Urologic Procedures Flashcards
What are some of the concerns for laparascopic renal surgery?
Potential for extravasation of insufflated carbon dioxide to
retroperitoneal space and thorax
• Potential for postoperative airway compromise secondary to
subcutaneous emphysema and pharyngeal obstruction
• Increased incidence of acidosis due to absorption of carbon
dioxide
• Higher incidence of intraoperative oliguria potentially due to
perirenal pressure from pneumoperitoneum
• Potentially longer duration than open procedure
Know the dermatomes.
Nipple: T4
Lower end of scapula: T7
Belly: T10
What is the consideration for CYSTOSCOPY
for passage of a rigid scope through the urethra ?
Minor procedure may be done with 2% lidocaine jelly
Urethral stimulation, dilation and distention of bladder can be painful requiring general or regional anesthesia
If regional anesthesia is chosen a T9-T10 sensory level is required/ T8 for ureters
What type of scope is used in percutaneous nephrolithotomy?
Stones are removed via a rigid operating scope inserted in the
lower calyx of the kidney under fluoroscopy. Once located, calculi
are pulverized by using laser, electrohydraulic, or ultrasound probes placed directly on the stones.
What are some of the complication of TURP?
Fluid overload
Water intoxication or Hypo-osmolality
Hyponatremia
Hemolysis
Coagulopathy/bleeding
bladder performation
infection
What are some complications of lithotripsy?
hemorrhagic lesions on the kidneys,secondary to vascular damage.
Perforation of the abdominal organs or vasculature.
What is the potential complication of the surgical position in nephrectomy?
Lateral-flex table and use kidney bar:
◦May cause vena cava compression and hypotension
What are the different surgical methods for prostatectomy?
A retropubic prostatectomy describes a procedure that accesses the prostate by going through the lower abdomen and behind the pubic bone.
A suprapubic prostatectomy describes a procedure cuts through the lower abdomen and through the bladder to access the prostate.
A perineal prostatectomy is done by making an incision between the rectum and scrotum on the underside of the abdomen.
What are some indications for cystoscopy for retrograde ureteral catheterization?
To visualize the ureter and kidney
To place stents
To drain obstructions
To remove renal calculi
What does TURP stand for?
transuretheral resection of the prostate
What is the management of bladder perforation?
• Stop surgery and achieve hemostasis.
• Treat hypotension with IV crystalloids, vasopressors, and
inotropes.
• Obtain a hematocrit. Start blood transfusion.
• Perform a cystourethrogram to locate the perforation.
• For most perforations, suprapubic cystotomy, an indwelling
Foley catheter, and (occasionally) ureteral stents are sufficient.
In some instances, immediate exploratory laparotomy may be
necessary to control bleeding and repair the perforation.
What are the side effects of indigo carmine?
hypertension (d/t alpha receptor stimulating effect) and bradycardia
decreased oxygen saturation
Kidney transplant recipients may require surgery for nontransplant-related procedures. What are some of the surgical management goals?
Management involves maintenance of
adequate volume status, avoiding nephrotoxic medicines such as
nonsteroidal antiinflammatory drugs (NSAIDs) or contrast dyes,
and proper dosing of immunosuppressive drugs.
What is TURP syndrome?
It is a procedure-induced combination
of water intoxication, fluid overload, and hyponatremia
What are the S/S of bladder perforation during TURP?
shoulder discomfort, nausea, and vomiting
Blood loss, Hypothermia, bacteremia
suprapubic fullness, abdominal spasm and pain
hypertension, tachycardia, then hypotension
DIC
What are the surgical positions for prostatectomy?
Suprapubic and retropubic approach: supine, flex table and trendelenburg
Perineal approach: extreme lithotomy position
Which prostatectomy approach has the greatest risk of hemorrhage?
Retropubic approach
Blood loss occurs during control of dorsal venous complex.
Define cold ischemia time.
Cold ischemia is the clamping of blood vessels with kidney cooling.
Ends: Perfusion of harvested organ with cold preservation solution; storage at 4°C
or
Perfusion by recipient
What is the preop goal of the renal transplant recipient?
K+ < 5.5 mEq/L
Coag studies and acid-base status normal
Serum creatinine < 10 mg/dL
BUN < 60 mg/dL
Define warm ischemia time.
Warm ischemia is the clamping of blood vessels without cooling the kidney in renal transplant.
Begins: Clamping of donor vessels or initial placement in
recipient
Ends: Vascular anastomosis in recipient or interrupted with
perfusion of cold preservation solution
What are the clinical manifestations of TURP syndrome?
Fluid overload: Hypertension, bradycardia, arrhythmia,
angina, pulmonary edema and hypoxemia
Water intoxication: Confusion and restlessness; twitching or
seizures, lethargy or coma, dilated,
sluggish pupils, papilledema, low-voltage
EEG, hemolysis
Hyponatremia: CNS changes as above, reduced inotropy,
widened QRS complex, low-voltage ECG,
T-wave inversion on ECG
What are some of the indications for urologic procedures?
Performed to visualize and evaluate the upper and lower urinary tracts. To diagnose and treat such conditions as:
◦Hematuria
◦Pyuria
◦Calculi
◦Trauma
◦Cancer
What type of fluid should be given during transplantation?
0.9% NaCl
Avoid LR or any other K+ containing solution
What preparations must be taken by the recipient in the renal transplantation?
Must not be acutely ill.
Acute alterations in fluid and electrolyte balance should be corrected with dialysis carried out 24hours before transplantation. Postdialysis laboratory values should be checked.
What muscle relaxant should be used during renal transplantation?
Cisatracurium, owing to its Hoffman Elimination.
Succinylcholine can be used if K+ level is normal.
What type of anesthesia is preferred in renal transplantation?
General anesthesia. Regional can cause hypotension associated with sympathetic blockade, the length of the procedure, and heparinization of the kidney.
Due to the prolonged surgery, large amounts of sedation may be needed to supplement regional techniques
If TURP syndrome is detected intraoperatively, what should be the next course of action?
Control bleeding.
Comeplete surgery.
Diuretic.
Hypertonic solution.
What are the complications associated with ESWL?
- Hypothermia, hyperthermia
- Cardiac arrhythmias
- Skin bruising hematomas
- Petechiae, soft tissue
- Renal hematoma
- Lung injury
- Flank pain
- Hypertension, hypotension
- Nausea, vomiting
What are the indications for orchiopexy, orchiectomy and urogenital plastic procedures
Performed to treat congenital malformation
Neoplasm
Impotence
Torsion of testicle
Supine or lithotomy
General or regional
T9 sensory needed
What is the borderline sodium level for the development of severe reactions in hyponatremia?
120 mEq/L
What sensory level should be blocked in spinal anesthesia for TURP?
T10 sensory level
What is the consideration in providing steroids to impede organ rejection?
Infection from immunosuppression
What is the indication for percutaneous nephrolithotomy?
When lithotripsy fails to resolve the stone or to remove kidney stones 20 mm or greater
What are the indications for radical cystectomy?
Patient with invasive bladder tumors
Pelvic malignancies
Neurogenic bladder
Chronic lower urinary tract obstruction
Post radiation bladder dysfunction
Creation of a uretero-ileal anastomosis and ileostomy
What is the indication for extracorporeal shock-wave
lithotripsy (ESWL)?
ESWL is used for stones less than 10 to 20
mm in the proximal or midureter.
Why does TURP syndrome occur?
Venous absorption of irrigation fluid
Open sinuses provide direct communication to the circulation. The amount of solution absorbed into the systemic circulation depending on the amount of pressure and time of exposure
What is the surgical position for nephrectomy and how is the incision made?
Lateral-flex table and use kidney bar
Performed by lateral retroperitoneal or anterior abdominal incision
Why is spinal anesthesia preferred in TURP?
Early signs and symptoms of TURP syndrome, hypervolemia, and bladder perforation are more easily detected in a responsive patient.
The bladder will be atonic with a large capacity, thus glycine infusion pressure can be low, emptying less frequent, facilitating resection
Postoperative bladder spasm is prevented allowing for hemostasis
Briefly describe how the kidney is attached to the recipient in renal transplant.
The donor kidney is placed extraperitoneally in the recipient’s iliac fossa. The renal artery is anastomosed to the internal iliac artery, the renal vein to either the external or the common iliac vein, and the ureter to the bladder.
What is extracorporeal shock-wavelithotripsy (ESWL) and how is it delivered?
ESWL breaks upper urinary tract stones with external shock waves-cushion interface with skin or patient submersed in a tank of water.
The shock is delivered in synchronous with R wave on the ECG to prevent dysrhythmia.
Atropine or glycopyrrolate may be given to increase the heart rate and thus the shock-wave rate.
Adequate hydration and diuretics to help pass stone fragments.
How is the donor’s kidney stored?
In a cold storage solution at 4 Celcius
Continuous perfusion of the kidney causing a pulsatile flow of cold preservation pumped at 40-60 mm Hg
Solution is glucose, potassium, magnesium, antibiotics, sodium bicarb, and heparin (can trigger hypersensitivy reaction in recipient)
What drug is preferred to facilitate urinary output in renal transplantation?
Mannitol
What is a complication of renal transplant and its signs/symptoms?
Graft rejection.
Oliguria, hyperkalemia, hypernatremia, hyperphosphatemia, fever.
List the disadvantages of each irrigation solution in TURP.
Glycine: retinal toxic effect, encephalopathy (from ammonia conversion)
Mannitol: pulmonary edema, hyponatremia d/t hypervolemia
Sorbitol: hyperglycemia, lactic acidosis, hypokalemia
What are some indications for nephrectomy?
◦Chronic infection
◦Trauma
◦Cystic or calculus disease
◦Neoplasm
Is transfusion warranted if the transplant recipient is anemic?
In chronically anemic patients, blood transfusion is not needed if oxygen delivery is adequate.
If blood transfusion is required, it should be done with dialysis to avoid volume overload.
What is the concern for hyponatremia?
Central pontine mylenolysis, also referred to as osmotic demyelination syndrome (ODS).
Symptoms usually occur ~1 week after the osmotic stress and may include seizures, palsy, dysarthria, paralysis, mental changes, and coma.
What is the anesthetic goal in the management of the donor in renal transplant?
Adequate amounts of balanced salt solution and colloid bolus to ensure brisk diuresis
Maintenance of a Pao2 over 100 mmHg; normocapnia; hematocrit
30% or greater; and systolic blood pressure 100 mmHg or greater
When is regional block contraindicated in renal transplant.
When there is preexisting coagulopathy and or immunosuppression
What type of anesthesia does percutaneous nephrolithotomy require?
General anesthesia and post op hospitalization
What are some contraindications to lithotripsy?
active urinarytract infection
uncorrected bleeding disorder or coagulopathy
distal obstruction
pregnancy.
What is the indication for ureterorenoscopy (URS).
To remove stones in the distal ureters, of all sizes.
Why is the use of 0.9% NaCl or LR discouraged in TURP?
Normal saline or Lactated Ringer’s solution is highly ionized and promotes dispersion of high current from the resectoscope.
What is the consideration for a patient with pacemaker undergoing TURP?
The device must be converted to a fixed rate
What opioids can be used during renal transplantation?
Fentanyl, sufentanil, alfentanil
(Not remifentanil)
What is the treatment plan for hyponatremia in TURP?
Hypertonic saline (3% to 5% sodium chloride) at a rate no greater than 100 mL/hr.
Sodium correction should not exceed 0.5 mEq/L per hour or 8 mEq/day.
Severe symptoms may require initial doses of 1-2 mEq/L per hour.
Target level for correction is 120 mEq/L.
What are some preoperative preparations for lithotripsy?
Discontinuation of aspirin-containing medications, anticoagulants, platelet inhibitors, and nonsteroidal antiinflammatory agents for 7 to 10 days before the procedure
What is the position for cystoscopy and what are some potential nerve damages?
lithotomy position
◦Common peroneal: Compression of fibular head on leg brace
◦Saphenous: Compression of medial tibial condyle
◦Sciatic: Excessive external rotation of legs or excessive extension of the knees
◦Obturator and femoral: Excessive flexion of the groin
What are some complications of cystectomy?
Hypothermia
Inadequate fluid replacement
peritonitis
Need for post op ventilation
What are the two most common causes of ESRD?
Diabetes and HTN
What is an obturator reflex?
Bladder rupture/injury secondary to adductor muscle contraction from obturator nerve stimulation from electrocautery. This risk is increased when resecting lateral wall tumors, as electrosurgical resection of these lesions is more likely to inadvertently stimulate the obturator nerve.
Describe Transurethral resection of the bladder (TURBT) and its anesthesia management.
TURBT endoscopic resection and electrodesiccation are used to treat superficial bladder tumors
General anesthesia-no coughing or straining can cause bladder perforation
Regional anesthesia-the bladder becomes atonic and may become thinner when distended, increasing the risk of perforation
What are the irrigating solutions for TURP?
Per powerpoint slide:
Glycine (1.5%), Sorbitol (3.3%), Mannitol (5%)
Per Nagelhout:
Cytal (sorbitol 2.7% and mannitol 0.54%), glycine 1.2% or 1.5%, or physiologic saline.
What are some of the side effects/complications of methylene blue dye?
hypertension, headache, confusion, N/V, discoloration of urine, anemia, serotonin syndrome, hypoxia
What three interrelated variables affect surgical
outcomes of renal transplant?
management of the donor
preservation of the harvested organ
perioperative care of the transplant recipient
What is the surgical position in renal transplant?
Supine with a roll under the hip
What diagnostic dyes are used to identify ureters?
Methylene blue
Indigo carmine
What is the consideration in cystectomy?
Fluid shifting can be extensive-unable to monitor urine
Need for CVP and arterial line monitoring
Diuretics may be needed to stimulate output
Indigo carmine and Methylene Blue used at times
Name two ways to protect the AV fistula in renal transplantation?
Do not insert an IV on the same side.
No blood pressure cuff on the same side.
What is the surgical position in percutaneous nephrolithotomy?
prone or supine
What are the preventive measures for TURP syndrome?
* avoid the Trendelenburg position as it promotes fluid absorption
*limit resection time to less than 1 hour
* keep the prostate capsule intact until the end of the resection
* place irrigating fluids less than 60 cm above the prostate gland
* measure electrolytes during and after the procedureas indicated;
* use a regional technique with light sedation so mental changes can be identified
What are the early signs of venous absorption of the irrigation fluid during TURP?
hypertension and tachycardia
CVP may rise as cardiac decompensation occurs
Awake patient may complain of dyspnea or nausea
Cardiac complications from hyponatremia begin to manifest at what sodium level?
115 mEq/L
What is the indication of TURP and how does it work?
Neoplastic or obstructive prostate tissue is removed by electrosurgical resection under direct endoscopic vision
This is performed by application of a high-frequency current to a wire loop. Hemostasis is achieved by sealing the vessels with the coagulation current.
An optically clear, nonconductive, nonhemolytic, nontoxic solution is required to distend the bladder
How long can the donor’s kidney be preserved?
With renal perfusion 72hours
Cold storage 48 hours before necrosis jeopardizes graft survival
