Urology Flashcards
What does endoscopy assess?
Performed to visualize and evaluate the upper and lower urinary tracts.
To diagnoses:
Hematuria
Pyuria
Calculi
Trauma
Cancer
What is considered the upper urinary tract?
The ureter and kidney
What is considered the lower urinary tract?
Bladder, prostate and urethra
What nerve injuries can occur from urologic procedures?
Common peroneal
Saphenous
Sciatic
Obturator
Femoral
Usually from lithotomy position
How does injury of the common peroneal nerve occur?
Compression of fibular head on leg brace
How does injury of the Saphenous nerve nerve occur?
Compression of medial tibial condyle
How does injury of the Sciatic nerve occur?
Excessive external rotation of legs
Excessive extension of the knees
How does injury of the Obturator and femoral nerve occur?
Excessive flexion of the groin
Don’t forget pooling of blood (About 500 cc’s of blood in each leg)
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.
How is cystoscopy done?
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’s the most stimulating thing about doing a general?
laryngoscopy
What’s the 2nd most stimulating thing about doing a general?
Incision
What’s the 3rd most stimulating thing about doing a general?
closing/emergence
What is the purpose of cystoscopy for retrograde ureteral catheterization?
To visualize the ureter and kidney
To place stents
To drain obstructions
To remove renal calculi
Key points on transurethral resection of the bladder
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
Key points on bladder perforation
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
What type of anesthesia is preferred for a TURP?
Spinal anesthesia
General anesthesia-coughing must be avoided increase the risk of bleeding
what are the 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 and TURP
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
What is TURP syndrome?
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
Different Irrigating Solutions
Glycine (1.5%)
Sorbitol (3.3%)
Mannitol (5%)
Disadvantages of glycine
*Glycine-less likelihood of TURP syndrome-can cause transient post-op visual impairment
Disadvantages of sorbitol
*Sorbitol- again less likely-can cause Hyperglycemia and lactic acidosis
Disadvantages of mannitol
*Mannitol- nonmetabolized, osmotic diuresis causing hypervolemia (because it pulls in fluids…and if used as irrigation it can pull in fluids)
What do you do if TURP syndrome occurs?
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
What % risk of impotence is there with radical prostatectomy?
50%
Open prostate- radical prostatectomy
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!!
What happens to your sats with methylene blue?
They drop
Does Indigo carmine dye 0.8% increase or decrease bp?
has an alpha sympathomimetic effect increase BP
What can methylene blue 1% cause?
hypotension
What are the indications for nephrectomy?
Chronic infection
Trauma
Cystic or calculus disease
Neoplasm
Can nephrectomy cause vena cava compression and hypotension?
Yep
Key points about kidney transplant
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
