Endoscopic Urologic Procedures- Jerry Flashcards
Why do a cystoscopy for retrograde ureteral catheterization?
- to visualize ureter and kidney
- to place stents
- to drain obstructions
- to remove renal calculi
What is a transureteral resection of the bladder (TURBT) done for?
To treat superficial bladder tumors
What type of anesthesia is used for a TURBT?
- GA—> no coughing or straining- could cause bladder perforation
- Regional—> bladder becomes atonic and may become thinner when distended—> increasing risk of perforation
What are consequences of bladder perforation?
In the awake pt:
- shoulder discomfort and nausea/vomiting if peritoneal cavity entered
- suprapubic fullness, abdominal spasms and pain
All patients:
- early HTN and tachycardia, followed by severe hypotension
- blood loss
- hypothermia
- Bacteremia
- if high-grade malignancy present—> risk of seeding into peritoneum
- cool irrigation causes vasoconstriction - systemic cooling (warm fluids decrease this risk)
- DIC from release of prostatic thrombogenic substances- esp. with prostate CA
-
** possibility of open procedure—> ARE YOU READY???
- have 2 large bore IVs before hands tucked for procedure
How is a transurethral resection of the prostrate (TURP) done?
- neoplasm or obstructive prostate tissue removed by electrosurgical resection under direct endoscopic vision
- apply a high frequency current to a wire loop
- hemostasis by sealing vessels with coagulating current
- constant bladder irrigation to keep bladder distended
What type of bladder irrigation is used for a TURP?
- clear, non-conductive, non-hemolytic, non-toxic solution
- can have systemic absorption, often hypotonic solutions used
—> hyponatremia, hypervolemia, pulmonary edema, CHF, hypothermia, coagulopathy
What type of anesthesia is used for a TURP?
GA—> coughing must be avoided
- Spinal anesthesia preferred related to benefits provided
What happens during a spinal for a TURP?
- atonic bladder: thus irritant pressure can be low, emptying less frequent, facilitating resection
- prevents post-op bladder spasms—> allows for hemostasis
- awake pts: supply early detection of complications- since you can talk to them
What are complications of a TURP?
- blood loss
- venous absorption of irrigation fluid if pressure of irrigation is higher than pressure in venous sinus (very high IV pole)
- open sinuses proved direct communication with systemic circulation (Pouisielle’s law)
What are S/S of venous absorption of bladder irrigation?
- early signs: HTN and tachycardia
- rise in CVP
- c/o dyspnea or nausea (if awake)
- hypoxia and/or hyponatremia—-> TURP syndrome, water intoxication, glycine intoxication
What are signs of TURP syndrome?
- apprehension
- disorientation
- convulsions
- coma
What are signs of systemic absorption of glycine, sorbital and mannnitol? (Keep in mind these are all less likely to occur than TURP syndrome)
- Glycine (1.5%): transient post-op visual impairment - blindness
- when absorbed, metabolized by liver to ammonia
- Sorbital (3.3%): hyperglycemia and lactic acidosis
- Mannitol (5%): non-metabolic osmotic diuretics—> hypervolemia, CHF, pulmonary edema, then urination
What is the treatment of TURP syndrome?
- ask surgeon to control bleeding and finish surgery
- send blood sample (BNP): if Na <120mEq/L —> SERIOUS!
- correct hypervolemia and hyponatremia. With fluid restrictions and diuretics (furosemide 10-20mg)
- increase Na cautiously with hypertonic solutions
- give NS or LR
- ** postpone if Na <125 mEq/L
What are positioning considerations for an open (radical) prostatectomy?
- supropubic/retropubic approach:
- supine, flex table and t-burg
- perineal approach—> extreme lithotomy
- more hemorrhage with retropubic approach
- blood loss during control of dorsal venous complex
- large IVs a must!!
What is significant regarding the dyes used for a radical prostatectomy?
- dyes used to identify ureters
- methylene blue 1% can cause (or inhibit-depending on the source) hypotension
- indigo carmine dye 0.8%: alpha sympathomimetic increases BP
- both will temporarily drop O2 sats: ~ 65% for 1 minute—> don’t freak out
When is a nephrectomy indicated?
- chronic infection
- trauma
- cystic or calculus disease
- neoplasm
How is a nephrectomy performed?
- lateral retroperitoneal or anterior abdominal incision
- lateral-flex table with kidney bar
- may cause vena cava compression and hypotension
- GA or combined GA with regional
What are key things to know about a renal transplant?
- optimize pt prior to transplant
- normalize K+, correct metabolic acidosis
- anemia is common
- no anectine, atracurium or cistacurium
*** no regional anesthesia if pre-existing coagulopathy or immunosuppression - to discourage rejection—> use methylprednisone
- position supine with roll under hip
- kidney is usually anastomoses to external iliac arteries or
—> with previous nephrectomy- end to end vascular and ureteral anastomoses performed
Regarding fluids, what are things to keep in mind for the renal transplant patient?
- use NS—> avoid LR and K+ containing solutions
- adequate hydration is critical:
- use crystalloids, colloid and blood for revascularization of kidney
- if oliguric: use low dose dopamine
- diuretics
What are some complications of renal transplant?
- hyperkalemia
- delayed renal function
- graft failure
- pt will be on a lot of meds: steroids, anti-rejection meds
How is the donor kidney often preserved?
- cold storage: preserves kidney graft survival, minimizes tissue necrosis and edema
- 4˚C is goal—> reduces metabolic demands and provides nutrients to maintain metabolic activity
- continuous pulsatile perfusion- pumped at 40-60mmHg
- solution is glucose, K+, Mg+, antibiotics, NaHCO3, heparin (can trigger hypersensitivity reaction in recipient)
What is the difference between POPS (portable organ preservation system) and cold storage for the donor kidney?
Has changed the time frame
- POPS: kidney can stay viable up to 72 hours
- cold storage: 48 hours then necrosis jeopardizes graft survival
When is a radical cystectomy indicated?
- invasive bladder tumors
- pelvic malignancies
- neurogenic bladder
- chronic lower urinary tract obstruction
- post radiation bladder dysfunction
- creation or ureteral-ideal anastomosis and ileostomy
What are anesthetic considerations of a radical cystectomy?
- supine position
- GA or combined
- arterial line and CVP, large bore IVs
- extensive fluid shifting—> unable to monitor UOP—> need CVP
- diuretics to stimulated UOP
- indigo carmine and methylene blue may be used
What are complications of a radical cystectomy?
- hypothermia
- inadequate fluid replacement
- post-op ventilation—> ICU
When would an orchiodopexy (move undescended testicle into scrotum), orchiectomy(removal of testicle) and urogenital plastic procedure be performed?
- To treat congenital malformation
- neoplasm
- impotence
- torsion of testicle
What are anesthetic considerations for a orchiodopexy, orchiectomy or urogenital surgery?
- will be done in supine or lithotomy
- GA or regional
- T9 sensory block needed
What are anesthetic considerations for placement of an AV shunt and fistula for HD?
- supine with arm extended
- GA, regional and local infiltration ALL acceptable
- find out which arm is being used and DO NOT START IV ON THAT ARM!!!
- give some local, then sedate
- find out which arm is being used and DO NOT START IV ON THAT ARM!!!
What are co-existing medical problems for a pt needing an AV fistula or shunt?
- anemia
- CAD
- DM
What takes place during an extra corporal Shock Wave Lithotripsy (ESWL)?
- shock waves break up upper urinary tract stones
- shock delivery triggered by QRS
- must hook up pt to ECG
- risk or R on T wave triggered V-tach
What are anesthesia considerations for an ESWL?
- lithotomy for stent placement, then transfer to table supine
- MAC: fentanyl and versed
- hydration and diuretics to help pass stone fragments
What are pediatric considerations for any of the urologic surgeries?
- upper airway: recently sick—> spasms
- pulmonary system
- apnea
- CV
- temperature control
- fluid/electrolyte balance
- premies are at risk of SIDS
Why perform endoscopic urologic procedures?
- visualize and evaluate upper and lower urinary tracts to diagnose and treat:
- hematuria
- pyuria (pus in urine)
- calculi
- trauma
- CA
What is considered upper urinary tract?
ureter and kidney
What is considered lower urinary tract?
Bladder
Prostate
Urethra
What are common nerve injuries during endoscopic urologic surgery and how do they occur?
Usually performed in lithotomy:
- common peroneal—>lateral knee, compression on fibulae head on leg brace
- saphenous—> medial knee, compression of medial tibial condole
- sciatic—> from excessive external rotation of leg, and excessive knee extension
- obtrurator and femoral nerves—> from extensive flexion of groin
What is significant regarding pooling of blood in the lithotomy position?
- there is about 5L of blood per leg
- when legs drop…..BP drops
What can occur as a result of the obturator reflex during endoscopic urologic surgery?
- bladder injury/rupture occurs secondary to contraction of adductor muscle from stimulation to obturator nerve during electrocautery
- risk is increased when resecting lateral wall tumors
- more likely to stimulate the obturator nerve
- risk is increased when resecting lateral wall tumors
What is a cystoscopy, and what are anesthetic considerations for a cystoscopy?
Passage of a rigid or flexible scope through the urethra
- minor procedure: may be done with 2% lidocaine jelly
** urethral stimulation, dilation, and distention of bladder are very painful—> requires GA or regional
- T8 is the level of the ureters
- T9 or T10 sensory block needed for a cystoscopy
—> if sedation is too light- pts legs will clamp down on surgeons head
What are some things to keep in mind with a regional block?
Sensory level is 2 levels below autonomic blockade (ASM)
- cardiac accelerators are at T1-T4
What are the dermatomes?
C1-C8
T1-T12
L1-L5
S1-S5
