Genitourinary procedures Flashcards
Indications for Urological Surgery (5)
Biopsies/evaluate bleeding
Retrograde pyelography
Laser/retrieve stones
Remove/treat stricture
Resect masses
Position for urologic surgery
lithotomy
Nerve injuries in lithotomy
Femoral/peroneal nerve injury
Concerns for lithotomy position (4)
Femoral/peroneal nerve injury
Skin breakdown d/t stirrup pressure
Hip dislocation/back strain
Vessel compression
Concerns with vessel compression in lithotomy position
DVT
Venous pooling
Compartment syndrome
Best measure of glomerular function
GFR
normal GFR
Normal 125 mL/min…
GFR is asymtomatic until _____
asymptomatic until 50% drop
Moderate insufficiency in renal function signs
inc Bun/ creat, anemia, decreased energy
Severe insufficiency in renal function signs
Severe insufficiency: profound uremia; acidemia; volume overload
Normal BUN
8-18mg/dL
What influences BUN
Influenced by exercise, steroids, dehydration
Bun is Not elevated in kidney disease until GFR is ____of normal
Not elevated in kidney disease until GFR is 75% of normal
Normal creatinine
0.8-1.2 mg/dl
what does creatinine vary with?
Varies with age, sex (men w/ muscles)
Preoperative Eval of Patients with CRF (5)
Hypervolemia
Acidosis
Hyperkalemia
Cardiac/Pulm. Symptoms
Hematologic Symptoms
Decreased production of ammonia can lead to what?
acidosis, increasing anion gap
What is hyperkalemia in CRF preciptated by____ (3)
Precipitated by hemorrhage, transfusions, metabolic acidosis
Hematologic Symptoms with CRF
Normochromic, normocytic, iron deficient anemia
Abnormal platelet aggregation and prothrombin consumption
Most drugs lipid soluble in ____state
non-ionized state
metabolism of lipid-soluble drugs (3)
Termination doesn’t depend on renal excretion
Use redistribution and metabolism
Excreted as water-soluble compounds
highly ionized drugs are eliminated _____ in urine
unchanged
Drugs of concern with renal insufficiency patients (6)
Muscle relaxants
Cholinesterase inhibitors
Thiazide diuretics
Digoxin
Many antibiotics
Metabolites of opioids (morphine/meperidine)
urethroscopy
Through urethra
cystoscopy
Through bladder
ureteroscopy
Through ureteral orifice
Scope options and features
Flexible or rigid scope
Hooked to irrigating system
Guide wire inserted through scope
Catheter/instruments placed over wire
Radiopaque dye injected through catheter
if want to look further than the bladder what kind of scope do we need?
flexible ureteroscope
Visualize the urethra and/or bladder d/t urinary symptoms
Urethroscopy/Cystoscopy
Reason for urthroscopy (4)
Pain, burning, hematuria, difficult urination
Diagnosis and treatments with Urethroscopy/Cystoscopy
Diagnosis: lesions, strictures
Dilate stricture, treat cystitis, stent placement, resect tumors
Procedure of choice for mid/distal ureter or bilateral stones
Ureteroscopy
What procedure Can incorporate laser technology
Ureteroscopy
Occurrence of renal calculi
Lifetime: 10% men; 5% women
50% recurrence
Stones contain______
Contain calcium and are radiopaque
what can be used to Diagnos kidney stones
Diagnosed on CT, KUB, IVP
complications with Ureteroscopy (2)
Perf 5%,
stricture formation <2%
Medical therapy for renal calculus
medical expulsive therapy (MET)
NSAIDs
Aggressive fluid administration
Calcium channel/alpha blockers
Choices for kidney stone surgeries
- Stone basket vs. Laser
- Shock Wave Lithotripsy
- Perc nephrolithotomy
Best suited for small/medium intranephric stones
Shock Wave Lithotripsy
what can cause Risk of kidney injury or sub-capsular hematoma
Shock Wave Lithotripsy
Old SWL
Water baths
Hypothermia
Painful
Newer SWL (3)
Water-filled coupler device
More tightly focused beam
Lower pressured pulse….decreased pain
Absolute contraindications of SWL
Bleeding disorder/anticoagulation
Pregnancy
Relative contraindications of SWL (5)
Large calcified aortic/renal aneurysms
Untreated UTI
Obstruction distal to the renal calculi
Pacemaker, ICD, neuro-stimulator
Morbid obesity
Preop considerations for SWL
Appropriate antibiotics within 1 hour of “cut time”
Iodine allergy?
Procedure Useful for large intranephric stones
Percutaneous Nephrolithotomy (Uncommon due to SWL)
Requires initial placement of ureteral stents for what procedure and why?
Percutaneous Nephrolithotomy
prevent obstruction as fragments pass
concerns for Percutaneous Nephrolithotomy
Uses larger amounts of fluoroscopy
TUR syndrome possible
Position for Percutaneous Nephrolithotomy
Lateral position
spermatic cord is clamped, cut, and sutured
Orchiectomy- almost always bilateral
orchiectomy is done for what patients?
Metastatic prostate cancer
wall of hydrocele excised and edges sutured to prevent recurrence
Hydrocelectomy
must be performed within 6 hrs to prevent irreversible ischemic damage.
Testicular torsion
Penectomy can also include what?
Penectomy-may include inguinal lymph node bx
for Squamous cell carcinoma
What patients get a Penile prosthesis
Diabetes, spinal cord injury
Penile innervation
Pudendal nerve (S2-S4)
Manipulation of genitals can cause what hemodynamic change?
vagal bradycardia
Penile surgery position
supine
Indications for simple Cystectomy
Simple- benign conditions
Hemorrhagic cystitis
Radiation cystitis
Indications for radical cystectomy and whats included?
Radical- malignant conditions
Invasive bladder cancer
Includes ureters, prostate/uterus, ovaries
cystectomy requires….
Requires ileal conduit or bladder substitution
Preop considerations for cystectomy
Risk factors for CAD or pulmonary disease? (malignant issues)
Anticoagulant use? EKG
Bowel prep likely- because will be open/ going into belly
Position for cystectomy
Supine
Common complications with cystectomy
Blood loss-up to 3 liters
1-2 PIV; Type and crossmatch blood
3rd space losses
Hypothermia (bare hugger or underwater body blankets)
“Gold-standard” for BPH
Transurethral Resection of Prostate
Transurethral Resection of Prostate uses ____ or ____
Uses electrocautery or laser
EBL for Transurethral Resection of Prostate
Blood loss 2-4ml/min
TURB
transurethral resection of the bladder
Risk factors for TURP (6)
Patients generally 30-50’s so….
Obesity
Hypertension
Hyperparathyroidism
CRI
Paraplegia
safest way to do TURP
SAB - stay away to notice Na+ change
Position for TURP
Lithotomy
intra op concerns for TURP
Possible transfusion
TUR syndrome
Robotic Prostatectomy considerations
Arterial line
Phenylephrine drips
LIMIT IV fluids- because trendelenburg and getting alot with irrigation
Symptoms related to hypervolemic water intoxication
TUR Syndrome
Tur Syndrome happens because Excessive volume expansion through _______
Excessive volume expansion through venous sinuses -> hyponatremia
Na 120 cns and ecg changes
Confusion Restlessness
? Widening of QRS
Na 115 cns and ecg changes
Somnolence
Nausea
Elevated ST segs
Widened QRS
na 110 cns and ecg changes
Seizures Coma
Vtach or Vfib
Glycine irrigants concerns
Metabolized in liver to ammonia (dont give to liver failure pts)
Water irrigation concerns
Intravascular hemolysis
saline irrigants concern
Volume overload
Current dispersion with monopolar cautery
Sorbital irrigant concerns
Metabolized to CO2 and fructose
Volume overload
TURP irrigation rates and absorption rates
Irrigation rates 300ml/min
Absorption 20ml/min-200ml/min
> 2L of absorption usually required for TUR syndrome
How Do You Prevent TUR Syndrome? (3)
Limit resection time to 1 hour
Suspend the irrigating fluid < 30cm above the table
Treat hypotension for SAB with vasopressors NOT IVF
Treatment of TUR Syndrome
ABC’s
Terminate procedure as soon as possible
Consider invasive lines…for cardiovascular instability
Treatment for mild TUR symptoms
Mild symptoms (Na > 120)
Fluid restriction
Loop diuretics
Treatment for severe TUR symptoms
Severe symptoms (Na < 120)
3% IV saline
Nephrectomy occurrences
50,000 nephrectomies/yr
Nephrectomy post op complications (7)
Up to 20% postop complications;
Mortality
Peritonitis
Acute Renal failure
Hernia
Visceral injury
Hemorrhage
Pneumothorax
Nephrectomy Types
Simple- just kidney
radical
donor
Simple nephrectomy indications (3)
Irreversible non-malignant disease (autoimmune diseaseas)
Trauma
Congenital disease (PKD)
radical nephrectomy includes ____ and indications
Radical: includes adrenal glands
Renal cell carcinoma
Complications of renal cell carcinoma
thrombus attached to the kidney and grows up the vena cava
Positioning for nephrectomy
Reverse T burg
trendelenbug
kidney rest
lateral
nephrectomy patients usually have what other comorbidities
CAD
CRI/ESRD
HTN
What gas to avoid in nephrectomy
Avoid nitrous
intra op considerations for nephrectomy
Consider arterial line
Consider central line
Ipsilateral to surgical site
Consider regional anesthesia for postoperative pain
What do we need available for nephrectomy (5)
colloid, blood, rapid transfusion set up, mannitol, furosemide
The kidney gets how much CO
25%
usually kidney to take for transplant and why
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.
what do you anastomose first
vein first then artery
1/3 of all renal nephrectomies are _____
Living Donor Nephrectomies
2/3 = coming from cadaver
DBD / DCD alterations compared to living donor
Healthy
Two kidneys
No diabetes, HIV, liver disease, cancer
Waiting times avoided
Decreases cold ischemic time
Anesthesia for the Living Donor
Starts a couple of hours prior to recipient
Left kidney preferred
lateral position
hydration for living kidney donor
Aggressive isotonic hydration (10-20 ml/kg/hr)
If urine output for donor isn’t enough and we want it to be doing more_____
give Lasix/ fluid or bumex or mannitol
Furosemide, mannitol to maintain 2 ml/kg/hr
Why anticoagulation for living donor?
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.
heparin and Protamine dose
Heparin = 5000 units
Reverse 1:1. 50 mg is 1:1 for 5,000 units of heparin (5,000 units = 50 mg)
DBD neurologic changes
hours to days
Cushing’s sign…HTN, bradycardia, wide pulse pressure
Catastrophic ICP elevation
DBD cardiac chages
Massive release of catecholamines
Acute MI common
Cardiovascular collapse
DBD pulmonary changes
Neurogenic pulmonary edema
SIRS
DBD metabollic changes
Dysfunction of hypothalamus and pituitary systems
Thermoregulation, hormones, insulin, electrolytes, DIC
Anesthesia for Cadaver Donor
Don’t need anesthetic….need stabilization until retrieval
lung protective ventilation
6-8 ml/kg of ideal body weight
5-10cm PEEP
Why to avoid glucose containing solutions for cadaver donors
Avoid glucose containing solutions; metabolized then becomes a hypoteonic solution
steroids for donor; how much and why
Steroids to attenuate immune response (in recipient)- 125 mg = help with immune repsone
Ischemic time for kidney
48-72 hours
During ischemia the kidney_____ (4)
Lack of oxygen
Depletion of ATP/glycogen
Failure of Na/K pump
Increased intracellular sodium…edema
Preop evaluation for the recipient?
Last dialysis
40% have CAD and most HTN
diabetic? BG?
If PCKD, is nephrectomy concurrent
meds to consider for the recipient
may use Anectine if K+ appropriate (raises 0.5meq/L)
Consider cisatracurium
avoid roc/ vec (cleared by kidney)
Steroids, mannitol, lasix, bumex, antithymocyte, albumin
Infusion of rabbit-derived antibodies against human T cells to prevent/treat acute rejection
anti-thymocyte
side effect of anti-thymocyte
Cytokine release syndrome: high grade fevers (over 39oC), chills, and possibly rigors.
treatment for cytokine release syndrome (3)
steroids (normally methylprednisolone)
diphenhydramine 25–50 mg
acetaminophen 650 mg
