Common Urological procedures

Question 1

What is a cytoscopy?

What kind of surgeries are done under cystoscopy?

Answer 1

• Most commonly performed urologic procedure
• Passing a rigid scope through the urethra into the bladder
• indicated for:
  
  • hematuria
  • recurrent urinary infections
  • urinary obstruction
• other surgeries performed under cysto include:
  
  • bladder biopsies
  • extraction of renal stones
  • placement of renal stent

Question 2

What are endoscopy procedures?

Answer 2

• visualized the ureter, kidney, bladder, prostate, and ureter
• Dx and Tx for renal calculi, hematuria, trauma, cancer

Question 3

What is the anesthetic technique for cystoscopy?

Answer 3

• usually GA
  
  • procedure is short (15-20 minutes)
  • most pts apprehensive
  • LMA
• regional
  
  • spinal preferred (faster onset)
  • no need to wait for spinal to set to move to lithotomy position
• 2% lidocaine jelly can be used on scope
• regional or GA for discomfort caused by bladder distension

Question 4

What level regional do you need for cystoscopy?

spinal dose:

lumbar epidural dose

Answer 4

• T8-T10
• Spinal
  
  • 0.75% bupivacaine 10-12 mg if >1hr
  • 0.75% bupivacaine 7.5 mg if <1 hr
• Lumbar epidural
  
  • 1.5-2% lidocaine with epi 15-25 ml
  • supplement with 5-10 ml bolus as needed
• **dont need to know doses for this exam

Question 5

What is the issue with regional anesthesia for a cystoscopy?

Answer 5

• does not abolish the obturator reflex, which may be stimulated when the electrocautery gets touches the nerve which is close tothe bladder wall
• causes external rotation and adduction of thigh
• Obturator reflex can be blocked only by muscle paralysis

Question 6

What is the TURP procedure done for?

how?

Answer 6

• to alleviate urinary obstruction from BPH
• most common GU surgery for men >60
• Done with resectoscope inserted into the urethra/bladder which allows for capability of both cutting and coagulation of tissue and vessels

Question 7

What are the different types of TURPS?

Answer 7

• M-Turp (monopolar)- traditional, uses electric current
  
  • cannot have ions in fluid
  • pt becomes hyponatremic
• B-turp (bipolar)- keeps current contained to unit
  
  • can use NS for fluid
  • pt can still become ofluid overloaded
• L-Turp (laser)- lithotripsy
  
  • can use NS

Question 8

What are problems that can be caused by the absorption of fluid from the irrigation during a TURP?

Answer 8

• pulm edema
• hyponatremia
• cardiac and retinal toxic effects
• increased blood volume
• hyperglycemia
• turp syndrom- neurologic changes from hyponatremia
• hypothermia- warm fluids

Question 9

Anesthetic technique

position

pre-op meds

abx

ebl

Answer 9

• Lithotomy with slight trendelenburg
• pre-op sedation as needed for anxiety
• Abx per surgeion, usually Gentamycin 80 mg IV slowly
• EBL about 500 mls
  
  • EBL is 2-4 ml/min of resection time
  • consider type and cross

Question 10

Should you do general or spinal for a TURP?

Answer 10

• No difference in outcomes between GA and spinal
• Spinal is technique of choice for an M-turp so you can monitor their neuro status
  
  • also allows for recognition of bladder perforation
  • reduces opst-op venous thrombosis
  • reduces intra-op blood loss
• General- difficult to notice turp syndrome

Question 11

What is TURP syndrom?

Answer 11

• Caused by absorption of the irrigation solutions
• can lead to hyponatremia
• some solutions have glycine in them, which is an inhibitor neurotransmitter
• Presents as HA, confusion, cyanosis, dyspnea, arrhythmias, hypotension, bradycardia, sz

Question 12

How can TURP syndrome be prevented?

Answer 12

• Hang irrigating solution no higher than 60 cm above surgical table
• amt of irrigating fluid absorbed is proportional to surgical time
  
  • approx 20 ml/min of resection time

Question 13

How is TURP treated?

Answer 13

• early recognition
• fluid resitriction
• loop diuretic
• hypertonic solution if hyponatremia present
  
  • 100 ml 3% Saline over 1-2 hrs
  • Ideally pts Na is >120
• treat sz with midaz, propofol, or phenytoin
  
  • if glycine used, try magnesium
• intubate if necessary

Question 14

What is ESWL?

What is 1st generation vs 3rd generation

Answer 14

• extracorporal shock wave lithotripsy
  
  • disintigrates calculi in kidneys or upper 2/3 of ureters
  • shock waves focused on the calculi
• 1st generation- high energy units; pt was submerged in H2O
• 2nd and 3rd generation- low energy; no water bath
  
  • use a small water-filling coupling device instead and tightly focused sound beam

Question 15

ESWL

How is the procedure related to the pts HR?

Answer 15

• Shock waves are synchronized to 20 ms after R wave
  
  • during ventricular refractory period
• bradycardia can prolong the procedures
• pts with pacemaker or AICD are at risk of developing arrhythmias

Question 16

What is important when managing the anesthesia for an ESWL procedure?

Answer 16

• Immobilization
• Can use GA or regional
• GA
  
  • controlled ventilation (smaller TV, less chance of lungs getting in way of US)
  • prevents pt exposure to loud noise
• Regional
  
  • flank infiltation and IC block with MAC ok with 3rd generation, newer lithotripters
  • continuous epidural
  • cannot control diaphragm

Question 17

Regional for ESWL

Answer 17

T6 sensory level requires

Flank infiltation and IC block with MAC ok with 3rd generation, newer lithotripters

continuous epidural- avoid injecting air because it can cause sound waves to disperse and damage nearby tissues

cannot control diaphragm

Question 18

When would you use MAC for ESWL?

Answer 18

• For low energy lithotripsy
• propofol with midaz and opioid
• avoid movement!!