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My APA 2 > Endoscopic Urologic Procedures- Jerry > Flashcards

Endoscopic Urologic Procedures- Jerry Flashcards

1
Q

Why do a cystoscopy for retrograde ureteral catheterization?

A
  • to visualize ureter and kidney
  • to place stents
  • to drain obstructions
  • to remove renal calculi
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2
Q

What is a transureteral resection of the bladder (TURBT) done for?

A

To treat superficial bladder tumors

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3
Q

What type of anesthesia is used for a TURBT?

A
  • GA—> no coughing or straining- could cause bladder perforation
  • Regional—> bladder becomes atonic and may become thinner when distended—> increasing risk of perforation
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4
Q

What are consequences of bladder perforation?

A

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
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5
Q

How is a transurethral resection of the prostrate (TURP) done?

A
  • 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
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6
Q

What type of bladder irrigation is used for a TURP?

A
  • clear, non-conductive, non-hemolytic, non-toxic solution
  • can have systemic absorption, often hypotonic solutions used
    —> hyponatremia, hypervolemia, pulmonary edema, CHF, hypothermia, coagulopathy
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7
Q

What type of anesthesia is used for a TURP?

A

GA—> coughing must be avoided

- Spinal anesthesia preferred related to benefits provided

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8
Q

What happens during a spinal for a TURP?

A
  • 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
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9
Q

What are complications of a TURP?

A
  • 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)
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10
Q

What are S/S of venous absorption of bladder irrigation?

A
  • 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
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11
Q

What are signs of TURP syndrome?

A
  • apprehension
  • disorientation
  • convulsions
  • coma
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12
Q

What are signs of systemic absorption of glycine, sorbital and mannnitol? (Keep in mind these are all less likely to occur than TURP syndrome)

A
  • 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
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13
Q

What is the treatment of TURP syndrome?

A
  • 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
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14
Q

What are positioning considerations for an open (radical) prostatectomy?

A
  • 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!!
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15
Q

What is significant regarding the dyes used for a radical prostatectomy?

A
  • 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
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16
Q

When is a nephrectomy indicated?

A
  • chronic infection
  • trauma
  • cystic or calculus disease
  • neoplasm
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17
Q

How is a nephrectomy performed?

A
  • 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
18
Q

What are key things to know about a renal transplant?

A
  • 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
19
Q

Regarding fluids, what are things to keep in mind for the renal transplant patient?

A
  • 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
20
Q

What are some complications of renal transplant?

A
  • hyperkalemia
  • delayed renal function
  • graft failure
  • pt will be on a lot of meds: steroids, anti-rejection meds
21
Q

How is the donor kidney often preserved?

A
  • cold storage: preserves kidney graft survival, minimizes tissue necrosis and edema
  • 4ËšC 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)
22
Q

What is the difference between POPS (portable organ preservation system) and cold storage for the donor kidney?

A

Has changed the time frame

  • POPS: kidney can stay viable up to 72 hours
  • cold storage: 48 hours then necrosis jeopardizes graft survival
23
Q

When is a radical cystectomy indicated?

A
  • invasive bladder tumors
  • pelvic malignancies
  • neurogenic bladder
  • chronic lower urinary tract obstruction
  • post radiation bladder dysfunction
  • creation or ureteral-ideal anastomosis and ileostomy
24
Q

What are anesthetic considerations of a radical cystectomy?

A
  • 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
25
Q

What are complications of a radical cystectomy?

A
  • hypothermia
  • inadequate fluid replacement
  • post-op ventilation—> ICU
26
Q

When would an orchiodopexy (move undescended testicle into scrotum), orchiectomy(removal of testicle) and urogenital plastic procedure be performed?

A
  • To treat congenital malformation
  • neoplasm
  • impotence
  • torsion of testicle
27
Q

What are anesthetic considerations for a orchiodopexy, orchiectomy or urogenital surgery?

A
  • will be done in supine or lithotomy
  • GA or regional
    • T9 sensory block needed
28
Q

What are anesthetic considerations for placement of an AV shunt and fistula for HD?

A
  • 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
29
Q

What are co-existing medical problems for a pt needing an AV fistula or shunt?

A
  • anemia
  • CAD
  • DM
30
Q

What takes place during an extra corporal Shock Wave Lithotripsy (ESWL)?

A
  • 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
31
Q

What are anesthesia considerations for an ESWL?

A
  • lithotomy for stent placement, then transfer to table supine
  • MAC: fentanyl and versed
  • hydration and diuretics to help pass stone fragments
32
Q

What are pediatric considerations for any of the urologic surgeries?

A
  • upper airway: recently sick—> spasms
  • pulmonary system
  • apnea
  • CV
  • temperature control
  • fluid/electrolyte balance
  • premies are at risk of SIDS
33
Q

Why perform endoscopic urologic procedures?

A
  • visualize and evaluate upper and lower urinary tracts to diagnose and treat:
    • hematuria
    • pyuria (pus in urine)
    • calculi
    • trauma
    • CA
34
Q

What is considered upper urinary tract?

A

ureter and kidney

35
Q

What is considered lower urinary tract?

A

Bladder
Prostate
Urethra

36
Q

What are common nerve injuries during endoscopic urologic surgery and how do they occur?

A

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
37
Q

What is significant regarding pooling of blood in the lithotomy position?

A
  • there is about 5L of blood per leg

- when legs drop…..BP drops

38
Q

What can occur as a result of the obturator reflex during endoscopic urologic surgery?

A
  • 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
39
Q

What is a cystoscopy, and what are anesthetic considerations for a cystoscopy?

A

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

40
Q

What are some things to keep in mind with a regional block?

A

Sensory level is 2 levels below autonomic blockade (ASM)

- cardiac accelerators are at T1-T4

41
Q

What are the dermatomes?

A

C1-C8
T1-T12
L1-L5
S1-S5

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