mg, acetaminophen 650 mg
