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ANAESTHESIA FOR UROLOGICAL SURGERY
Outline: Types of surgical procedures Points of importance to the anaesthetist Anaesthesia for common urological procedures
If only 5% dextrose/water is available add 20ml of 50% dextrose to 200ml of 5% dextrose/water + 15 units insulin and give over 30-60 mins. The other problems encountered in patients with renal failure are discussed in Chapter 37. respiratory and other problems common to their age. obstructive lesions of the urinary tract. 152 . Positioning the patient Nephrectomy is performed with the patient in the lateral position.g. Endoscopic surgery − Cystoscopy − Trans-urethral resection of the prostate − Resection of bladder lesions − Urethral dilatations POINTS OF IMPORTANCE TO THE ANAESTHETIST Geriatric problems Many patients presenting for urological procedures are older people. These problems are discussed under Anaesthesia for the Elderly in Chapter 36.TYPES OF SURGICAL PROCEDURES Open surgery. The surgery performed will be for the purpose of correcting for example. Some patients will present with hyperkalaemia which if > 6.5 needs to be corrected before surgery. A suggested regime would be: Insulin 15 units in 200ml 10% dextrose/water given over 30-60 mins. cystoscopies and TUR in the lithotomy position. They therefore present with cardiovascular. Renal failure A proportion of patients will be in renal failure. These positions may affect the cardiovascular and respiratory systems. ureters and kidneys. Special care is also needed to prevent injury to peripheral nerves. This may provide a temporary improvement and allow surgery to proceed. e. surgery of the bladder.
A spinal anaesthetic is not routinely justified because the procedure is such a short one. Repeated anaesthetics There can be a problem with repeated anaesthetics eg. Place the patient in the lithotomy position. Give ketamine 2 mg/kg IV (or 5-7 mg/kg IM) and diazepam 0. 153 . Regional anaesthesia A spinal may be indicated in patients who are unfit for any of the above techniques. equipment for ventilating the patient and suction available. ANAESTHESIA FOR COMMONLY PERFORMED UROLOGICAL PROCEDURES CYSTOSCOPY AND RETROGRADE PYELOGRAPHY Local anaesthesia 1 or 2% Lignocaine jelly may be used but is contraindicated in cystitis or infection of the urethra. in the presence of trauma to the urethra or bleeding from the urethra. Record the blood pressure and leave the cuff in place. The patient may need supplementary doses every 20 minutes. Insert an IV cannula. Have an oxygen source. The patient must be medically fit for a general anaesthetic.Electrocautery The use of electrocautery is a contraindication to the use of flammable anaesthetic agents. in patients who present for check cystoscopies for bladder tumours or urethral dilatations. with halothane. Swab the operative field. General anaesthesia using spontaneous ventilation N2O/oxygen and volatile would be suitable. Ketamine/diazepam technique This has been discussed under "Anaesthetic Techniques" in Chapter 14.1 mg/kg IV.
This is suitable in the fit patient who is not obese. • Intra-operative complications are more easily detected if the patient is awake. vomiting. • It provides good operating conditions with analgesia and relaxation. Restlessness may signify absorption of irrigating fluid into the circulation. • Bleeding is significantly reduced. − Controlled ventilation using nitrous oxide. pain may signify accidental perforation of the bladder or prostatic capsule. It may also indicate cardiovascular overload. • It reduces the risk of explosion. e.9% saline or Hartmann’s. All these complications can increase bleeding. • Spinal anaesthesia is especially suitable for older patients. relaxant. or pethidine or relaxant technique with ketamine infusion is useful in the less fit. who may have medical problems. General anaesthesia The use of the EMO with ether is not recommended for trans-urethral resection of the prostate gland because of the use of diathermy and the need for oxygen in this group of elderly patients. oxygen.g. • It reduces post-operative problems such as nausea. oxygen and volatile other than ether. fentanyl. Spinal anaesthesia should reach to the level of T10.g.CIRCUMCISION This can be performed under • Local infiltration (avoid vasoconstrictors in the local anaesthetic) • Ketamine/diazepam • General anaesthesia with spontaneous ventilation • Regional techniques e. dry retching or coughing. spinal • Penile block TRANS URETHRAL RESECTION OF THE PROSTATE Spinal (or epidural block) This is the recommended technique for the following reasons. 154 . IV fluids for the patient should be 0. supplemented with volatile. Special care must be taken with electrical equipment if this technique is used. This is helped by a head down tilt. the obese or bullnecked patient. More suitable techniques would be: − Spontaneous respiration with nitrous oxide.
cardiovascular collapse and death.9% saline is used for irrigation post–operatively for 24 hours. dyspnoea. This causes water intoxication leading to hyponatraemia. Intraoperative Complications • Blood loss. A conscious patient complains of abdominal discomfort and shoulder pain. hypoxia. hypothermia and heavy blood loss increases with duration of surgery. air. • Bladder perforation. Considerable bleeding may occur. 155 .5% glycine is the fluid of choice for TURP intraoperative irrigation. oxygen. confusion. nitrous oxide. cerebral and pulmonary oedema. Surgery should be restricted to 1 hour as the incidence of TURP syndrome. causing fibrinolysis and platelet consumption. Treatment: − Stop surgery − Restrict fluids − Supportive measures for respiratory and cardiovascular problems − Slow correction of hyponatraemia with isotonic saline (occasionally hypertonic saline may be required). Suitable techniques would be: − Spinal anaesthesia − General anaesthesia with controlled ventilation.g. Reabsorption is normally at a rate of 1litre/hour and can be as great as 5 litres in total. 0. This is difficult to assess because it is mixed with irrigation fluid and increases with operating time. e. volatile. SUPRAPUBIC PROSTATECTOMY Relaxation of abdominal muscles is required. • TURP Syndrome This is due to reabsorption of large volumes of water from the prostatic bed. It increases further if plasminogen activators are released from the prostate. Dextrose should not be used as the TURP syndrome is caused in part by hyponatremia (see below). Hyperfibrinolysis and disseminated intravascular coagulation are discussed in more advanced textbooks.Bladder irrigation fluid: 1. relaxant and supplement with opioid.
opioid (e. • Bleeding from the renal pedicle may be excessive. This is managed with an underwater drain. General anaesthesia is necessary. UROLOGICAL SURGERY IN PATIENTS WITH SPINAL CORD INJURIES Patients with spinal cord injuries often lose bladder control.g. morphine or pethidine) and a muscle relaxant. This is prevented by flexing the operating table only moderately. with controlled ventilation using nitrous oxide. Occasionally hypotension may occur after induction of anaesthesia. A 16G cannula should be inserted before the anaesthetic starts. • Thrombosis in the dependent extremity due to obstruction of the venous flow. A rise in blood pressure may require an antihypertensive agent.g. so repeated cystoscopies may be required. noting rises or falls. using elastic bandages and encouraging early ambulation. oxygen. Additional problems • The patient is placed in the lateral jack knife position. Anaesthetic technique Spinal anaesthesia is unsuitable.NEPHRECTOMY The principles outlined for abdominal surgery should be followed. This may be encountered in cystoscopies and trans-urethral resection of the prostate. obstruction of the inferior vena cava. 156 . post-operative atelectasis and if the patient is in the right lateral position. Hartmann’s solution should be commenced. An IV infusion of e. . • Pneumothorax may occur as a result of technical difficulties. volatile. Spinal anaesthesia reduces the complication of hypertension. Blood pressure should be monitored carefully. This is associated with hypoventilation. Autonomic imbalance Paraplegics with spinal cord injuries at or above the level of the 5th thoracic vertebra may respond to distension of the bladder by irrigating fluid with hypertension and bradycardia.