Urologic Procedures

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Urologic Procedures Anesthetic Implications

• Eric Larson, M.D.

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Skegemog Lake
Our Cottage
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TURP

• Transurethral Resection of the Prostate
• Surgical Procedure Cystoscope and electrocautery
• Positioning Lithotomy
• EBL 500ml
• Anesthetic Choice Spinal vs. General
• Monitoring Standard

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TURP

• TURP Syndrome
• Because of large amounts of irrigation used to
  clear field, significant absorption may take
  place.
• Fluid is isoosmotic usually with manitol, glycine
  and sorbitol so an electric charge cannot be
  conducted.
• Massive absorption can lower sodium and cause
  symptoms
• N/V
• Mental Status changes (Na lt 120)
• HTN
• Seizures
• Cardiovascular collapse, dysrhythmias (Na lt100)

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TURP

• Spinal Anesthesia
• Usually not necessary to use epidural
• Level should be to T9
• Advantage over general is that it is easier to
  monitor for TURP syndrome with mental status.

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Macinac Bridge (spanning upper and lower
peninsulas)
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Prostatectomy

• Two types, simple and radical
• Simple Prostatectomy
• Incision to enter thru bladder and shell out
  tumor
• Radical Prostatectomy
• Entire prostate excised using a retropubic or
  perineal approach

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Prostatectomy

• Positioning Lithotomy (anticipate hypotension
  when returning from lithotomy)
• EBL 500ml (simple), 1500ml (radical)
• Anesthetic choice All types valid. Usually T8-10
  for regional depending on incision site.
• Monitoring Standard Art CVP

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Prostatectomy

• Complications
• Indigo Carmine leads to false oxygen saturations,
  rare allergic reactions with rash
  bronchoconstriction hypotension
• Peroneal nerve injury from positioning

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Grand Rapids, MI
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Nephrectomy

• Nephrectomy
• Simple Benign diagnoses
• Partial Small neoplasms, duplicated collecting
  systems
• Radical Renal cell CA, Wilms tumors
• Incision Flank (Simple, Partial, Radical)
• Dorsal along paraspinous (Simple)
• Transabdominal (Radical)

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Nephrectomy

• Positioning Flank (Simple, Partial, Radical)
• Prone (Simple)
• Supine (Radical)
• EBL 500 ml (Simple, radical), 1200 ml (Partial)
• Complications Pneumothorax, unrecognized pleural
  perforation

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Macinac Island
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Cystectomy

• Types Simple, partial, radical
• Position Supine
• Incision Midline, transperitoneal
• EBL Simple (1000ml), Partial (minimal), Radical
  (1500ml)
• Anesthetic Choice GA, Epidural, Spinal Requires
  a T4 sensory level.
• Monitoring Standard, art, CVP, PA Cath
• Collecting System Ileal conduit or bladder
  substitution
• Remember May cause a non gap metabolic acidosis
  (bicarbonate and potassium losses)

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Ileal Conduit
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Extracorporeal Shock Wave Lithotripsy

• Position Supine
• EBL Minimal
• Anesthetic Choice GA, regional
• Monitoring Standard
• Complications secondary to shock waves
• Flank ecchymoses
• Punctate hemorrhages on stomach/bowel
• Pulmonary damage possible
• Dysrhythmias (even despite timing of ESWL pulses
  in cardiac refractory period)
• VQ mismatching from decreased FRC
• Physiological changes Increased blood pressure,
  decreased VC, FRC, TV

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Lake Michigan
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Orchiectomy

• Position Supine
• EBL Minimal
• Anesthetic Choice GA, regional (should obtain T6
  level)
• Complications N/V, Failure to void

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Hypospadias Repair

• Position Supine
• Incision Ventral penis
• EBL 50 ml
• Anesthetic choice GA, caudal, spinal, epidural
• Complications Urinary retention
• Postop Analgesia Narcotics, caudal, NSAIDS

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Caudal Block
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References

• Anesthesiologists Manual of Surgical Procedures,
  2nd ed. Jaffe, Richard
• Anesthesia, 5th ed., Miller