Exam 3 Genitourinary Surgery [7/15/24] Flashcards
List the structures of the genitourinary system from the top to bottom.
- Kidney
- Ureter
- Bladder
- Urethra
additional info
What lab is the best measure of glomerular function?
- GFR
S2
- What is normal GFR?
- When will patients become symptomatic?
- 125 mL/min
- Asymptomatic until a 50% drop
S2
- What will be the result of moderate GFR insufficiency?
- ↑ BUN/Creat
- Anemia
- Decreased energy
Moderate GFR is BAD
S2
What will be the result of severe GFR insufficiency?
- Profound uremia (high levels of waste product in the blood)
- Acidemia
- Volume overload
S2
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 urea into nitrogen, which is eventually eliminated from the body through urine.
S2 - extra
What is a Normal BUN?
- 8-18 mg/ dL
S2
What will influence the BUN level?
- Exercise
- Steroids
- Dehydration
S2
BUN will not be elevated in the kidney disease until GFR is ____% of normal.
- 75%
S2
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.
S2- ANDY
What is normal Creatinine?
- 0.8 - 1.2 mg/dL
- Varies with age & sex
- Higher in men d/t more muscle mass
S2
What are the considerations during the preoperative evaluations of patients with Chronic Renal Failure?
- Hypervolemia
- ↑Na, ↑H2O)
- Hyperkalemia (may live @ an elevated K+ level)
- precipitated by hemorrhage, pulm edema, metabolic acidosis
- Hematologic Symptoms
- Cardiac/Pulmonary Symptoms
- Acidosis
- ↓ production of ammonia
- Normal anion gap becomes elevated as disease progresses.
2Hyper Cats Had Acid
S3
Cardiac/Pulm symptoms that should be considered preoperatively for pts with CRF
- HTN d/t renin-angiotensin system
- May have:
- atherosclerosis
- pulmonary edema
- ventricular hypertrophy
S3
Hematologic Symptoms that should be considered preoperatively for pts with CRF
- normochromic (color), normocytic (size), iron deficient anemia
- Abnormal platelet aggregation and prothrombin consumption
S3
Anesthesia Drug Effects in Patients with Renal Insufficiency
- Because most anesthetic drugs are _________ soluble in a non-ionized state, termination doesn’t depend on ____.
- What does it use instead?
- How is it excreted?
- Because most anesthetic drugs are lipid soluble in a non-ionized state, termination doesn’t depend on Renal Excretion.
- Use redistribution and metabolism
- Metabolite of these drugs are excreted as water-soluble compounds
S4
What are drugs of concern for patients with Renal Insufficiency?
- Drugs that are highly ionized and eliminated unchanged in urine
- H2 receptor blockers
- Muscle relaxants (pancuronium)
- Cholinesterase inhibitors (neostigmine)
- Thiazide diuretics
- Many antibiotics
- Active metabolites (morphine/meperidine/ketamine/midazolam)
- Digoxin
Harmful Muscles Cant Take Many Active Drugs
S4
What is the active metabolite of morphine?
- Morphine-6-glucuronide
S4-Andy
when would we want to implement renal protection?
- patients with moderate insufficiency
- Esp in cardiac/valve surgery
- Sepsis, crush/burn injuries, toxins, NSAIDs
S5
what is the mortality rate of AKI?
50%
S5
What are things we can do for renal protection?
- Adequate hydration
- Maintenance of adequate RBF
- Use of:
- Mannitol
- loop diuretic
- low-dose dopamine
- bicarbonate drips
- fenoldopam
- N-acetylcysteine
renal protection Might Look Dopey, But Feels Nice
S5
Indications for Urological Surgery
- Direct visualization of urethra, bladder, ureter, kidney
- Biopsies/evaluate bleeding
- Retrograde pyelography
- Laser/retrieve stones
- Remove/treat stricture
- Resect masses
S6
What position will the patient be in for Urological Surgery?
- Lithotomy
S7
In the Lithotomy position, the stirrups can cause what type of nerve injury?
- Peroneal Nerve Injury
- Femoral Nerve Injury
S7
What other problems can occur besides nerve injuries in the Lithotomy position?
- Skin breakdown d/t stirrup pressure
- Hip dislocation
- Finger injury
- Back strains
- Vessel compression (DVT, Compartment Syndrome, Venous Pooling)
S7
Remember to move both legs simultaneously to prevent torsion and injury to lower spine
Endoscopic evaluations (scope procedures) of the lower urinary tract can be done through which areas and are called what?
- Through urethra (urethroscopy)
- Through bladder (cystoscopy)
- Through ureteral orifice (ureteroscopy)
S9
What are the two types of scopes used for urological procedures?
- Flexible
- Rigid (this scope to the ureter, it will stop in the bladder)
S9/10
Never use which type of scope in the ureters?
Rigid scope.
S9-lecture
Even if the surgery starts with a rigid scope, if they decide they need to look in the ureter, we will have to switch to a flexible scope.
How is a scope used for a urological procedure?
- Scope hooked to irrigation system
- Guid Wire is inserted through scope for catheter and instruments
- Catheter/instruments placed over wire
- Radiopaque dye injected through catheter
S9
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).
S11
The procedure of choice for mid/distal ureter or bilateral stones?
What does it sometimes incorporate?
- Ureteroscopy (flexible scope)
- Can incorporate laser technology
S12
- What percentage of men and women lifetime will experience ureter stones?
- What is the recurrence percentage?
- Men: 10%
- Women: 5%
- Recurrence: 50%
S12
characteristics of uretur stones
contain calcium and are radiopaque
S12
How are ureter stones diagnosed?
- CT
- KUB X-RAY
- IVP (Intravenous Pyelogram)
S12
Complications of ureteroscopy are low.
What are the complications and their percentage of occurance?
- Perforation: 5%
- Stricture formation: < 2%
S12
What are some medical therapy for ureter stones?
- MET (Medical Expulsive Therapy)
- NSAIDs
- Aggressive Fluid intake (↑ Water, ↑ Cranberry Juice)
- CCB and alpha blockers to vasodilate
- Surgery/ Procedures
S13
What are the choices for surgery/procedure for kidney stones?
- Stone basket vs. Laser (preferred)
- Shock Wave Lithotripsy
- Percutaneous nephrolithotomy (least preferable)
S14
Shock wave Lithotripsy is best suited for ____ intranephric stones.
- small/medium
S15
we worry about the pressure of those shock waves pounding on more than just the stone.
What is the risk for Shock Wave Lithotripsy (SWL)?
- Risk of kidney injury or sub-capsular hematoma
S15
d/t shock waves hitting the kidney and/instead of the stone.
Compare the Old SWL vs New SWL.
- Old SWL:
- Water baths,
- hypothermia,
- painful
- New SWL:
- Water-filled coupler device,
- more tightly focused beam,
- decrease pressure pulse
- less painful
S15
- What are ABSOLUTE contraindications to SWL?
- What are the relative CI to SWL?
- Absoloute
- Bleeding disorder/ anticoagulants
- Pregnancy (we do not thump babies)
- Relative contraindications:
- Large calcified aortic/renal aneurysm,
- untreated UTI,
- Obstruction distal to renal calculi
- Pacemaker, ICD, neurostimulator (waves are rhythmic)
- Morbid Obesity.
S16
Preoperative anesthetic considerations for shock wave lithotripsy (SWL), stone basket, or laser therapy.
- Single IV
- Consider anxiolytics
- Appropriate ABX within 1 hour “cut time”
- Iodine Allergy- pretreat b/c lots of dye in these procedures
S17
Intraoperative anesthetic considerations for shock wave lithotripsy (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 (document!)
- Lead for providers (cover breast, thyroid, sex organs, corneas)
S17
Postoperative anesthetic considerations for SWL, stone basket, or laser therapy.
pt usuallly go to PACU
S17
What procedure will be indicated for large intranephric stone removal?
- Percutaneous Nephrolithotomy
- however, uncommon d/t SWL
S18
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 Larger amounts of fluoroscopy
- Transurethral Resection (TUR) syndrome possible
S18
Preoperative anesthetic considerations for percutaneous nephrolithotomy.
- Single PIV
- Consider anxiolytics
- Appropriate ABX within 1 hour “cut time”
S19
Testicular torsion surgery must be performed within ____ hours to prevent irreversible ischemia.
- 6 hours
S20
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
S26/27
What arteries and veins do transplanted kidneys attach to?
- Transplanted kidneys are attached to the common iliac vein and artery
S43 lecture
