Urologic Procedures

Question 1

Endoscopy is performed to visualize and evaluate the upper and lower urinary tracts. To diagnose and treat such conditions as (5)

Answer 1

Hematuria
Pyuria
Calculi
Trauma
Cancer

Question 2

Upper urinary tract

Answer 2

Ureter and Kidney

Question 3

Lower urinary tract

Answer 3

Bladder, prostate, urethra

Question 4

What nerve injuries are common when doing urologic procedures?

Answer 4

Common peroneal
Saphenous
Sciatic
Obturator
Femoral

Question 5

What position are urologic procedures usually performed in?

Answer 5

Lithotomy

Question 6

How does the common peroneal nerve get injured?

Answer 6

compression of fibular head on leg brace

Question 7

How does the saphenous nerve get injured?

Answer 7

Compression of medial tibial condyle

Question 8

How does the sciatic nerve get injured?

Answer 8

Excessive external rotation of legs

Excessive extension of the knees

Question 9

How does the obturator and femoral nerve get injured?

Answer 9

excessive flexion of the groin

Question 10

What happens to circulating blood when in lithotomy position?

Answer 10

Blood pools in the trunk - when legs put down BP drops even further

Question 11

What is the obturator reflex?

Answer 11

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 12

Definition of cystoscopy

Answer 12

passage of a rigid scope through the urethra

Question 13

Cystoscopy is a minor procedure and may be done with

Answer 13

2% lidocaine

Question 14

Urethral stimulation, dilation and distention of bladder can be painful requiring general or regional anesthesia. If regional anesthesia is chosen a ______ sensory level is required/ ____ for ureters

Answer 14

T9-T10

T8 ureters

Question 15

When doing a spinal, where is the sensory and motor levels?

Answer 15

Sensory 2 levels higher

Motor 2 levels lower

Question 16

What are the cardiac accelerators

Answer 16

T1-T4

Question 17

Cystoscopy for retrograde ureteral catheterization

Answer 17

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

Question 18

What is a TURBT

Answer 18

Transurethral resection of the bladder

Question 19

What is a TURBT used to treat

Answer 19

TURBT endoscopic resection and electrodesiccation are used to treat superficial bladder tumors

Question 20

What type of anesthesia would you use for a TURBT?

Answer 20

General anesthesia-no coughing or straining can cause bladder perforation

Question 21

Why shouldn’t you use regional anesthesia for a TURBT?

Answer 21

the bladder becomes atonic and may become thinner when distended, increasing the risk of perforation

Question 22

If a bladder ruptured and entered the peritoneal cavity, what would you see?

Answer 22

shoulder discomfort, nausea, and vomiting may occur in the awake patient

Question 23

If there was a high grade malignancy and the bladder ruptured - what could happen?

Answer 23

risk of seeding it into the peritoneum

Question 24

What are some other risks from a bladder rupture?

Answer 24

Blood loss
Hypothermia (cold fluid into peritoneum)
bacteremia

Question 25

If there is a bladder perforation on an awake patient, what will that tell you

Answer 25

suprapubic fullness, abdominal spasm and pain

Question 26

What are the early and late signs of bladder rupture

Answer 26

Htn and tachycardia are early signs followed by severe hypotension

Question 27

What does the cool irrigation cause?

Answer 27

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

Question 28

How is DIC triggered with bladder rupture?

Answer 28

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

Question 29

What is TURP

Answer 29

Transurethral resection of the prostate

Question 30

How is a TURP performed

Answer 30

Neoplastic or obstructive prostate tissue is removed by electrosurgical resection under direct endoscopic vision. This is performed by application of a high-frequency current to a wire loop. Hemostasis is achieved by sealing the vessels with the coagulation current.

Question 31

What type of solution is required to extend the bladder for a TURP

Answer 31

An optically clear, nonconductive, nonhemolytic, nontoxic solution

Question 32

What type of anesthetic is used for a TURP

Answer 32

General anesthesia-coughing must be avoided increase the risk of bleeding Spinal anesthesia is preferred r/t benefits provided

Question 33

Benefits of a spinal for TURP

Answer 33

The bladder will be atonic with a large capacity, thus glycine infusion pressure can be low, emptying less frequent, facilitating resection Postoperative bladder spasm is PREVENTED allowing for hemostasis Awake patients may supply early detection of complications

Question 34

Complications of TURP

Answer 34

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

Question 35

Venous absorption: early signs

Answer 35

hypertension and tachycardia

Question 36

Venous absorption: CVP may rise as

Answer 36

cardiac decomposition occurs

Question 37

Venous absorption: awake patients make complain of

Answer 37

dyspnea or nausea

Question 38

Hypoxia and /or hyponatremia causes what??????????

Answer 38

TURP syndrome

Question 39

What is TURP syndrome

Answer 39

WATER INTOXICATION—OR GLYCINE TOXICITY Apprehension(spinal), disorientation (spinal), convulsions, and coma (spinal)

Question 40

What are the 3 types of irrigation solutions?

Answer 40

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

Question 41

Disadvantage of glycine

Answer 41

can cause transient post-op visual impairment (blindness) less likelihood of TURP syndrome

Question 42

Disadvantage of sorbitol

Answer 42

can cause Hyperglycemia and lactic acidosis

Question 43

Disadvantage of mannitol

Answer 43

nonmetabolized, osmotic diuresis causing hypervolemia

Question 44

What to do for TURP syndrome

Answer 44

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 45

Why are Open prostate- radical prostatectomy emotional?

Answer 45

50% chance of impotence

Question 46

2 positions for open prostate - radical prostatectomy

Answer 46

Suprapubic (retropubic) approach, supine, flex table, and trendlenburg - (MORE HEMORRHAGE) Perineal approach, extreme lithotomy position

Question 47

When does the blood loss occur?

Answer 47

during control of dorsal venous complex

Question 48

T/F: Large IV is a must

Answer 48

TRUE!!!

Question 49

Diagnostic dyes used to identify ureters What happens with each dye? Methylene blue 1% Indigo carmine dye 0.8%

Answer 49

Methylene blue 1% - CAN CAUSE HYPOTENSION Indigo carmine dye 0.8% has an alpha sympathomimetic effect increase BP

Question 50

What happens to SaO2 with the dye

Answer 50

SaO2 down to 85% Sao2 down to 65% for 1-2 minutes Methylene blue greater effect than indigo

Question 51

Indications for a nephrectomy

Answer 51

Chronic infection Trauma Cystic or calculus disease Neoplasm

Question 52

What position and table do you use for a nephrectomy?

Answer 52

Performed by lateral retroperitoneal or anterior abdominal incision Lateral-flex table and use KIDNEY BAR May cause vena cava compression and hypotension General or combined general regional

Question 53

What type of anesthetic is contraindicated in renal transplant and why?

Answer 53

Regional contraindicated by preexisting coagulopathy and or immunosuppression

Question 54

What fluids do you use for a renal transplant?

Answer 54

normal saline--- avoid LR and K+ Adequate hydration is critical use crystalloid, colloid and blood for revascularization of the kidney

Question 55

What does Methyl prednisone and diuretics do for transplant patients?

Answer 55

to help discourage rejection and diuresis

Question 56

If still oliguric, what could you give?

Answer 56

Low dose dopamine

Question 57

Complications of renal transplant

Answer 57

Hyperkalemia Delayed renal function Graft failure

Question 58

Indications for a radical cystectomy

Answer 58

``` Patient with invasive bladder tumors Pelvic malignancies Neurogenic bladder Chronic lower urinary tract obstruction Post radiation bladder dysfunction Creation of a uretero-ileal anastomosis & ileostomy ```

Question 59

Anesthetic considerations for radical cystectomy

Answer 59

Done in supine position General or combined anesthesia Arterial and CVP Large IV (duh) Fluid shifting can be extensive-unable to monitor urine –need for CVP Diuretics may be needed to stimulate output Indigo carmine & Methylene Blue used at times

Question 60

Complications of radical cystectomy

Answer 60

Hypothermia Inadequate fluid replacement Need for post op ventilation

Question 61

Highlights for orchidopexy, orchiectomy and urogenital plastic procedures

Answer 61

``` Performed to treat congenital malformation Neoplasm Impotence Torsion of testicle Supine or lithotomy General or regional T9 sensory needed ``` usually a child and making them sterile

Question 62

Highlights for A/V fistulas

Answer 62

``` Access for dialysis Patient lies supine with arm extended General, regional and local infiltration all acceptable Co-existing medical problems Anemia CAD Diabetes ```

Question 63

Why is BP very labile with pts getting AV fistulas?

Answer 63

because they are chronic HTN - clamped down so with anesthetic = hypotension

Question 64

For ESWL - when is the shock delivered?

Answer 64

on the QRS worried about R on T “5,000 hits"

Question 65

If you see radical, what should you think?

Answer 65

large bore IV