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Cystoscopy

Preoperative considerations: Indications include hematuria, recurrent urinary tract infections (UTIs), renal calculi, and urinary obstruction. Possible procedures include bladder biopsy, retrograde pyelography, resection of bladder tumor, extraction or laser lithotripsy, and ureteral stent placement. Children usually need general anesthesia (GA). Diagnostic cystoscopies in woman can be done with topical lidocaine. If the procedure includes biopsy, cauterization, or ureteral stent manipulation, use regional or GA. Men typically prefer regional or GA for diagnostic and operative procedures.

Intraoperative management: The lithotomy position is commonly used. Avoid sores, compartment syndrome, and neuropathy with careful positioning and padding. Use padded leg supports or straps that do not impede circulation.

Associated nerve injuries: Common peroneal nerve injury (loss of dorsiflexion) from lateral knee resting on strap supports. Saphenous nerve injury (medial calf numbness) from medial strap support. Femoral and obturator nerve injury from excessive thigh flexion at the groin. The brachial plexus is the most common nerve injury.

Physiological alterations: ↓ Functional residual capacity (FRC) leads to atelectasis and hypoxia made worse with steep Trendelenburg.

↑ Venous return from leg elevation, causing congestive heart failure (CHF) exacerbation.

↓ Venous return from leg lowering leads to hypotension.

Anesthetic: (1) GA with a laryngeal mask airway (LMA). Be mindful of O₂ saturation with obese, elderly, marginal pulmonary reserve patients with lithotomy or Trendelenburg positioning. (2) Regional anesthesia (RA): Spinal is preferred over epidural because of its faster onset. T10 sensory level needed.

Noncancer Surgery of the Upper Ureter and Kidney

Overview: Laparoscopic procedures are common, and anesthetic management is similar to that for other laparoscopic procedures. Open procedures for kidney stones and nephrectomies are in the “kidney rest position” in which the patient is lateral with the dependent leg flexed and the other extended. An axillary roll is needed to decrease brachial plexus injury. Kidney rest increases surgical exposure.

Complications

1. Pulmonary

2. Cardiovascular: Decreased venous return secondary to inferior vena cava compression from the kidney rest occurs. Large-bore intravenous (IV) and arterial line are used because of the potential for large blood loss.

Transurethral Resection of the Prostate (TURP)

Preoperative management: Indications include benign prostatic hypertrophy (BPH) with obstructive uropathy, bladder calculi, frequent urinary retention, UTIs, or hematuria as well as prostate cancer with associated urinary obstruction. Evaluate patient for coexistent major organ dysfunction. Surgical complications include clot retention, failure to void, uncontrolled hematuria, UTI, TURP syndrome, disseminated intravascular coagulation (DIC), hypothermia, and bladder perforation. Preoperative type and screen usually adequate, but crossmatched blood is needed for anemic patients and those needing large resection.

Intraoperative management: GA versus regional (spinal or epidural with T10 sensory level). Regional is associated with decreased deep venous thrombosis (DVT) and faster recognition of TURP syndrome and bladder perforation. Tachycardia and decreased oxygen saturation may indicate fluid overload. Monitor temperature even if using RA to detect hypothermia. Blood loss is difficult to assess because of irrigation but is typically 200 to 300 mL. About 18% of patients have perioperative ischemic electrocardiographic (ECG) changes.

Complications: Avoid hypothermia with body temperature irrigating solutions. Suspect bladder perforation if the patient has sudden, unexplained hypotension or hypertension with acute bradycardia. Awake patients may complain of abdominal pain. There is also risk of coagulopathy with subclinical DIC as well as dilutional thrombocytopenia as part of TURP syndrome. Suspect coagulopathy if there is diffuse, uncontrollable bleeding. Treat primary fibrinolysis with Amicar and treat DIC with heparin, platelets, and clotting factor replacement. Decrease risk of septicemia with prophylactic antibiotics.

TURP syndrome: Transurethral prostatic resection opens venous sinuses, leading to possible systemic absorption of irrigating fluid, which can be rapidly fatal.

• Clinical signs: Headache, restlessness, confusion, arrhythmia, hypotension, cyanosis, dyspnea, and seizure. Pulmonary congestion or pulmonary edema can occur if large amounts of irrigation fluid are absorbed, especially if cardiac reserve is limited.

• Irrigating fluid: Typically, glycine 1.5% or mixture of sorbitol 2.7% and mannitol 0.54%. These are hypo-tonic nonelectrolyte solutions, which can lead to water absorption. Acute hyponatremia and hypoosmolality may occur, leading to neurological manifestations. Hypotonicity causing intravascular hemolysis can also result from use of these solutions.

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