Urologic surgeries part 2

Question 1

What are the common urologic procedures.

Answer 1

cystoscopy
extra-corporeal shock wave lithotripsy (ESWL)
transurethral resection of the prostate (TURP)
laparoscopic/robotic urologic procedure
open nephrectomy
renal transplant

Question 2

Cystoscopy is when the

Answer 2

urologist uses a cystoscope to examine urethra & bladder

Question 3

The anesthetic considerations for cystoscopy include

Answer 3

-local/MAC
-spinal anesthesia- offers relaxation with real-time patient assessment
general anesthesia- LMA vs. ETT
lithotomy
procedures can be very quick or last hours

Question 4

ESWL is a

Answer 4

non-invasive treatment that uses high energy ultrasound waves to break up the calculi

Question 5

______ is common in ESWL

Answer 5

hematuria

Question 6

Describe the management of nephrolithiasis

Answer 6

affects 9% of the population

• if calculi <5 mm in diameter, expected to pass without intervention
• 5-10mm –> medical management
• > 10 mm–> unlikely to pass spontaneously

Question 7

For ESWL, it is typically performed

Answer 7

outpatient under general anesthesia
water immersion is not used today
ECG placement is important (R wave used to trigger shocks)

Question 8

Describe contraindications to ESWL

Answer 8

active UTI
uncorrected bleeding disorder or coagulopathy
distal obstruction
pregnancy

Question 9

Describe complications for ESWL

Answer 9

• dose-dependent hemorrhagic lesions on kidneys
• perforation, rupture or damage to colon, hepatic structures, lungs, spleen, pancreas, abdominal aorta, or iliac veins
• HEMATURIA develops in most patients
• diabetes, new onset HTN or decreased renal function

Question 10

Anesthesia for ESWL can be performed under

Answer 10

MAC
GA- rapid onset, can control patient movement
Spinal/epidural (T4/T6 level)
Topical LA

Question 11

Anesthesia considerations for ESWL include

Answer 11

laser eye protection
HCG-ionizing radiation can damage fetus
document negative urine culture
discontinue ASA, anticoagulants, platelet inhibitors, and NSAIDs 7-10 days prior to procedure

Question 12

Percutaneous nephrolithotomy is a

Answer 12

procedure to remove kidney stones 25 mm or smaller

rigid scope is inserted in renal calyx under fluoroscopy

Question 13

Percutaneous nephrolithotomy is performed under

Answer 13

GA and requires postoperative hospitalization

patient prone or supine

Question 14

Complications of percutaneous nephrolithotomy includes

Answer 14

pain, fever, UTI, renal colic, septicemia, bleeding, pneumothorax, hemothorax, anaphylaxis

Question 15

The most common surgical procedure performed in men over 60 is

Answer 15

TURP

Question 16

_____ percent of men will require intervention for BPH

Answer 16

40%

Question 17

__________ are used for medical management of BPH

Answer 17

alpha-blocking agents

Question 18

Anesthetic risks with TURP are related to

Answer 18

patient age & associated comorbidities

Question 19

Describe a TURP.

Answer 19

scope placed through urethra to cut away obstructing lobes of the prostrate
bladder distended and continuous irrigated is used

Question 20

TURP is commonly performed via

Answer 20

general anesthesia

Spinal anesthesia is anesthetic of choice because signs and symptoms of complications are better detected

Question 21

TURP syndrome is a

Answer 21

rare, but significant complication with mortality as high as 25%
large amounts of fluid absorbed through the prostate

Question 22

The hallmark symptoms of TURP syndrome are related to****

Answer 22

a combination of water intoxication, fluid overload & hyponatremia

Question 23

Describe what issues fluid overload can cause in TURP syndrome.

Answer 23

HTN, bradycardia, arrhythmia, angina, pulmonary edema, CHF, & hypotension

Question 24

Describe the issues that water intoxication can cause in TURP syndrome.

Answer 24

confusion, restlessness, seizure, lethargy, coma, dilated sluggish pupils

Question 25

Describe the issues that hyponatremia presents as in TURP syndrome.

Answer 25

CNS changes, widened QRS, T-wave inversion

Question 26

Describe the issues that glycine toxicity presents as in TURP syndrome.

Answer 26

N/V, headache, transient blindness, myocardial depression

Question 27

If you're performing a spinal for a TURP, you must block up to

Answer 27

T10

Question 28

Irrigation solutions used for TURP syndrome include

Answer 28

distilled water, saline, cytal (sorbitol & mannitol), glycine

Question 29

Complications of TURP syndrome include

Answer 29

volume overload with pulmonary edema, dilutional hyponatremia with hypoosmolality, cardiac effects, renal toxicity (glycine), hyperglycemia, hypothermia

Question 30

Additional complications of TURP syndrome include

Answer 30

glycine absorption bleeding- not common but difficult to assess due to irrigation bladder perforation- not common; symptoms vary depending on whether intraperitoneal or extraperitoneal infection skin burns- greater incidence with monopolar cutting device, may also impact patients with pacemakers

Question 31

With TURP syndrome, fluid absorption is dependent upon****

Answer 31

``` size of resection duration of resection irrigation solution pressure number of venous sinuses open at one time provider experience ```

Question 32

Up to _____ mL of fluid can be absorbed per minute

Answer 32

30 mL; up to 8L in two hours

Question 33

Uptake of 1L of irrigant can decrease serum Na+ by

Answer 33

5-8 mEq/L | serum Na+ <120 mEq/L associated with severe reactions

Question 34

Glycine is an amino acid that acts as an

Answer 34

inhibitory transmitter

Question 35

Excessive absorption of glycine can lead to

Answer 35

nausea & vomiting, fixed & dilated pupils, headache, weakness, muscle incoordination, TURP blindness, seizures, & hypotension

Question 36

Prevention of TURP includes

Answer 36

****avoid Trendelenburg position limit resection to less than one hour place irrigating solution less than 60 cm above prostate monitor electrolytes use a regional technique with light sedation

Question 37

Treatment of TURP syndrome includes

Answer 37

early recognition correcting hyponatremia- 3-5% saline at no greater than 100 mL/hr, goal is Na >120 mEq/L, increase Na 0.5 mEq/hour or 8 mEq/day, rapid reversal can lead to demyelination syndrome 20 mg IV furosemide labs/tests: Hct, electrolytes, creatinine, glucose, ABG, 12 lead ECG IV midazolam 1 mg at a time for seizures intubate for pulmonary edema PRBCs if necessary investigate for DIC or primary fibrinolysis

Question 38

Anesthetic concerns of laparoscopic urologic surgery include

Answer 38

pneumoperitoneum alterations in renal & hepatic perfusion Co2 absorption- potential for acidosis extremes in patient position (increased intrabdominal & intrathoracic pressures) hemorrhage urologic system is retroperitoneal- communicates with thorax- risk for subcutaneous emphysema

Question 39

Two categories of robotic urologic assisted surgery include:

Answer 39

upper tract surgery- simple or radical nephrectomy, radical nephroureterectomy, nephron-sparing surgery pelvic surgery: radical cystectomy, radical prostatectomy

Question 40

Positioning considerations for the robotic urologic surgery case include

Answer 40

steep Trendelenburg (+lithotomy for prostatectomy), arms tucked at sides airway assessment before extubation limit fluids until urethra is reconnected (2L total IVF)

Question 41

Duration & EBL of robotic urologic surgery includes

Answer 41

duration: 3-4 hours | EBL <300 mL

Question 42

Additional surgical considerations for robotic urologic surgery includes

Answer 42

``` large bore PIV +/- arterial line DVT prophylaxis eye protection OGT Bair hugger antibodies dexamethasone remifentanil infusion is common ```

Question 43

Nephrectomies can be performed

Answer 43

open or laparoscopic

Question 44

Anesthetic considerations for nephrectomy include

Answer 44

``` lateral jack-knife position cardiovascular compromise third-spacing & edema hemodynamic monitoring postoperative pain management ```

Question 45

Renal transplant is the

Answer 45

mainstay treatment for ESRD | donors may be living or deceased

Question 46

The 5 year survival rate of renal transplant is

Answer 46

70%

Question 47

The most frequent solid organ transplanted today is

Answer 47

the kidney

Question 48

Describe the anesthetic considerations for the patient undergoing renal transplant.

Answer 48

GA- propofol (cisatricurium), arterial line, CVP monitoring, T&C, 18 G & central line, a-line, avoid neo & epi, give dopamine for renal blood flow, clamping Foley, give lasix & mannitol

Question 49

Patients undergoing renal transplant will be on

Answer 49

immunosuppressant therapy

Question 50

The transplanted kidney is placed

Answer 50

in the right or left extraperitoneal fossa (right side preferred)

Question 51

The transplanted kidney is attached via

Answer 51

vascular anastomoses of external iliac artery & vein & ureter anastomosed to bladder