Urologic Procedures Flashcards
Endoscopy is performed to visualize and evaluate the upper and lower urinary tracts. To diagnose and treat such conditions as (5)
Hematuria Pyuria Calculi Trauma Cancer
Upper urinary tract
Ureter and Kidney
Lower urinary tract
Bladder, prostate, urethra
What nerve injuries are common when doing urologic procedures?
Common peroneal Saphenous Sciatic Obturator Femoral
What position are urologic procedures usually performed in?
Lithotomy
How does the common peroneal nerve get injured?
compression of fibular head on leg brace
How does the saphenous nerve get injured?
Compression of medial tibial condyle
How does the sciatic nerve get injured?
Excessive external rotation of legs
Excessive extension of the knees
How does the obturator and femoral nerve get injured?
excessive flexion of the groin
What happens to circulating blood when in lithotomy position?
Blood pools in the trunk - when legs put down BP drops even further
What is the 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.
Definition of cystoscopy
passage of a rigid scope through the urethra
Cystoscopy is a minor procedure and may be done with
2% lidocaine
Urethral stimulation, dilation and distention of bladder can be painful requiring general or regional anesthesia. If regional anesthesia is chosen a ______ sensory level is required/ ____ for ureters
T9-T10
T8 ureters
When doing a spinal, where is the sensory and motor levels?
Sensory 2 levels higher
Motor 2 levels lower
What are the cardiac accelerators
T1-T4
Cystoscopy for retrograde ureteral catheterization
To visualize the ureter and kidney
To place stents
To drain obstructions
To remove renal calculi
What is a TURBT
Transurethral resection of the bladder
What is a TURBT used to treat
TURBT endoscopic resection and electrodesiccation are used to treat superficial bladder tumors
What type of anesthesia would you use for a TURBT?
General anesthesia-no coughing or straining can cause bladder perforation
Why shouldn’t you use regional anesthesia for a TURBT?
the bladder becomes atonic and may become thinner when distended, increasing the risk of perforation
If a bladder ruptured and entered the peritoneal cavity, what would you see?
shoulder discomfort, nausea, and vomiting may occur in the awake patient
If there was a high grade malignancy and the bladder ruptured - what could happen?
risk of seeding it into the peritoneum
What are some other risks from a bladder rupture?
Blood loss
Hypothermia (cold fluid into peritoneum)
bacteremia
If there is a bladder perforation on an awake patient, what will that tell you
suprapubic fullness, abdominal spasm and pain
What are the early and late signs of bladder rupture
Htn and tachycardia are early signs followed by severe hypotension
What does the cool irrigation cause?
Cool irrigation causes vasoconstriction-systemic cooling—warm fluids will decrease this risk
How is DIC triggered with bladder rupture?
triggered by release of prostatic thrombogenic substances-especially with cancer of prostate
What is TURP
Transurethral resection of the prostate
How is a TURP performed
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.
What type of solution is required to extend the bladder for a TURP
An optically clear, nonconductive, nonhemolytic, nontoxic solution
What type of anesthetic is used for a TURP
General anesthesia-coughing must be avoided increase the risk of bleeding
Spinal anesthesia is preferred r/t benefits provided
Benefits of a spinal for TURP
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
Awake patients may supply early detection of complications
Complications of TURP
Blood loss
Venous absorption of irrigation fluid-open sinuses provide direct communication to the circulation-depending on pressure time of exposure
Venous absorption: early signs
hypertension and tachycardia
Venous absorption: CVP may rise as
cardiac decomposition occurs
Venous absorption: awake patients make complain of
dyspnea or nausea
Hypoxia and /or hyponatremia causes what??????????
TURP syndrome
What is TURP syndrome
WATER INTOXICATION—OR GLYCINE TOXICITY
Apprehension(spinal), disorientation (spinal), convulsions, and coma (spinal)
What are the 3 types of irrigation solutions?
Glycine (1.5%)
Sorbitol (3.3%)
Mannitol (5%)
Disadvantage of glycine
can cause transient post-op visual impairment (blindness)
less likelihood of TURP syndrome
Disadvantage of sorbitol
can cause Hyperglycemia and lactic acidosis
Disadvantage of mannitol
nonmetabolized, osmotic diuresis causing hypervolemia
What to do for TURP syndrome
Ask surgeon to control bleeding and finish surgery
Send blood sample-if decrease in serum SODIUM less than 120 mEq/l- serious
Hypervolemia and hyponatremia correct with fluid restrictions and diuretics ( furosemide 10-20 mg)
Hyponatremia give hypertonic solutions correct cautiously
Normal saline or ringer’s lactate—postpone if sodium <=125 mEq/l
Why are Open prostate- radical prostatectomy emotional?
50% chance of impotence
2 positions for open prostate - radical prostatectomy
Suprapubic (retropubic) approach, supine, flex table, and trendlenburg - (MORE HEMORRHAGE)
Perineal approach, extreme lithotomy position
When does the blood loss occur?
during control of dorsal venous complex
T/F: Large IV is a must
TRUE!!!
Diagnostic dyes used to identify ureters
What happens with each dye?
Methylene blue 1%
Indigo carmine dye 0.8%
Methylene blue 1% - CAN CAUSE HYPOTENSION
Indigo carmine dye 0.8% has an alpha sympathomimetic effect increase BP
What happens to SaO2 with the dye
SaO2 down to 85%
Sao2 down to 65% for 1-2 minutes
Methylene blue greater effect than indigo
Indications for a nephrectomy
Chronic infection
Trauma
Cystic or calculus disease
Neoplasm
What position and table do you use for a nephrectomy?
Performed by lateral retroperitoneal or anterior abdominal incision
Lateral-flex table and use KIDNEY BAR
May cause vena cava compression and hypotension
General or combined general regional
What type of anesthetic is contraindicated in renal transplant and why?
Regional contraindicated by preexisting coagulopathy and or immunosuppression
What fluids do you use for a renal transplant?
normal saline— avoid LR and K+
Adequate hydration is critical use crystalloid, colloid and blood for revascularization of the kidney
What does Methyl prednisone and diuretics do for transplant patients?
to help discourage rejection and diuresis
If still oliguric, what could you give?
Low dose dopamine
Complications of renal transplant
Hyperkalemia
Delayed renal function
Graft failure
Indications for a 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 & ileostomy
Anesthetic considerations for radical cystectomy
Done in supine position
General or combined anesthesia
Arterial and CVP
Large IV (duh)
Fluid shifting can be extensive-unable to monitor urine –need for CVP
Diuretics may be needed to stimulate output
Indigo carmine & Methylene Blue used at times
Complications of radical cystectomy
Hypothermia
Inadequate fluid replacement
Need for post op ventilation
Highlights for orchidopexy, orchiectomy and urogenital plastic procedures
Performed to treat congenital malformation Neoplasm Impotence Torsion of testicle Supine or lithotomy General or regional T9 sensory needed
usually a child and making them sterile
Highlights for A/V fistulas
Access for dialysis Patient lies supine with arm extended General, regional and local infiltration all acceptable Co-existing medical problems Anemia CAD Diabetes
Why is BP very labile with pts getting AV fistulas?
because they are chronic HTN - clamped down so with anesthetic = hypotension
For ESWL - when is the shock delivered?
on the QRS
worried about R on T
“5,000 hits”
If you see radical, what should you think?
large bore IV
