Renal and Urologic Surgery Flashcards
Indications for a cystoscopy
Hematuria Recurrent UTIs Urinary obstruction Bladder biopsies Extraction of kidney stones
Spinal levels that must be blocked if regional is planned for cystoscopy
T8-10
Plans for regional/local anesthesia for cystoscopy
Spinal
- If > 1hr, give 10-12 mL of 0.75% bupiv
- If
Possible nerve injuries with the lithotomy position
Common peroneal
Saphenous
Obturator and femoral
Sciatic
Intra-op considerations for cysto
1) Implications of lithotomy position
- Nerve damage
- Increased venous return (does pt have CHF?)
2) Bladder perforation
- May go unnoticed under GA
- Consider diagnosis if unexplained HTN or hypoTN and tachycardia
- Shoulder pain in PACU
3) Fever or bacteremia may be present (pt may not need warming blanket)
4) Bleeding (coagulopathies present with renal disease)
TURP involves the excision of these lobes of the prostate to alleviate outlet obstruction by an enlarging prostate
Lateral and medial lobes
Continuous irrigation is needed during TURP to
- Distend the bladder
- Wash away blood and tissue
- Maintain visibility
Absorption of irrigation during TURP can result in
TURP Syndrome Increased blood volume CHF Bradycardia Pulmonary edema Hyponatremia Cardiac and retinal toxic effects Hyperglycemia (if sorbitol or glucose solutions are used) Hypothermia Depressed mentation or coma if glycine containing solutions are used
Non-electrolyte irrigating solutions is used for this procedure so that electrocautery is not conducted. This can result in a lot of problems if over-absorbed into the prostatic venus plexus.
The height of the irritant solution should not be more than __cm above the surgical table during TURP
60cm
However, Brash states that the limit should be 30cm, and a max of 15cm during the final stages of the surgery.
The amount of irrigation fluid absorbed is proportional to
Surgical time. About 20mL/min of resection time is expected, but may be as high as 200mL/min.
Absorption also depends on the number and size of open venous sinuses. Larger blood loss implies greater potential for irrigation absorption. Also low venous pressure at the interface can increase absorption.
Resection time should be limited to 1 hour to minimize
Common antibiotic in cysto
Gentamycin
Expected EBL in TURP
About 500cc, or 2-4cc/min of resection time.
Block level needed for TURP
T10
Benefits of regional for TURP
Allows for recognition of bladder perforation and TURP syndrome
Decreased risk of post-op DVT
Decreased blood loss
Acute hyponatremia from TURP syndrome may delay emergence if GA is used.
Clinical presentation of TURP syndrome in an awake patient
HA Restlessness/irritatibility Confusion or apprehension Cyanosis Dyspnea (2/2 pulm edema) Hyponatremia
Levels of hyponatremia and their clinical effects
Na
Treatment of TURP syndrome
Early recognition is key!!
- Alert the surgeon to the change in pt condition so they can finish as quickly as possible
- Fluid restriction (especially anything that is hypotonic!)
- Loop diuretics
- Hypertonic saline (3% NS with max rate of 100mL/hr)
- CV support (be prepared to treat CHF, bradycardia, etc)
Difference in M&M for TURP between GA and spinal
No difference in M&M
Higher mortality does exist if:
- Procedure > 90min
- Gland is > 45g
- There is acute urinary retention
- Pt is > 85 years old
Overview of ESWL
- Tissue has the same acoustic density as water, so the waves are able to travel through the body tissues without causing damage
- Acoustic impedance occurs when the wave hits the stone, causing shearing and tearing forces
- Stone fragments travel down the ureter, and to ease their passage, a ureteral stent is placed
- Tissue destruction may occur to lung and bowel if they get in the way
ESWL and the heart
- The shock waves are delivered during the ventricular refractory period
- Bradycardia thus may prolong the procedure
- Patients with pacemakers and AICD are at risk for developing arrhythmias
Contraindications to ESLW
Absolute contraindications
- Pregnancy (might destroy the fetus or fuck up it’s heart!)
- Untreated bleeding disorders
Relative contraindications
- AICD / pacemaker
- Large calcified aortic or renal artery aneurysms - could result in massive calcified emboli
- Morbid obesity (would need energy levels too high to reach it safely)
Anesthetic considerations for ESWL
- Give adequate IV hydration for passage of the stone fragments
- Pt’s may be in a large amount of pain 2/2 the kidney stone
- Immobiliztion is very important. Need either very compliant patient or GA.
- Regional requires T6 level
- Surgeon may ask for decreased RR or TV. Heavy GA not needed. Can go lighter on the gas.
Regional anesthesia for ESWL
- Continuous epidural is most common for this technique
- Need T6 block
- Major disadvantage to this technique is the inability to control ventilations, which can cause the stone to move in and out of the range
MAC for ESWL
Used for low energy lithotripsy.
Use fentanyl, versed, and propofol gtt
Anesthesia considerations for laser lithotripsy
- Used to break up ureteral stones
- A beam is carried over a bare wire passed through a rigid ureteroscope
- There is risk of ureteral perforation
- GA is advised to prevent patient movement
- If regional is used, need T8-T10 block
- May see hematuria post-op
- Make sure to hydrate the patient well
- Staff needs to use protective eye-wear
ESWL is used for treatment of stones located where?
In the kidneys or upper two thirds of the ureters
Blockage of urine flow can result in
ARF. Clots, stones, bladder obstruction, or urethral obstruction can block urine flow and cause ARF. Can be reversed if cause is found within a few hours.
Pt may require a percutaneous nephrostomy.
Generalities of prostate CA
Most common CA in men
2nd most common cause of CA death in men for those > 55
75% incidence in those over 75
Anesthesia implications for radical prostatectomy
- Often required for elderly men, so think about those considerations
- May be associated with significant blood loss
- Need good IV access and invasive monitoring
- Consider normovolemia hemodilution or autologous blood donation
- Pt will be in a hyper-extended position (risk of soft tissue, joint, and nerve injuries)
- Risk of VAE
- Positioning may be either hyper-extended supine for abdominal approach or lithotomy for perineal approach.
- Surgeon may ask you to give indigo carmine for visualization of the ureters
- Blood loss is equal with both GA and RA. GA is more common d/t uncomfortable positioning
- Anticipate large blood loss!!! Think about all the venous plexuses, etc.
Surgical details of radical prostatectomy
- Curative for prostate CA for those who failed to respond to XRT
- Involves removal of the prostate, seminal vesicles, ejaculatory ducts, and part of the bladder neck
Positioning for radical prostatectomy
1) Hyperextended supine
- Supine with iliac breast over the break in the OR table
- Table is then tilted to make the operative field supine
2) Thoracoabdominal incision position
- Placed in hyperextended position
- Knee on the non-operative side is flexed 90 degrees
- Shoulder on the operative side is then brought over the chest on an armrest
Regional for radical prostatectomy
- T8 level needed
- Spinal, give 7.5% bupivacaine or hyperbaric tetracaine
- Epidural, give 15-25mL of 1.5-2% lido with epi
- Avoid opioids in the mixture because it can lead to urinary retention
- Deep sedation may be required on top of the block d/t uncomfortable positioning
Characteristics of renal cell CA
- Most common malignancy of the kidney
- Surgery is necessary because it does not respond to chemo or radiation
- Characterized by flank pain, hematuria, and a palpable mass in 10% of patients
Pre-op concerns for radical nephrectomy for renal cell CA
- Focus on determining the degree of renal impairment
- Realize that the majority of pts will be anemic, and may even require blood transfusion pre-op
- Will need large bore IV access, a-line, and central line (preferable on the left side if the IVC is involved)
Positioning for radical nephrectomy
Flank or prone
Fluid requirements for radical nephrectomy
4-6mL/kg/hr of crystalloid
For 70 kg, that is 280-420mL/hr
Radical nephrectomy involves the removal of
Kidney, adrenal gland, and the perinephric fat
Expected blood loss for radical nephrectomy
LARGE, because these tumors are large and very vascular. Doesn’t help that the pt is anemic. This is why transfusion is considered pre-op.
Retraction of the IVC during radical nephrectomy can result in
Hypotension
Anesthesia for pelvic lymph node dissection
- May be done for staging of prostate CA
- Commonly done with Davinci robotics
- Pt will be in steep trendelenberg (can make ventilation difficult)
- Potential for hypothermia from copious fluids used to irrigate clots
- Avoid N2O, which could cause bowel distention and make surgical visualization difficult
Radical cystectomy for bladder CA involves the removal of
For men:
- Bladder
- Lower ureters
- Prostate
- Seminal vesicles
For women:
- Bladder
- Uterus
- Ovaries
- Anterior vaginal wall
Large incision from xiphoid process to pubis
Anesthesia considerations for radical cystectomy
- Surgery is 4-6 hours
- Expect large blood loss
- Will probably transfuse
- GA with relaxant is best
- May need controlled hypotension (get an a-line)
- Combined GA and RA may be good for post-op pain control
- Have CVP if cardiac patient
- Can’t really get accurate UO for case because urine will be spilling into surgical field
Problem with RA for radical cystectomy
Can produce hyper-peristalsis, which can make creation of urinary diversion (ileal conduit) difficult
Radical orchiectomy for testicular CA
Typically young and have undergone chemo. May have had bleomycin, so consider risk of pulmonary fibrosis, and don’t give high O2 concentrations. Typically give GA.
