Urologic surgeries part 2 Flashcards
What are the common urologic procedures.
cystoscopy
extra-corporeal shock wave lithotripsy (ESWL)
transurethral resection of the prostate (TURP)
laparoscopic/robotic urologic procedure
open nephrectomy
renal transplant
Cystoscopy is when the
urologist uses a cystoscope to examine urethra & bladder
The anesthetic considerations for cystoscopy include
-local/MAC
-spinal anesthesia- offers relaxation with real-time patient assessment
general anesthesia- LMA vs. ETT
lithotomy
procedures can be very quick or last hours
ESWL is a
non-invasive treatment that uses high energy ultrasound waves to break up the calculi
______ is common in ESWL
hematuria
Describe the management of nephrolithiasis
affects 9% of the population
- if calculi <5 mm in diameter, expected to pass without intervention
- 5-10mm –> medical management
- > 10 mm–> unlikely to pass spontaneously
For ESWL, it is typically performed
outpatient under general anesthesia
water immersion is not used today
ECG placement is important (R wave used to trigger shocks)
Describe contraindications to ESWL
active UTI
uncorrected bleeding disorder or coagulopathy
distal obstruction
pregnancy
Describe complications for ESWL
- dose-dependent hemorrhagic lesions on kidneys
- perforation, rupture or damage to colon, hepatic structures, lungs, spleen, pancreas, abdominal aorta, or iliac veins
- HEMATURIA develops in most patients
- diabetes, new onset HTN or decreased renal function
Anesthesia for ESWL can be performed under
MAC
GA- rapid onset, can control patient movement
Spinal/epidural (T4/T6 level)
Topical LA
Anesthesia considerations for ESWL include
laser eye protection
HCG-ionizing radiation can damage fetus
document negative urine culture
discontinue ASA, anticoagulants, platelet inhibitors, and NSAIDs 7-10 days prior to procedure
Percutaneous nephrolithotomy is a
procedure to remove kidney stones 25 mm or smaller
rigid scope is inserted in renal calyx under fluoroscopy
Percutaneous nephrolithotomy is performed under
GA and requires postoperative hospitalization
patient prone or supine
Complications of percutaneous nephrolithotomy includes
pain, fever, UTI, renal colic, septicemia, bleeding, pneumothorax, hemothorax, anaphylaxis
The most common surgical procedure performed in men over 60 is
TURP
_____ percent of men will require intervention for BPH
40%
__________ are used for medical management of BPH
alpha-blocking agents
Anesthetic risks with TURP are related to
patient age & associated comorbidities
Describe a TURP.
scope placed through urethra to cut away obstructing lobes of the prostrate
bladder distended and continuous irrigated is used
TURP is commonly performed via
general anesthesia
Spinal anesthesia is anesthetic of choice because signs and symptoms of complications are better detected
TURP syndrome is a
rare, but significant complication with mortality as high as 25%
large amounts of fluid absorbed through the prostate
The hallmark symptoms of TURP syndrome are related to****
a combination of water intoxication, fluid overload & hyponatremia
Describe what issues fluid overload can cause in TURP syndrome.
HTN, bradycardia, arrhythmia, angina, pulmonary edema, CHF, & hypotension
Describe the issues that water intoxication can cause in TURP syndrome.
confusion, restlessness, seizure, lethargy, coma, dilated sluggish pupils
Describe the issues that hyponatremia presents as in TURP syndrome.
CNS changes, widened QRS, T-wave inversion
Describe the issues that glycine toxicity presents as in TURP syndrome.
N/V, headache, transient blindness, myocardial depression
If you’re performing a spinal for a TURP, you must block up to
T10
Irrigation solutions used for TURP syndrome include
distilled water, saline, cytal (sorbitol & mannitol), glycine
Complications of TURP syndrome include
volume overload with pulmonary edema, dilutional hyponatremia with hypoosmolality, cardiac effects, renal toxicity (glycine), hyperglycemia, hypothermia
Additional complications of TURP syndrome include
glycine absorption
bleeding- not common but difficult to assess due to irrigation
bladder perforation- not common; symptoms vary depending on whether intraperitoneal or extraperitoneal
infection
skin burns- greater incidence with monopolar cutting device, may also impact patients with pacemakers
With TURP syndrome, fluid absorption is dependent upon**
size of resection duration of resection irrigation solution pressure number of venous sinuses open at one time provider experience
Up to _____ mL of fluid can be absorbed per minute
30 mL; up to 8L in two hours
Uptake of 1L of irrigant can decrease serum Na+ by
5-8 mEq/L
serum Na+ <120 mEq/L associated with severe reactions
Glycine is an amino acid that acts as an
inhibitory transmitter
Excessive absorption of glycine can lead to
nausea & vomiting, fixed & dilated pupils, headache, weakness, muscle incoordination, TURP blindness, seizures, & hypotension
Prevention of TURP includes
**avoid Trendelenburg position
limit resection to less than one hour
place irrigating solution less than 60 cm above prostate
monitor electrolytes
use a regional technique with light sedation
Treatment of TURP syndrome includes
early recognition
correcting hyponatremia- 3-5% saline at no greater than 100 mL/hr, goal is Na >120 mEq/L, increase Na 0.5 mEq/hour or 8 mEq/day, rapid reversal can lead to demyelination syndrome
20 mg IV furosemide
labs/tests: Hct, electrolytes, creatinine, glucose, ABG, 12 lead ECG
IV midazolam 1 mg at a time for seizures
intubate for pulmonary edema
PRBCs if necessary
investigate for DIC or primary fibrinolysis
Anesthetic concerns of laparoscopic urologic surgery include
pneumoperitoneum
alterations in renal & hepatic perfusion
Co2 absorption- potential for acidosis
extremes in patient position (increased intrabdominal & intrathoracic pressures)
hemorrhage
urologic system is retroperitoneal- communicates with thorax- risk for subcutaneous emphysema
Two categories of robotic urologic assisted surgery include:
upper tract surgery- simple or radical nephrectomy, radical nephroureterectomy, nephron-sparing surgery
pelvic surgery: radical cystectomy, radical prostatectomy
Positioning considerations for the robotic urologic surgery case include
steep Trendelenburg (+lithotomy for prostatectomy), arms tucked at sides
airway assessment before extubation
limit fluids until urethra is reconnected (2L total IVF)
Duration & EBL of robotic urologic surgery includes
duration: 3-4 hours
EBL <300 mL
Additional surgical considerations for robotic urologic surgery includes
large bore PIV +/- arterial line DVT prophylaxis eye protection OGT Bair hugger antibodies dexamethasone remifentanil infusion is common
Nephrectomies can be performed
open or laparoscopic
Anesthetic considerations for nephrectomy include
lateral jack-knife position cardiovascular compromise third-spacing & edema hemodynamic monitoring postoperative pain management
Renal transplant is the
mainstay treatment for ESRD
donors may be living or deceased
The 5 year survival rate of renal transplant is
70%
The most frequent solid organ transplanted today is
the kidney
Describe the anesthetic considerations for the patient undergoing renal transplant.
GA- propofol (cisatricurium), arterial line, CVP monitoring, T&C, 18 G & central line, a-line, avoid neo & epi, give dopamine for renal blood flow, clamping Foley, give lasix & mannitol
Patients undergoing renal transplant will be on
immunosuppressant therapy
The transplanted kidney is placed
in the right or left extraperitoneal fossa (right side preferred)
The transplanted kidney is attached via
vascular anastomoses of external iliac artery & vein & ureter anastomosed to bladder
