Exam 3 Genitourinary Surgery [7/15/24] Flashcards
1
Q
List the structures of the genitourinary system from the top to bottom.
A
- Kidney
- Ureter
- Bladder
- Urethra
additional info
2
Q
What lab is the best measure of glomerular function?
A
- GFR
S2
3
Q
- What is normal GFR?
- When will patients become symptomatic?
A
- 125 mL/min
- Asymptomatic until a 50% drop
S2
4
Q
- What will be the result of moderate GFR insufficiency?
A
- ↑ BUN/Creat
- Anemia
- Decreased energy
Moderate GFR is BAD
S2
5
Q
What will be the result of severe GFR insufficiency?
A
- Profound uremia (high levels of waste product in the blood)
- Acidemia
- Volume overload
S2
6
Q
What is BUN?
A
- 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
7
Q
What is a Normal BUN?
A
- 8-18 mg/ dL
S2
8
Q
What will influence the BUN level?
A
- Exercise
- Steroids
- Dehydration
S2
9
Q
BUN will not be elevated in the kidney disease until GFR is ____% of normal.
A
- 75%
S2
10
Q
What is Creatinine?
A
- 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
11
Q
What is normal Creatinine?
A
- 0.8 - 1.2 mg/dL
- Varies with age & sex
- Higher in men d/t more muscle mass
S2
12
Q
What are the considerations during the preoperative evaluations of patients with Chronic Renal Failure?
A
- 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
13
Q
Cardiac/Pulm symptoms that should be considered preoperatively for pts with CRF
A
- HTN d/t renin-angiotensin system
- May have:
- atherosclerosis
- pulmonary edema
- ventricular hypertrophy
S3
14
Q
Hematologic Symptoms that should be considered preoperatively for pts with CRF
A
- normochromic (color), normocytic (size), iron deficient anemia
- Abnormal platelet aggregation and prothrombin consumption
S3
15
Q
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?
A
- 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
16
Q
What are drugs of concern for patients with Renal Insufficiency?
A
- 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
17
Q
What is the active metabolite of morphine?
A
- Morphine-6-glucuronide
S4-Andy
18
Q
when would we want to implement renal protection?
A
- patients with moderate insufficiency
- Esp in cardiac/valve surgery
- Sepsis, crush/burn injuries, toxins, NSAIDs
S5
19
Q
what is the mortality rate of AKI?
A
50%
S5
20
Q
What are things we can do for renal protection?
A
- 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
21
Q
Indications for Urological Surgery
A
- Direct visualization of urethra, bladder, ureter, kidney
- Biopsies/evaluate bleeding
- Retrograde pyelography
- Laser/retrieve stones
- Remove/treat stricture
- Resect masses
S6
22
Q
What position will the patient be in for Urological Surgery?
A
- Lithotomy
S7
23
Q
In the Lithotomy position, the stirrups can cause what type of nerve injury?
A
- Peroneal Nerve Injury
- Femoral Nerve Injury
S7
24
Q
What other problems can occur besides nerve injuries in the Lithotomy position?
A
- 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
25
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
26
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
27
Never use which type of scope in the ureters?
Rigid scope.
| S9-lecture
## Footnote
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.
28
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
29
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
30
The procedure of choice for mid/distal ureter or bilateral stones?
What does it sometimes incorporate?
* Ureteroscopy (flexible scope)
* Can incorporate laser technology
| S12
31
* What percentage of men and women lifetime will experience ureter stones?
* What is the recurrence percentage?
* Men: 10%
* Women: 5%
* Recurrence: 50%
| S12
32
characteristics of uretur stones
contain calcium and are radiopaque
| S12
33
How are ureter stones diagnosed?
* CT
* KUB X-RAY
* IVP (Intravenous Pyelogram)
| S12
34
Complications of ureteroscopy are low.
What are the complications and their percentage of occurance?
* Perforation: 5%
* Stricture formation: < 2%
| S12
35
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
36
What are the choices for surgery/procedure for kidney stones?
* Stone basket vs. Laser (preferred)
* Shock Wave Lithotripsy
* Percutaneous nephrolithotomy (least preferable)
| S14
37
Shock wave Lithotripsy is best suited for ____ intranephric stones.
* small/medium
| S15
## Footnote
we worry about the pressure of those shock waves pounding on more than just the stone.
38
What is the risk for Shock Wave Lithotripsy (SWL)?
* Risk of kidney injury or sub-capsular hematoma
| S15
## Footnote
d/t shock waves hitting the kidney and/instead of the stone.
39
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
40
* 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
41
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
42
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
43
Postoperative anesthetic considerations for SWL, stone basket, or laser therapy.
pt usuallly go to PACU
| S17
44
What procedure will be indicated for large intranephric stone removal?
* Percutaneous Nephrolithotomy
* however, uncommon d/t SWL
| S18
45
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
46
Preoperative anesthetic considerations for percutaneous nephrolithotomy.
* Single PIV
* Consider anxiolytics
* Appropriate ABX within 1 hour "cut time"
| S19
47
Intraoperative anesthetic considerations for percutaneous nephrolithotomy.
* General ETT
* **Short-acting** NMBD's
* Lateral position (bean bag, pillows)
* Lead apron for provider
* Eye covering for laser (document!)
| S19
48
postoperative anesthetic considerations for percutaneous nephrolithotomy
pts usually go to PACU
| S19
49
What are 3 scrotal operations disccused in lecture?
* orchiectomy
* hydroelectomy
* testicular torsion
| S20
50
What is an orchiectomy?
* *Orchiectomy is a surgical procedure in which one or both testicles are removed.*
* **Almost always bilateral**
* **Spermatic cord is clamped, cut, and sutured**
* Usually in younger males with tumor or **metastatic prostate cancer.**
| S20
51
What is a Hydrocelectomy?
* *Hydrocelectomy is surgery to remove a hydrocele.*
* *A hydrocele is a fluid-filled sac inside the scrotum.*
* **Wall of hydrocele excised and edges sutured to prevent recurrence.**
| S20
52
Testicular torsion surgery must be performed within ____ hours to prevent irreversible ischemia.
* 6 hours
| S20
53
What are 4 penile operations disscused in lecture?
* circumcision
* hypospadius repair
* penectomy
* penile prosthesis
| S21
54
What are the reasons for circumcision in older males?
* Phimosis (tight foreskin)
* Penile/ prostate cancer risk
| S21
55
What is hypospadias?
* Birth defect in boys in which the opening of the urethra is not located at the tip of the penis.
| S21- Andy
56
What is a Penectomy?
* Removal of squamous cell carcinoma on the penis
* may include inguinal lymph node biopsy
| S21
57
What population group would seek a penile prosthesis discussed in the lecture?
* Diabetic patients
* Spinal cord injury patients
| S21
58
Anesthetic considerations for scrotal and penile operations.
* Preop anxiolytics
* General: ETT vs LMA
* SCIP (take care with prosthesis touching skin before insertion)
* Supine
* Penile Block (S2-S4)
* Manipulation of genitals ---vagal bradycardia, have glycopyrrolate ready
| S22
59
What is a Cystectomy?
* Surgical removal of all or part of the urinary bladder. (usually for cancer)
| S23 Andy
60
* What are the indications for cystectomy?
* What do they require?
* Simple-benign conditions
* hemorrhagic cystitis, radiation cystitis
* Radical - malignant conditions
* invasice bladder cancer
* includes removal of ureters, prostate, uterus, ovaries
* Requires ileal conduit or bladder substitution
| S24
61
Preoperative anesthetic considerations for cystectomy.
* Risk factors for CAD or pulmonary disease, CXR? (older patients)
* Anticoagulant use? EKG.
* Bowel prep likely
| S25
62
Intraoperative anesthetic considerations for cystectomy.
* GETA, SAB, epidural
* SCIP
* Supine
| S25
63
What are common complications of cystectomy?
* Blood loss: up to 3L
* 1-2 PIV, type and crossmatch blood
* 3rd space losses d/t open belly
* Hypothermia
* Use Bair Hugger or underbody water blankets
| S25
64
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
65
When would a TURP be performed?
* performed after failure of medical therapy and recurrent symptoms
* need for open resection?
| S27
66
What is the estimated blood loss of a TURP?
* 100-200ml
* *2-4 ml/min [andy]*
| S27
67
What comorbidities will patients receiving a TURP procedure have?
* Patients are generally in their 50-60's:
* Obesity
* HTN
* CAD
* family history
* Chronic Renal Insufficiency
* men over 80 y/o > 90% affected
| S28
68
Preoperative anesthetic considerations for TURP?
* Consider comorbidities
* Consider if the patient is on anticoagulants
* Large bore IV (18G or 16G)
| S29
69
Intraoperative anesthetic considerations for TURP?
* General/ SAB (**textbook: perform a SAB**)
* Lithotomy
* Possible transfusion
* TUR syndrome- w/ scope, we usually don't have time for this to develop
| S29
## Footnote
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.
70
What is TUR syndrome?
* Symptoms r/t hypervolemic water intoxication d/t irrigation into now open vascular beds
* Excessive volume expansion through venous sinuses
* results in Hyponatremia
| S30
71
What are CNS and EKG changes with a serum Na+ level of 120 mEq/L?
* **CNS changes**
* Confusion
* Restlessness
* **EKG changes**
* Widening of QRS
| S30
72
What are CNS and EKG changes with a serum Na+ level of 115 mEq/L?
* **CNS changes**:
* Somnolence
* Nausea
* **EKG changes**
* Elevated ST segments
* Widened QRS
| S30
73
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
| S30
74
* What are the types of irrigants used in TURP?
* What are considerations for them?
* **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
| S31
75
* 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
* in 20min (@100mL/min), we get 2L of fluid absorption...
| S32
76
Greater than ____ (volume) of irrigation fluid absorption is usually required for TUR syndrome.
* Greater than 2 Liters
| S32
77
How do you prevent TUR syndrome?
* Limit resection time to 1 hour
* Suspend the irrigation fluid < 30 cm above the table
* Treat hypotension for SAB with vasopressors **NOT IVF**.
| S33
78
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
| S34
79
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 (<500cc)
| S35
80
What is a nephrectomy?
* Surgical removal of a kidney, performed to treat several kidney diseases.
| S36
81
* How many nephrectomies are performed each year?
* Complication rate and complications?
* 50,000 nephrectomies/yr
* 20% post-op compilation rate
* Complications: ** MAP HPV **
* mortality
* acute renal failure
* peritonitis
* Hernia
* Hemorrhage
* Pneumothorax
* Visceral injury
| S37
82
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**
| S38
83
Positioning of nephrectomies is usually?
lateral decubitus with kidney rest and bed flexed.
| S39
84
Nephrectomies are commonly associated with these conditions.
* CAD
* CRI/ESRD
* HTN
| S40
85
Preoperative anesthetic considerations for nephrectomy.
* Anxiolytics
* SCIP
* Type/Screen or Type/Cross
* 2 large bore IV
| S40
86
Intraoperative anesthetic considerations for nephrectomy.
* GETA: avoid nitrous
* Consider an arterial line
* Consider a central line: Ipsilateral to the surgical site or large bore RIC line
* Consider regional anesthesia for postop pain
* Have these items available: Colloids, Blood, Rapid transfusion set up, mannitol, furosemide
| S41
87
Nephrectomies can possibly have what?
Vena Cava Tumor Thrombi
| S42
88
Which kidney has a long ureter and longer vascular supply?
* Left Kidney, so we usually take this kidney if we have a choice.
| S43 lecture
89
What arteries and veins do transplanted kidneys attach to?
* Transplanted kidneys are attached to the common iliac vein and artery
| S43 lecture
90
Do you re-anastomose the vein, artery, or ureter first in a kidney transplant?
* Re-anastomose the vein first, then the artery, then the ureter.
| S43 lecture
91
What fraction of all nephrectomies are living donor nephrectomies?
* one-third
| S44
92
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
| S44
93
What are the parameters of being a living donor?
* Healthy
* Two Kidneys
* No DM, HIV, Liver Disease, Cancer
| S44
94
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 (5000u of heparin)
-Protamine reversal (50 mg)
* Need diuresis
-Furosemide, mannitol to **maintain 2 ml/kg/hr**
SKAN for the living donor
| S45
95
What physiological alterations/instability will occur in DBD?
Neurological, cardiac, pulmonary, and metabolic instability
| S46
96
What neurological instability will occur with brain death?
* neurologic instability happens in hours to days
* Cushing’s sign: HTN, bradycardia, wide pulse pressure
* Catastrophic ICP elevation
| S46
97
What cardiac instability will occur with brain death?
* Massive release of catecholamines
* Acute MI (40% occurrence)
* Cardiovascular collapse (catecholamines run out, massive dilation)
| S46
98
What pulmonary instability will occur with brain death?
* Neurogenic pulmonary edema
* SIRS [Systemic inflammatory response syndrome]
| S46
99
What metabolic instability will occur with brain death?
* Dysfunction of the hypothalamus and pituitary systems
* Thermoregulation, hormones, insulin, electrolytes, DIC
| S46
100
Anesthesia Considerations for the Cadaver Donors.
* Don’t need anesthetic….need **stabilization** until retrieval
* Maintain hemodynamics with **short-acting agents** [vaso, levo/neo, dopamine, dobutamine]
* Significant bradycardia not responsive to anticholinergics…use **isuprel** [isoproterenol]
* 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)
(Stabilize PASSCI)
| S47
101
Donor Management Goals:
CVP
* 4-10 mmHg
* 6-8 mmHg for lung transplant
| S48
102
Donor Management Goals:
MAP
* 60-120 mmHg
| S48
103
Donor Management Goals:
PaO2
* >300 mmHg on 5cm PEEP on 100% O2
| S48
104
Donor Management Goals:
PaCO2
* 35-45 mmHg
| S48
105
Donor Management Goals:
ABG pH
* 7.35-7.45
| S48
106
Donor Management Goals:
Urine Output
* Greater than 1 mL/kg/hr
| S48
107
Donor Management Goals:
Sodium
* 135-160 mEq/L
| S48
108
Donor Management Goals:
Glucose
* less than 150
| S48
109
Donor Management Goals:
Ejection Fraction
* >50%
| S48
110
Donor Management Goals:
Hemoglobin
* > 9
| S48
111
Donor Management Goals:
Pressors
1 and low dose
| S48
112
Ischemic time for kidney
* 48-72 hours
| S49
113
What happens to the donor kidney during ischemia?
* Lack of O2
* Depletion of ATP/glycogen
* Failure of Na/K Pump
* Increase intracellular sodium....edema
| S49
114
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)
PCKD = Polycystic kidney disease?
| S50
115
Intraoperative consideration for kidney transplantation.
* GETA, may use Anectine if K+ appropriate
* Consider cisatracurium (not cleared by liver or kidney)
* Supine; watch AV access
* CVP/art line…..**STERILE**. Pt will be on immunosuppressants.
* Donor anastomoses to recipient (vein, artery, ureter)
* Steroids, mannitol, lasix, bumex, antithymocyte, albumin
* Extubate on table…to ICU (D/C next day)
| S51
116
What is an anti-thymocyte?
* Infusion of rabbit-derived antibodies against human T cells to prevent/treat acute rejection
| S52
117
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
| S52
