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Principles of Anesthesia > Genitourinary Procedures (Exam IV) > Flashcards

Genitourinary Procedures (Exam IV) Flashcards

1
Q

What are the indications for genitourinary surgery?

A
  • Biopsies
  • Evaluation of bleeding
  • Retrograde Pyelography
  • Stone retrieval/lasering
  • Strictures
  • Mass resection
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2
Q

What are the disadvantages/complications of the lithotomy position?

A
  • Peroneal/femoral nerve injury
  • Skin break down (stirrups)
  • Hip dislocation & back strain
  • Vessel compression (DVT, pooling, compartment syndrome)
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3
Q

What is the best measure of glomerular function?

A

GFR

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4
Q

What is normal GFR?

A

125mL/min

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5
Q

A patient will be asymptomatic until a ___% drop in GFR occurs.

A

50%

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6
Q

What s/s would be noted with moderate renal insufficiency?

A
  • ↑ BUN/Ct
  • Anemia
  • Fatigue
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7
Q

What s/s would be noted with severe renal insufficiency?

A
  • Uremia
  • Acidemia
  • Hypervolemia
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8
Q

What are normal values for BUN?

A

~ 8 - 18 mg/dL

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9
Q

What normal factors can influence and distort BUN levels?

A
  • Exercise
  • Dehydration
  • Steroids
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10
Q

BUN won’t be elevated in kidney disease until GFR is ___% of normal.

A

75%

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11
Q

Creatinine is higher in which sex?

A

males

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12
Q

What are normal creatinine levels?

A

0.8 - 1.2 mg/dL

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13
Q

What occurs with ammonia during kidney disease?

A

Decreased production of ammonia.

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14
Q

What occurs to kidney patients anion gaps?

A

Anion gap increases as disease progresses

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15
Q

What hematologic factors can be normal in renal patients?

A

Normochromic
Normocytic

Normal RBC size and color.

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16
Q

What hematologic pathologies are typically present in renal patients?

A
  • Iron deficiency anemia
  • Abnormal Plt aggregation
  • Abnormal prothrombin consumption
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17
Q

Are ionized or non-ionized drugs primarily a concern with renal disease patients? Why?

A

Ionized

Non-ionized drugs are typically lipid-soluble and aren’t terminated via renal excretion.

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18
Q

What drugs/drug classes are of concern with renal patients?

A
  • Muscle relaxants
  • Cholinesterase inhibitors
  • Thiazide diuretics
  • Digoxin
  • Antibiotics (lots, not all)
  • Opioid metabolites
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19
Q

Rigid scopes are best used for ureteroscopies. T/F?

A

False. Rigid scopes are inappropriate when moving past urethroscopies and cystoscopies.

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21
Q

What is the treatment of choice for mid-distal ureter stones?

A

Ureteroscopy

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21
Q

Which sex is more inclined to develop kidney stones?

A

10% men vs 5% women

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22
Q

Typical stones are primarily composed of what element?

A

Calcium

Also radiopaque.

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23
Q

What are the typical complications of ureteroscopy?

A
  • Perforation 5%
  • Stricture formation <2%
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24
Q

What is the typical recurrence rate for kidney stones?

A

50%

ouch

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25
Q

What is firstline therapy for kidney stones?

A

MET (Medical expulsive therapy)

  • NSAIDs
  • Aggressive hydration
  • CCBs & α-blockers
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26
Q

What are the three options for kidney stone removal? (List in order of least invasive to most invasive)

A
  1. Stone Basket vs Laser
  2. Shock Wave Lithotripsy
  3. Percutaneous Nephrolithotomy
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27
Q

What types of stones is shock wave lithotripsy best suited for?

A

Small/medium intranephric stones

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28
Q

Risk of what two conditions can occur with shock wave lithotripsy?

A
  • Kidney injury
  • Sub-capsular hematoma
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29
Q

What are the characteristics of old-school SWL?

A
  • Water baths
  • Hypothermia
  • Pain
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30
Q

What are the characteristics of new SWL?

A
  • No baths (water-filled coupler device)
  • More focused beam
  • Lower pulse pressure
  • Less pain
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31
Q

What are absolute contraindications to SWL?

A
  • Bleeding disorder/ anticoagulation
  • Pregnancy
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32
Q

What are relative contraindications to SWL?

A
  • Large calcified aortic/renal aneurysms
  • UTI
  • Obstruction distal to the renal calculi
  • Pacemaker, ICD, neurostimulator
  • Morbid obesity
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33
Q

What allergy needs to be considered preoperatively for SWL?

A

Iodine allergy

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34
Q

What surgery is useful for large intranephric stones?

A

Percutaneous Nephrolithotomy

Uncommon now due to SWL

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35
Q

Percutaneous Nephrolithotomy requires the initial placement of what?

A

Ureteral stents to prevent obstruction as fragments pass by.

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36
Q

Which calculi surgery uses the most fluoroscopy?

A

Percutaneous Nephrolithotomy

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37
Q

In what calculi surgery is TUR syndrome most probable?

A

Percutaneous Nephrolithotomy

38
Q

What position are patients placed in for Percutaneous Nephrolithotomy?

A

Lateral

39
Q

When is orchiectomy typically indicated?

A

Metastatic prostate cancer

40
Q

Orchiectomies are typically ______.

A

Bilateral

41
Q

What is a hydrocelectomy?

A

Wall of hydrocele excised and edges are sutured close

42
Q

Testicular torsion repair must occur within ____ hours to prevent irreversible ischemic damage.

A

6 hours

43
Q

What are typical indications for circumcision is older men?

A
  • Phimosis
  • Penile/prostate cancer
44
Q

What conditions can result in the need for a penile prosthesis?

A
  • DM
  • Spinal cord injury
45
Q

What penile operations were discussed in lecture?

A
  • Circumcision
  • Hypospadius repair
  • Penectomy (for SCC)
  • Penile prosthesis
46
Q

What block is used for penile procedures?

A

Pudendal block (S2-S4)

47
Q

Manipulation of genitals during penile procedures may result in…

A

Bradycardia (from vagal response)

48
Q

What are simple cystectomies done for?

A

Simple non-metastatic conditions

  • Hemorrhagic cystitis
  • Radiation cystitis
49
Q

When are radical cystectomies indicated?

A

Malignant conditions (involves ureters prostate/uterus, ovaries)

  • Invasive bladder cancer
50
Q

What is required with a cystectomy?

A
  • Ileal conduit (urostomy)
  • Bladder substitution
51
Q

Is bowel prep necessary for cystectomies?

A

yes

52
Q

What anesthetic options does the CRNA have for a cystectomy?

A
  • GETA, SAB, Epidural
53
Q

What are common complications of cystectomies?

A
  • Bleeding (3L!)
  • 3rd space losses
  • Hypothermia
54
Q

What should the CRNA have preoperatively to combat bleeding in cystectomy’s?

A
  • 1-2 IV’s
  • Type and crossmatched blood ready
55
Q

What is the “gold-standard” surgical treatment for BPH?

A

TURP (Transurethral Prostatectomy)

56
Q

What is the expected blood loss for a TURP?

A

2-4 mL/min

57
Q

What comorbidities are common with TURP patients?

A
  • Obesity
  • HTN
  • Hyperparathyroidism
  • CRI (Chronic Renal Insufficiency)
  • Paraplegia
58
Q

What type of IV access is necessary for TURPs?

A

Large Bore

59
Q

Why might a SAB be preferable to general anesthesia for a TURP?

A

SAB will allow for neuro monitoring and evaluation of possible TURP syndrome.

60
Q

What atypical monitoring is necessary for a robotic prostatectomy?

A

Arterial line

Severe Trendelenburg necessitates minimal fluid use and increase pressor utilization.

61
Q

What causes TUR syndrome?

A

Hypervolemic water intoxication (Hyponatremia)

Volume absorbed through venous sinuses into blood stream.

62
Q

What s/s would be present for a serum Na⁺ of 120 mEq/L?

A
  • Confusion & restlessness
  • QRS widening
63
Q

What s/s would be present for a serum Na⁺ of 115 mEq/L?

A
  • Somnolence & Nausea
  • ↑ ST & widened QRS
64
Q

What s/s would be present for a serum Na⁺ of 110 mEq/L?

A
  • Seizures & Coma
  • Vtach & Vfib
65
Q

What irrigants can be used for TURP procedures?

A
  • Saline
  • Glycine
  • Water
  • Sorbitol
66
Q

What are the disadvantages to saline irrigation?

A
  • Volume overload
  • Monopolar cautery current dispersion
67
Q

What are the disadvantages to glycine irrigation?

A

Bad for liver patients due to ammonia accumulation

68
Q

What are the disadvantages to water irrigation?

A

Intravascular Hemolysis

69
Q

What are the disadvantages to sorbitol irrigation?

A
  • Metabolized to CO₂ and fructose
  • Volume overload
70
Q

What is the irrigation rate of TURPs?

A

300 mL/min

71
Q

What is the fluid absorption rate in TURPs?

A

20 - 200 mL/min

72
Q

How much fluid absorption usually has to occur for TURP syndrome to develop?

A

> 2L

73
Q

How is TURP syndrome avoided?

A
  • Treat hypotension w/ vasopressors, not fluid
  • Limit resection time to 1 hours
  • Suspend irrigation fluid < 30cm above the table
74
Q

How is TURP syndrome treated?

A
  • ABCs
  • Terminate procedure
  • Na⁺ > 120 → diuretics
  • Na⁺ < 120 → 3% saline
75
Q

What type of conditions would necessitate simple nephrectomy?

A
  • Autoimmune disease
  • Trauma
  • Polycystic Kidney disease
76
Q

What type of condition would necessitate a radical nephrectomy?

A

Renal Cell Carcinoma

Adrenal glands excised as well.

77
Q

What gas should be avoided with nephrectomy’s?

A

N₂O

Too close to the bowel.

78
Q

Where should the CVL be placed for a nephrectomy?

A

Ipsilateral to surgical site

79
Q

What should be considered for post-operative pain for a nephrectomy?

A

Regional anesthesia

80
Q

Which kidney is preferred as a donor organ?

A

Left Kidney

Longer ureter and vascular supply.

81
Q

What vessel should be anastamosed in first, a vein or an artery?

A

Vein to facilitate organ venous drainage

82
Q

Which type of nephrectomy donor is “easier”? Why?

A

Living Donor Nephrectomy (⅓ of cases)
- healthy
- two kidneys
- No DM, HIV, cancer, etc.
- No wait times
- ↓ cold ischemic time

83
Q

What type of IV fluid protocol is used for living donor nephrectomies?

A

Aggressive Isotonic hydration (10 - 20 mL/kg/hr)

84
Q

What is used for diuresis in the living kidney donor?

A
  • Furosemide
  • Mannitol

Maintain 2mL/kg/hr.

85
Q

What IV fluids should be avoided in cadaver donors?

A

Glucose containing solutions

86
Q

What ventilator settings protect a donors lung function until kidney retrieval is performed?

A
  • 6-8 mL/kg of IBW
  • 5-10 cm PEEP
87
Q

How long can kidneys be ishemic (on ice)?

A

48 - 72 hours

88
Q

What physiologic goals do we have for a kidney donor?

A
89
Q

What occurs physiologically during ischemic time for the kidney?

A
  • ↓ O₂
  • ↓ ATP/glycogen
  • Na⁺K⁺ATPase pump failure
  • ↑ Na⁺ ICF = Edema
90
Q

What is Anti-Thymocyte?

A

Infusion of rabbit-derived antibodies against human T-cells to prevent rejection.

91
Q

What can be developed as a side effect from anti-thymocyte administration?

A

Cytokine Release Syndrome

92
Q

How is cytokine release syndrome treated?

A
  • Steroids
  • Diphenhydramine
  • Acetaminophen

Principles of Anesthesia (24 decks)

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