Urology Procedures Flashcards
What group of individuals are especially prone to urological procedures?
Para and quadriplegics
Cysto is performed to evaluate for:
Hematuria Pyuria Calculi trauma cancer
Upper urinary tract:
Ureters and kidneys
Lower urinary tract:
bladder, prostate, urethra
Common nerves injured in urologic procedures:
Common peroneal saphenous sciatic obturator femoral
Most urologic procedures are in what position?
Lithotomy
Common peroneal injury:
compression of fibular head on leg brace
saphenous nerve injury:
compression of medial tibial condyle
sciatic nerve injury:
excessive external rotation of legs
excessive extension of the knees
Obturator and femoral nerve injury:
excessive flexion of the groin
don’t forget pooling of the blood.
Obturator reflex
Bladder rupture/injury secondary to adductor muscle contraction from obtrator 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.
Cystocopy
passage of a rigid scope through the urethra
cystoscopy for retrograde ureteral catherization:
to visualize ureter and kidney
place stents
drain obstructions
remove renal calculi
Transurethral resection of the bladder (TURBT)
endoscopic rescetion and electrodesiccation to treat superficial bladder tumor
Bladder perforation
If peritoneal cavity is entered, patient will feel shoulder discomfort, nausea in awake patient.
HTN, Tachycardia, followed by hypotension.
if a high-grade malignancy, risk of seeding into the peritoneum.
blood loss
hypothermia
bacteremia
Transurethral resection of the prostate (TURP)
General Anesthesia, spinal anesthesia preferred.
neoplastic or obstructive prostate tissue is removed by electrosurgical resection under direct endoscopic vision.
Distend the bladder with fluid
Complications of TURP
-Blood loss
- Venous absorption of irrigation fluid.
- early signs=HTN/Tachy
- CVP may rise as cardiac decompensation occurs
- awake patient will complain of nausea, dyspnea, apprehension, disorientation, convulsions, and coma
- early signs=HTN/Tachy
- General anesthesia: coughing or straining can cause bladder perforation.
- Regional anesthesia: the bladder becomes atonic and may become thinner when distended, increasing risk of perforation.
TURP Syndrome
Water intoxication or glycine toxcity
caused by absorbing too much irrigation fluid. dependent on time and pressure of fluids being irrigated with.
apprehension, disorientation, convulsions, coma
TURP Syndrome treatment
ask surgeon to control bleeding and finish surgery
send blood sample for NA
IF regional anesthesia is chosen for Cystoscopy, what sensory level is needed to cover the bladder/urethra?
What sensory level is needed to cover the ureters?
T9-T10 for bladder and urethra
T8 for ureters
Dermatomes: nipple line=
T4
Dermatomes: belly button=
T10
Why is DIC triggered by bladder perforation?
the release of prostatic thrombogenic substances, especially with cancer of the prostate .
What irrigation solutions are used for TURPs?
Glycine (1.5%)
Sorbitol (3.3%)
Mannitol (5%)
What is some advantages and disadvantage of using glycine for irrigation?
Advantage: lesser likelihood of TURP syndrome
DA: can cause transient post/op visual impairment.
What is some advantages and disadvantage of using Sorbitol for irrigation?
A: less likely to cause TURP syndrome
DA: can cause hyperglycemia and lactic acidosis
What is some advantages and disadvantage of using Mannitol for irrigation?
nonmetabolized, osmotic diuresis causing hypervolemia (when absorbed systemically)
Treatment of TURP syndrome:
- ask surgeon to control bleeding and finish up
- Send serum Sodium level. If sodium level is less than 120mEq/L= serious.
- Correct hypervolemia with fluid restrictions and diuretics (furosemide 10-20mg).
- Correct hyponatremai with hypertonic solutions…correct cautiously.
- Normal saline or LR if Sodium is geater than 125mEq/L.
what is a complication of the extreme trendelenberg position?
Increased intraoccular pressure. Can cause permanent visual problems.
What are 2 complications of using methylene blue for a radical prostatectomy?
- Can cause hypotension
- can effect the Sat reader, may go as low as 65% for 1-2 minutes despite adequate oxygenation.
Indications for nephrectomy:
- Chronic infection
- Trauma
- Cystic or calculus disease
- neoplasm
Because a nephrectomy is performed in the lateral or anterior abdominal area. What positioning and pathophysiological effects would be expected?
- Lateral position may cause vena cava compression and hypotension.
- Later-flex table and use kidney bar.
Renal transplant:
- optimize serum potassium and correct metabolic acidosis.
- anemia is common
- no succinylcholine, use cisatracurium (hoffman elimination)
- Use normal saline, avoid LR and K+
- regional anesthesia is contraindicated by preexisting coagulopathy and or immunosuppresion
- Adequate hydration is critical: use crystalloid, colloid and blood for revascularization of the kidney.
- methyl prednisone and diuretics to help discourage rejection and encourage diuresis.
- low dose dopamine of oliguric.
Complications associated with Renal Transplant:
- Hyperkalemia
- Delayed renal function
- graft failure
What is in the preserveration fluid the kidney is stored in?
Glucose, potassium, magnesium, antibiotics, sodium bicarbonate, and heparin (can cause hypersensitivity reaction in recipient.
How long can a kidney be preserved?
- 72 hours with renal perfusion
- 48 hours in cold storage before necrosis jeopardizes graft survival.
Why is Cisatricurium used for renal patients?
Hoffman Elimination. Does not require kidney function for breakdown.
Indications for Radical Cystectomy:
Entire bladder removed
- Invasive bladder tumors
- Pelvic malignancies
- Neurogenic bladder
- Chronic lower urinary tract obstruction
- Post radiation bladder dysfunction
- creation of uretero-ileal anastomosis and ileostomy.
Anesthetic considerations for Radical Cystectomy:
- Supine position
- General or combined
- Arterial and CVP (fluid shifts can be extensive-unable to monitor urine-need for CVP)
- diuretics may be needed to stimulate output.
- indigo carmine and methylene blue used at times.
Complications of Radical Cystectomy:
- Hypothermia
- inadequate fluid replacement
- need for post op ventilation
What dermatome sensory level needs to be achieved for orchidopexy, orchiechotmy, and urogenital plastics?
T9
General, regional, or combined.
What kind of anesthesia is used for Extracorporal shock wave lithotripsy?
MAC
Adequate hydration and diuretics to help pass stone fragments.
A/V shunts/fistula placement:
- Supine, MAC/LMA
- Coexisting medical problems: Anemia, CAD, DM
