Genitourinary Procedures (Exam IV) Flashcards
What are the indications for genitourinary surgery?
- Biopsies
- Evaluation of bleeding
- Retrograde Pyelography
- Stone retrieval/lasering
- Strictures
- Mass resection
What are the disadvantages/complications of the lithotomy position?
- Peroneal/femoral nerve injury
- Skin break down (stirrups)
- Hip dislocation & back strain
- Vessel compression (DVT, pooling, compartment syndrome)
What is the best measure of glomerular function?
GFR
What is normal GFR?
125mL/min
A patient will be asymptomatic until a ___% drop in GFR occurs.
50%
What s/s would be noted with moderate renal insufficiency?
- ↑ BUN/Ct
- Anemia
- Fatigue
What s/s would be noted with severe renal insufficiency?
- Uremia
- Acidemia
- Hypervolemia
What are normal values for BUN?
~ 8 - 18 mg/dL
What normal factors can influence and distort BUN levels?
- Exercise
- Dehydration
- Steroids
BUN won’t be elevated in kidney disease until GFR is ___% of normal.
75%
Creatinine is higher in which sex?
males
What are normal creatinine levels?
0.8 - 1.2 mg/dL
What occurs with ammonia during kidney disease?
Decreased production of ammonia.
What occurs to kidney patients anion gaps?
Anion gap increases as disease progresses
What hematologic factors can be normal in renal patients?
Normochromic
Normocytic
Normal RBC size and color.
What hematologic pathologies are typically present in renal patients?
- Iron deficiency anemia
- Abnormal Plt aggregation
- Abnormal prothrombin consumption
Are ionized or non-ionized drugs primarily a concern with renal disease patients? Why?
Ionized
Non-ionized drugs are typically lipid-soluble and aren’t terminated via renal excretion.
What drugs/drug classes are of concern with renal patients?
- Muscle relaxants
- Cholinesterase inhibitors
- Thiazide diuretics
- Digoxin
- Antibiotics (lots, not all)
- Opioid metabolites
Rigid scopes are best used for ureteroscopies. T/F?
False. Rigid scopes are inappropriate when moving past urethroscopies and cystoscopies.
Which sex is more inclined to develop kidney stones?
10% men vs 5% women
Typical stones are primarily composed of what element?
Calcium
Also radiopaque.
What are the typical complications of ureteroscopy?
- Perforation 5%
- Stricture formation <2%
What is the typical recurrence rate for kidney stones?
50%
ouch
What is firstline therapy for kidney stones?
MET (Medical expulsive therapy)
- NSAIDs
- Aggressive hydration
- CCBs & α-blockers
What are the three options for kidney stone removal? (List in order of least invasive to most invasive)
- Stone Basket vs Laser
- Shock Wave Lithotripsy
- Percutaneous Nephrolithotomy
What types of stones is shock wave lithotripsy best suited for?
Small/medium intranephric stones
Risk of what two conditions can occur with shock wave lithotripsy?
- Kidney injury
- Sub-capsular hematoma
What are the characteristics of old-school SWL?
- Water baths
- Hypothermia
- Pain
What are the characteristics of new SWL?
- No baths (water-filled coupler device)
- More focused beam
- Lower pulse pressure
- Less pain
What are absolute contraindications to SWL?
- Bleeding disorder/ anticoagulation
- Pregnancy
What are relative contraindications to SWL?
- Large calcified aortic/renal aneurysms
- UTI
- Obstruction distal to the renal calculi
- Pacemaker, ICD, neurostimulator
- Morbid obesity
What allergy needs to be considered preoperatively for SWL?
Iodine allergy
What surgery is useful for large intranephric stones?
Percutaneous Nephrolithotomy
Uncommon now due to SWL
Percutaneous Nephrolithotomy requires the initial placement of what?
Ureteral stents to prevent obstruction as fragments pass by.
Which calculi surgery uses the most fluoroscopy?
Percutaneous Nephrolithotomy
In what calculi surgery is TUR syndrome most probable?
Percutaneous Nephrolithotomy
What position are patients placed in for Percutaneous Nephrolithotomy?
Lateral
When is orchiectomy typically indicated?
Metastatic prostate cancer
Orchiectomies are typically ______.
Bilateral
What is a hydrocelectomy?
Wall of hydrocele excised and edges are sutured close
Testicular torsion repair must occur within ____ hours to prevent irreversible ischemic damage.
6 hours
What are typical indications for circumcision is older men?
- Phimosis
- Penile/prostate cancer
What conditions can result in the need for a penile prosthesis?
- DM
- Spinal cord injury
What penile operations were discussed in lecture?
- Circumcision
- Hypospadius repair
- Penectomy (for SCC)
- Penile prosthesis
What block is used for penile procedures?
Pudendal block (S2-S4)
Manipulation of genitals during penile procedures may result in…
Bradycardia (from vagal response)
What are simple cystectomies done for?
Simple non-metastatic conditions
- Hemorrhagic cystitis
- Radiation cystitis
When are radical cystectomies indicated?
Malignant conditions (involves ureters prostate/uterus, ovaries)
- Invasive bladder cancer
What is required with a cystectomy?
- Ileal conduit (urostomy)
- Bladder substitution
Is bowel prep necessary for cystectomies?
yes
What anesthetic options does the CRNA have for a cystectomy?
- GETA, SAB, Epidural
What are common complications of cystectomies?
- Bleeding (3L!)
- 3rd space losses
- Hypothermia
What should the CRNA have preoperatively to combat bleeding in cystectomy’s?
- 1-2 IV’s
- Type and crossmatched blood ready
What is the “gold-standard” surgical treatment for BPH?
TURP (Transurethral Prostatectomy)
What is the expected blood loss for a TURP?
2-4 mL/min
What comorbidities are common with TURP patients?
- Obesity
- HTN
- Hyperparathyroidism
- CRI (Chronic Renal Insufficiency)
- Paraplegia
What type of IV access is necessary for TURPs?
Large Bore
Why might a SAB be preferable to general anesthesia for a TURP?
SAB will allow for neuro monitoring and evaluation of possible TURP syndrome.
What atypical monitoring is necessary for a robotic prostatectomy?
Arterial line
Severe Trendelenburg necessitates minimal fluid use and increase pressor utilization.
What causes TUR syndrome?
Hypervolemic water intoxication (Hyponatremia)
Volume absorbed through venous sinuses into blood stream.
What s/s would be present for a serum Na⁺ of 120 mEq/L?
- Confusion & restlessness
- QRS widening
What s/s would be present for a serum Na⁺ of 115 mEq/L?
- Somnolence & Nausea
- ↑ ST & widened QRS
What s/s would be present for a serum Na⁺ of 110 mEq/L?
- Seizures & Coma
- Vtach & Vfib
What irrigants can be used for TURP procedures?
- Saline
- Glycine
- Water
- Sorbitol
What are the disadvantages to saline irrigation?
- Volume overload
- Monopolar cautery current dispersion
What are the disadvantages to glycine irrigation?
Bad for liver patients due to ammonia accumulation
What are the disadvantages to water irrigation?
Intravascular Hemolysis
What are the disadvantages to sorbitol irrigation?
- Metabolized to CO₂ and fructose
- Volume overload
What is the irrigation rate of TURPs?
300 mL/min
What is the fluid absorption rate in TURPs?
20 - 200 mL/min
How much fluid absorption usually has to occur for TURP syndrome to develop?
> 2L
How is TURP syndrome avoided?
- Treat hypotension w/ vasopressors, not fluid
- Limit resection time to 1 hours
- Suspend irrigation fluid < 30cm above the table
How is TURP syndrome treated?
- ABCs
- Terminate procedure
- Na⁺ > 120 → diuretics
- Na⁺ < 120 → 3% saline
What type of conditions would necessitate simple nephrectomy?
- Autoimmune disease
- Trauma
- Polycystic Kidney disease
What type of condition would necessitate a radical nephrectomy?
Renal Cell Carcinoma
Adrenal glands excised as well.
What gas should be avoided with nephrectomy’s?
N₂O
Too close to the bowel.
Where should the CVL be placed for a nephrectomy?
Ipsilateral to surgical site
What should be considered for post-operative pain for a nephrectomy?
Regional anesthesia
Which kidney is preferred as a donor organ?
Left Kidney
Longer ureter and vascular supply.
What vessel should be anastamosed in first, a vein or an artery?
Vein to facilitate organ venous drainage
Which type of nephrectomy donor is “easier”? Why?
Living Donor Nephrectomy (⅓ of cases)
- healthy
- two kidneys
- No DM, HIV, cancer, etc.
- No wait times
- ↓ cold ischemic time
What type of IV fluid protocol is used for living donor nephrectomies?
Aggressive Isotonic hydration (10 - 20 mL/kg/hr)
What is used for diuresis in the living kidney donor?
- Furosemide
- Mannitol
Maintain 2mL/kg/hr.
What IV fluids should be avoided in cadaver donors?
Glucose containing solutions
What ventilator settings protect a donors lung function until kidney retrieval is performed?
- 6-8 mL/kg of IBW
- 5-10 cm PEEP
How long can kidneys be ishemic (on ice)?
48 - 72 hours
What physiologic goals do we have for a kidney donor?
What occurs physiologically during ischemic time for the kidney?
- ↓ O₂
- ↓ ATP/glycogen
- Na⁺K⁺ATPase pump failure
- ↑ Na⁺ ICF = Edema
What is Anti-Thymocyte?
Infusion of rabbit-derived antibodies against human T-cells to prevent rejection.
What can be developed as a side effect from anti-thymocyte administration?
Cytokine Release Syndrome
How is cytokine release syndrome treated?
- Steroids
- Diphenhydramine
- Acetaminophen
What is the treatment of choice for mid-distal ureter stones?
Ureteroscopy
