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Principles > Genitourinary procedures > Flashcards

Genitourinary procedures Flashcards

1
Q

Indications for Urological Surgery (5)

A

Biopsies/evaluate bleeding

Retrograde pyelography

Laser/retrieve stones

Remove/treat stricture

Resect masses

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2
Q

Position for urologic surgery

A

lithotomy

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3
Q

Nerve injuries in lithotomy

A

Femoral/peroneal nerve injury

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4
Q

Concerns for lithotomy position (4)

A

Femoral/peroneal nerve injury

Skin breakdown d/t stirrup pressure

Hip dislocation/back strain

Vessel compression

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5
Q

Concerns with vessel compression in lithotomy position

A

DVT
Venous pooling
Compartment syndrome

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6
Q

Best measure of glomerular function

A

GFR

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7
Q

normal GFR

A

Normal 125 mL/min…

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8
Q

GFR is asymtomatic until _____

A

asymptomatic until 50% drop

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9
Q

Moderate insufficiency in renal function signs

A

inc Bun/ creat, anemia, decreased energy

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10
Q

Severe insufficiency in renal function signs

A

Severe insufficiency: profound uremia; acidemia; volume overload

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11
Q

Normal BUN

A

8-18mg/dL

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12
Q

What influences BUN

A

Influenced by exercise, steroids, dehydration

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13
Q

Bun is Not elevated in kidney disease until GFR is ____of normal

A

Not elevated in kidney disease until GFR is 75% of normal

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14
Q

Normal creatinine

A

0.8-1.2 mg/dl

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15
Q

what does creatinine vary with?

A

Varies with age, sex (men w/ muscles)

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16
Q

Preoperative Eval of Patients with CRF (5)

A

Hypervolemia
Acidosis
Hyperkalemia
Cardiac/Pulm. Symptoms
Hematologic Symptoms

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17
Q

Decreased production of ammonia can lead to what?

A

acidosis, increasing anion gap

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18
Q

What is hyperkalemia in CRF preciptated by____ (3)

A

Precipitated by hemorrhage, transfusions, metabolic acidosis

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19
Q

Hematologic Symptoms with CRF

A

Normochromic, normocytic, iron deficient anemia
Abnormal platelet aggregation and prothrombin consumption

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20
Q

Most drugs lipid soluble in ____state

A

non-ionized state

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21
Q

metabolism of lipid-soluble drugs (3)

A

Termination doesn’t depend on renal excretion
Use redistribution and metabolism
Excreted as water-soluble compounds

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22
Q

highly ionized drugs are eliminated _____ in urine

A

unchanged

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23
Q

Drugs of concern with renal insufficiency patients (6)

A

Muscle relaxants
Cholinesterase inhibitors
Thiazide diuretics
Digoxin
Many antibiotics
Metabolites of opioids (morphine/meperidine)

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24
Q

urethroscopy

A

Through urethra

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25
Q

cystoscopy

A

Through bladder

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26
Q

ureteroscopy

A

Through ureteral orifice

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27
Q

Scope options and features

A

Flexible or rigid scope
Hooked to irrigating system
Guide wire inserted through scope
Catheter/instruments placed over wire
Radiopaque dye injected through catheter

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28
Q

if want to look further than the bladder what kind of scope do we need?

A

flexible ureteroscope

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29
Q

Visualize the urethra and/or bladder d/t urinary symptoms

A

Urethroscopy/Cystoscopy

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30
Q

Reason for urthroscopy (4)

A

Pain, burning, hematuria, difficult urination

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31
Q

Diagnosis and treatments with Urethroscopy/Cystoscopy

A

Diagnosis: lesions, strictures
Dilate stricture, treat cystitis, stent placement, resect tumors

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32
Q

Procedure of choice for mid/distal ureter or bilateral stones

A

Ureteroscopy

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33
Q

What procedure Can incorporate laser technology

A

Ureteroscopy

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34
Q

Occurrence of renal calculi

A

Lifetime: 10% men; 5% women
50% recurrence

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35
Q

Stones contain______

A

Contain calcium and are radiopaque

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36
Q

what can be used to Diagnos kidney stones

A

Diagnosed on CT, KUB, IVP

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37
Q

complications with Ureteroscopy (2)

A

Perf 5%,
stricture formation <2%

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38
Q

Medical therapy for renal calculus

A

medical expulsive therapy (MET)

NSAIDs
Aggressive fluid administration
Calcium channel/alpha blockers

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39
Q

Choices for kidney stone surgeries

A
  1. Stone basket vs. Laser
  2. Shock Wave Lithotripsy
  3. Perc nephrolithotomy
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40
Q

Best suited for small/medium intranephric stones

A

Shock Wave Lithotripsy

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41
Q

what can cause Risk of kidney injury or sub-capsular hematoma

A

Shock Wave Lithotripsy

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42
Q

Old SWL

A

Water baths
Hypothermia
Painful

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43
Q

Newer SWL (3)

A

Water-filled coupler device
More tightly focused beam
Lower pressured pulse….decreased pain

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44
Q

Absolute contraindications of SWL

A

Bleeding disorder/anticoagulation
Pregnancy

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45
Q

Relative contraindications of SWL (5)

A

Large calcified aortic/renal aneurysms
Untreated UTI
Obstruction distal to the renal calculi
Pacemaker, ICD, neuro-stimulator
Morbid obesity

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46
Q

Preop considerations for SWL

A

Appropriate antibiotics within 1 hour of “cut time”
Iodine allergy?

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47
Q

Procedure Useful for large intranephric stones

A

Percutaneous Nephrolithotomy (Uncommon due to SWL)

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48
Q

Requires initial placement of ureteral stents for what procedure and why?

A

Percutaneous Nephrolithotomy

prevent obstruction as fragments pass

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49
Q

concerns for Percutaneous Nephrolithotomy

A

Uses larger amounts of fluoroscopy

TUR syndrome possible

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50
Q

Position for Percutaneous Nephrolithotomy

A

Lateral position

51
Q

spermatic cord is clamped, cut, and sutured

A

Orchiectomy- almost always bilateral

52
Q

orchiectomy is done for what patients?

A

Metastatic prostate cancer

53
Q

wall of hydrocele excised and edges sutured to prevent recurrence

A

Hydrocelectomy

54
Q

must be performed within 6 hrs to prevent irreversible ischemic damage.

A

Testicular torsion

55
Q

Penectomy can also include what?

A

Penectomy-may include inguinal lymph node bx
for Squamous cell carcinoma

56
Q

What patients get a Penile prosthesis

A

Diabetes, spinal cord injury

57
Q

Penile innervation

A

Pudendal nerve (S2-S4)

58
Q

Manipulation of genitals can cause what hemodynamic change?

A

vagal bradycardia

59
Q

Penile surgery position

A

supine

60
Q

Indications for simple Cystectomy

A

Simple- benign conditions
Hemorrhagic cystitis
Radiation cystitis

61
Q

Indications for radical cystectomy and whats included?

A

Radical- malignant conditions
Invasive bladder cancer
Includes ureters, prostate/uterus, ovaries

62
Q

cystectomy requires….

A

Requires ileal conduit or bladder substitution

63
Q

Preop considerations for cystectomy

A

Risk factors for CAD or pulmonary disease? (malignant issues)
Anticoagulant use? EKG
Bowel prep likely- because will be open/ going into belly

64
Q

Position for cystectomy

A

Supine

65
Q

Common complications with cystectomy

A

Blood loss-up to 3 liters
1-2 PIV; Type and crossmatch blood
3rd space losses
Hypothermia (bare hugger or underwater body blankets)

66
Q

“Gold-standard” for BPH

A

Transurethral Resection of Prostate

67
Q

Transurethral Resection of Prostate uses ____ or ____

A

Uses electrocautery or laser

68
Q

EBL for Transurethral Resection of Prostate

A

Blood loss 2-4ml/min

69
Q

TURB

A

transurethral resection of the bladder

70
Q

Risk factors for TURP (6)

A

Patients generally 30-50’s so….
Obesity
Hypertension
Hyperparathyroidism
CRI
Paraplegia

71
Q

safest way to do TURP

A

SAB - stay away to notice Na+ change

72
Q

Position for TURP

A

Lithotomy

73
Q

intra op concerns for TURP

A

Possible transfusion
TUR syndrome

74
Q

Robotic Prostatectomy considerations

A

Arterial line

Phenylephrine drips

LIMIT IV fluids- because trendelenburg and getting alot with irrigation

75
Q

Symptoms related to hypervolemic water intoxication

A

TUR Syndrome

76
Q

Tur Syndrome happens because Excessive volume expansion through _______

A

Excessive volume expansion through venous sinuses -> hyponatremia

77
Q

Na 120 cns and ecg changes

A

Confusion Restlessness
? Widening of QRS

78
Q

Na 115 cns and ecg changes

A

Somnolence
Nausea
Elevated ST segs
Widened QRS

79
Q

na 110 cns and ecg changes

A

Seizures Coma
Vtach or Vfib

80
Q

Glycine irrigants concerns

A

Metabolized in liver to ammonia (dont give to liver failure pts)

81
Q

Water irrigation concerns

A

Intravascular hemolysis

82
Q

saline irrigants concern

A

Volume overload
Current dispersion with monopolar cautery

83
Q

Sorbital irrigant concerns

A

Metabolized to CO2 and fructose
Volume overload

84
Q

TURP irrigation rates and absorption rates

A

Irrigation rates 300ml/min

Absorption 20ml/min-200ml/min

> 2L of absorption usually required for TUR syndrome

85
Q

How Do You Prevent TUR Syndrome? (3)

A

Limit resection time to 1 hour

Suspend the irrigating fluid < 30cm above the table

Treat hypotension for SAB with vasopressors NOT IVF

86
Q

Treatment of TUR Syndrome

A

ABC’s

Terminate procedure as soon as possible

Consider invasive lines…for cardiovascular instability

87
Q

Treatment for mild TUR symptoms

A

Mild symptoms (Na > 120)
Fluid restriction
Loop diuretics

88
Q

Treatment for severe TUR symptoms

A

Severe symptoms (Na < 120)
3% IV saline

89
Q

Nephrectomy occurrences

A

50,000 nephrectomies/yr

90
Q

Nephrectomy post op complications (7)

A

Up to 20% postop complications;
Mortality
Peritonitis
Acute Renal failure
Hernia
Visceral injury
Hemorrhage
Pneumothorax

91
Q

Nephrectomy Types

A

Simple- just kidney
radical
donor

92
Q

Simple nephrectomy indications (3)

A

Irreversible non-malignant disease (autoimmune diseaseas)
Trauma
Congenital disease (PKD)

93
Q

radical nephrectomy includes ____ and indications

A

Radical: includes adrenal glands
Renal cell carcinoma

94
Q

Complications of renal cell carcinoma

A

thrombus attached to the kidney and grows up the vena cava

95
Q

Positioning for nephrectomy

A

Reverse T burg
trendelenbug
kidney rest
lateral

96
Q

nephrectomy patients usually have what other comorbidities

A

CAD
CRI/ESRD
HTN

97
Q

What gas to avoid in nephrectomy

A

Avoid nitrous

98
Q

intra op considerations for nephrectomy

A

Consider arterial line

Consider central line
Ipsilateral to surgical site

Consider regional anesthesia for postoperative pain

99
Q

What do we need available for nephrectomy (5)

A

colloid, blood, rapid transfusion set up, mannitol, furosemide

100
Q

The kidney gets how much CO

A

25%

101
Q

usually kidney to take for transplant and why

A

L kidney is preferred because it has longer vascular supply and longer ureter = more length to sew things back together. The artery and vein go back to the iliac and the ureter goes back to the bladder.

102
Q

what do you anastomose first

A

vein first then artery

103
Q

1/3 of all renal nephrectomies are _____

A

Living Donor Nephrectomies

2/3 = coming from cadaver

104
Q

DBD / DCD alterations compared to living donor

A

Healthy
Two kidneys
No diabetes, HIV, liver disease, cancer
Waiting times avoided
Decreases cold ischemic time

105
Q

Anesthesia for the Living Donor

A

Starts a couple of hours prior to recipient
Left kidney preferred
lateral position

106
Q

hydration for living kidney donor

A

Aggressive isotonic hydration (10-20 ml/kg/hr)

107
Q

If urine output for donor isn’t enough and we want it to be doing more_____

A

give Lasix/ fluid or bumex or mannitol

Furosemide, mannitol to maintain 2 ml/kg/hr

108
Q

Why anticoagulation for living donor?

A

when kidney removed there is blood inside of it and its not moving / being circulated (likely to clot) – living donors get 5000 units of heparin so it doesn’t clot. Once removed we can reverse with protamine.

109
Q

heparin and Protamine dose

A

Heparin = 5000 units

Reverse 1:1. 50 mg is 1:1 for 5,000 units of heparin (5,000 units = 50 mg)

110
Q

DBD neurologic changes

A

hours to days
Cushing’s sign…HTN, bradycardia, wide pulse pressure
Catastrophic ICP elevation

111
Q

DBD cardiac chages

A

Massive release of catecholamines
Acute MI common
Cardiovascular collapse

112
Q

DBD pulmonary changes

A

Neurogenic pulmonary edema
SIRS

113
Q

DBD metabollic changes

A

Dysfunction of hypothalamus and pituitary systems
Thermoregulation, hormones, insulin, electrolytes, DIC

114
Q

Anesthesia for Cadaver Donor

A

Don’t need anesthetic….need stabilization until retrieval

115
Q

lung protective ventilation

A

6-8 ml/kg of ideal body weight
5-10cm PEEP

116
Q

Why to avoid glucose containing solutions for cadaver donors

A

Avoid glucose containing solutions; metabolized then becomes a hypoteonic solution

117
Q

steroids for donor; how much and why

A

Steroids to attenuate immune response (in recipient)- 125 mg = help with immune repsone

118
Q

Ischemic time for kidney

A

48-72 hours

119
Q

During ischemia the kidney_____ (4)

A

Lack of oxygen
Depletion of ATP/glycogen
Failure of Na/K pump
Increased intracellular sodium…edema

120
Q

Preop evaluation for the recipient?

A

Last dialysis
40% have CAD and most HTN
diabetic? BG?
If PCKD, is nephrectomy concurrent

121
Q

meds to consider for the recipient

A

may use Anectine if K+ appropriate (raises 0.5meq/L)

Consider cisatracurium

avoid roc/ vec (cleared by kidney)

Steroids, mannitol, lasix, bumex, antithymocyte, albumin

122
Q

Infusion of rabbit-derived antibodies against human T cells to prevent/treat acute rejection

A

anti-thymocyte

123
Q

side effect of anti-thymocyte

A

Cytokine release syndrome: high grade fevers (over 39oC), chills, and possibly rigors.

124
Q

treatment for cytokine release syndrome (3)

A

steroids (normally methylprednisolone)
diphenhydramine 25–50 mg
acetaminophen 650 mg

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