Urology

Question 1

What does endoscopy assess?

Answer 1

Performed to visualize and evaluate the upper and lower urinary tracts.

To diagnoses:

Hematuria
Pyuria
Calculi
Trauma
Cancer

Question 2

What is considered the upper urinary tract?

Answer 2

The ureter and kidney

Question 3

What is considered the lower urinary tract?

Answer 3

Bladder, prostate and urethra

Question 4

What nerve injuries can occur from urologic procedures?

Answer 4

Common peroneal
Saphenous
Sciatic
Obturator
Femoral

Usually from lithotomy position

Question 5

How does injury of the common peroneal nerve occur?

Answer 5

Compression of fibular head on leg brace

Question 6

How does injury of the Saphenous nerve nerve occur?

Answer 6

Compression of medial tibial condyle

Question 7

How does injury of the Sciatic nerve occur?

Answer 7

Excessive external rotation of legs
Excessive extension of the knees

Question 8

How does injury of the Obturator and femoral nerve occur?

Answer 8

Excessive flexion of the groin

Don’t forget pooling of blood (About 500 cc’s of blood in each leg)

Question 9

Obturator Reflex

Answer 9

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.

Question 10

How is cystoscopy done?

Answer 10

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

Question 11

What’s the most stimulating thing about doing a general?

Answer 11

laryngoscopy

Question 12

What’s the 2nd most stimulating thing about doing a general?

Answer 12

Incision

Question 13

What’s the 3rd most stimulating thing about doing a general?

Answer 13

closing/emergence

Question 14

What is the purpose of cystoscopy for retrograde ureteral catheterization?

Answer 14

To visualize the ureter and kidney
To place stents
To drain obstructions
To remove renal calculi

Question 15

Key points on transurethral resection of the bladder

Answer 15

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

Question 16

Key points on bladder perforation

Answer 16

If peritoneal cavity entered shoulder discomfort, nausea, and vomiting may occur in the awake patient

If a high-grade malignancy present—risk of seeding it into the peritoneum

Blood loss, Hypothermia, bacteremia

Awake patient will experience suprapubic fullness, abdominal spasm and pain

Htn and tachycardia are early signs followed by severe hypotension

Cool irrigation causes vasoconstriction-systemic cooling—warm fluids will decrease this risk

DIC triggered by release of prostatic thrombogenic substances-especially with cancer of prostate

Possibility of open procedure-r u ready

Question 17

What type of anesthesia is preferred for a TURP?

Answer 17

Spinal anesthesia

General anesthesia-coughing must be avoided increase the risk of bleeding

Question 18

what are the complications of TURP?

Answer 18

Blood loss

Venous absorption of irrigation fluid-open sinuses provide direct communication to the circulation-depending on pressure time of exposure

Question 19

Venous absorption and TURP

Answer 19

Early signs- hypertension and tachycardia

CVP may rise as cardiac decompensation occurs

Awake patient may complain of dyspnea or nausea
Hypoxia and /or hyponatremia causes what?????????? – TURP SYNDROME—WATER INTOXICATION—OR GLYCINE TOXICITY

Question 20

What is TURP syndrome?

Answer 20

This occurs when too much of the fluid used to wash the area around the prostate during the procedure is absorbed into the bloodstream. Initial symptoms of TURP syndrome include: feeling or being sick. confusion.

Apprehension, disorientation, convulsions, and coma

Question 21

Different Irrigating Solutions

Answer 21

Glycine (1.5%)
Sorbitol (3.3%)
Mannitol (5%)

Question 22

Disadvantages of glycine

Answer 22

*Glycine-less likelihood of TURP syndrome-can cause transient post-op visual impairment

Question 23

Disadvantages of sorbitol

Answer 23

*Sorbitol- again less likely-can cause Hyperglycemia and lactic acidosis

Question 24

Disadvantages of mannitol

Answer 24

*Mannitol- nonmetabolized, osmotic diuresis causing hypervolemia (because it pulls in fluids…and if used as irrigation it can pull in fluids)

Question 25

What do you do if TURP syndrome occurs?

Answer 25

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

Question 26

What % risk of impotence is there with radical prostatectomy?

Answer 26

50%

Question 27

Open prostate- radical prostatectomy

Answer 27

Resection of prostate

Suprapubic (retropubic) approach, supine, flex table, and trendlenburg

Perineal approach, extreme lithotomy position

More Hemorrhage with Retropubic approach

Blood loss occurs during control of dorsal venous complex

Regional or general

Large IV a must must!!

Question 28

What happens to your sats with methylene blue?

Answer 28

They drop

Question 29

Does Indigo carmine dye 0.8% increase or decrease bp?

Answer 29

has an alpha sympathomimetic effect increase BP

Question 30

What can methylene blue 1% cause?

Answer 30

hypotension

Question 31

What are the indications for nephrectomy?

Answer 31

Chronic infection
Trauma
Cystic or calculus disease
Neoplasm

Question 32

Can nephrectomy cause vena cava compression and hypotension?

Answer 32

Yep

Question 33

Key points about kidney transplant

Answer 33

Optimize prior to transplant-serum potassium normal and metabolic acidosis corrected
Anemia is common
Positioned supine with role under hip
Kidney is usually anastamosed to external iliac arteries in the pelvis or previous nephrectomy an end to end vascular and ureteral anastomosis is performed
IV access don’t use fistula side
General anesthesia no anectine -atracurium