ANAESTHESIA FOR UROLOGIC SURGERY

Deutsch, S - ASA Refresher course in Anaesthetics - 1992; New Orleans

(Peer reviewed)
Surgical and anaesthetic considerations in TURP - Hatch, PD. - AIC
(1987),15,203-211.
Melbourne short course notes - July 1993.

ANATOMIC CONSIDERATIONS

Kidneys

 retroperitoneal, lumbar fossa, paravertebral T12 - L2/3;

 sensory innervation T12 - L2;
 adrenergic fibres enter along renal arteries & are entirely
vasoconstrictive;
 innervation of ureter - T11 - T12 via hypogastric plexus + fibres from
iliohypogastric, ilioinguinal and ext. branch of genitofemoral nerves.
 referred ureteric pain -> inguinal region and scrotum,
 splachnic innervation -> smooth muscle relaxation,
 parasymathetic innervation -> smooth muscle relaxation,

Bladder and prostate

 innervation from T10 - L2, and S2 - S4,

 prostatic capsule continuous with bladder \ S2-4,
 Splachnic innervation --> bladder sm. muscle relaxation and int.
sphincter cont'n parasymathetic innervation --> sphincter inhibition
and bladder wall contraction,

Scrotal and testicular operations require sensory levels >= T10 - L2.

OPERATIVE PROCEDURES

CYSTOSCOPY

 most common procedure performed.

 Anaesthesia from topical to GA/regional.

CIRCUMCISION

 light GA, caudal in the infant provides some post-op analgesia;

 in the adult,
o regional - spinal (low), caudal,
 o local - penile nerve block,
o GA.

PROSTATECTOMY

 Most common operation in males for relief of obstruction due to

prostatomegaly, usually due to BPH, TURP being the lost common.
 50% males over 70 require prostatectomy.
 Mortality: open ~ 0.3-4%;
 TURP ~ 0.9-2.5% - morbidity higher with TURP! - 20-25% vs 12-
18% open.
 MI and other cardiac complications main causes of death - 0.2-0.5%.
 Resectoscope electrically energised, bladder distended with non-ionic
medium usually 1.5% glycine.
 Amount absorbed depends on
o height of bag,
o duration of surgery,
o degree of distension, and
o size of openings into venous sinusoids.
o ~ 15-30 ml.min-1 absorbed.

ANAESTHESIA FOR TURP

60-90% regionals +/- IV supplementation.

Advantages of regional

(i) less blood loss, fewer transfusions;

(ii) reduced incidence DVT/PE;
(iii) no evidence for fewer pulmonary complications;
(iv) reduction in stress response and ? less immune suppression - signif.
unknown;
(v) allows assessment intraop for TURP syndrome;

GA - SV vs IPPV -> better CO2 control -> less bleeding.

Regional - PDPH low incidence using 25g or Sprotte needle - 0.02-0.4%

Hyperbaric bupivacaine, sitting for 1 minute -> minimises splanchnic
blockade with adequate cephalad spread.

Capsular sign - capsular tear -> T10-L2 pain with exposure of venous
sinuses, increased irrigant absorption and risk of TURP syndrome.
Traditionally block kept below T10 to preserve capsular sign, but this risks
higher incidence of unsatisfactory blocks. Onus is on surgeon to keep
observing for large capsular tears which may require retroperitoneal
drainage and termination of procedure.

COMPLICATIONS

1. ANAESTHESIA RELATED

Regional

 inadequate or too high block,

 haemodynamic instability,
 respiratory failure,

General

 inadequate reversal of NMB,

 intubation trauma, tube malposition etc,
 anaphylaxis..............

Minimised by careful monitoring and early intervention.

2. PROCEDURE RELATED

Circulating volume - related to XS absorption due to

- hyponatraemia, glycine toxicity and frank pulmonary oedema/volume
overload, haemolysis.
High percentage of patients with prostate disease have intercurrent CVS
disease & tolerate fluid loads poorly.

TURP REACTION SYNDROME

Constellation of inter-related causes:

(i) dilutional hyponatraemia -> hypo-osmolality syndrome,

(ii) acute water intoxication (if H2O used),
(iii) glycine (including metabolite) toxicity.

Classical signs due to:

cerebral oedema - CNS signs/symptoms;

volume overload - HT, bradycardia, dyspnoea, LVF and CVS collapse;
low [Na+] - ECG changes - QRS prolongation, T inversion.

Incidence of severe hyponatraemia:

6% -> no change [Na+];
70% -> - 8 mmol.l-1 ch. in [Na+];
4% -> - 21 mmol.l-1 ch. in [Na+].

(a) Hyponatraemia

 CNS - restlessness, headache, irritability, confusion, seizures and

coma.
 ECG - QRS widening, ST elevations at [Na+] < 115 mmol.l-1.

[Na+] < 120 mmol.l-1 generally required before symptoms develop.

Rate of decrease more important - ie >= 20-30 mmol during case.
Easily diagnosed in regional anaesthesia, difficult in GA.
Progressive increase in BP is early sign of fluid overload.

(b) Glycine toxicity

- 2.4% isotonic,
- 1.5% is minimum non-haemolysing conc'n -> sl. hypotonic.

Clinical features - related to glycine's role as inhibitory neurotransmitter in

CNS, can be difficult to distinguish from low [Na +]. Each abnormality may
affect different organ systems.
Nausea, malaise, vomiting, mild confusion, stupor and coma, severe
disorientation and transient blindness correlated with the amount of glycine
absorbed.
Irrigant < 1 litre, symptoms unlikely - 1.5 - 2.0 l absorbed irrigant toxicity
likely.
Glycine metabolism results in amino acids
- oxalate, proline, alanine and aminobutyrate and ammonia which may
have a role in glycine toxicity.

NB 1.5 litres 1.5% gly. reduces [Na] - 140 -> 127 mmol.l -1, & osmo. - 290
-> 282.

Management

- prevention best!!!
- inform surgeon immediately, check bag height;
- check [Na+] & osmolality urgently;
- loop diuretic, (NB will promote further Na+ losses, but water > Na+);
- fluid restriction, avoidance D5%W;
- supplemental O2;
- hypertonic (3%) Na+ 100 ml over 30 minutes for severe CNS or CVS
symptoms, rapid [Na+] correction results in central pontine
myelinolysis with permanent brain damage.
Total correction to normonatraemia not indicated - aim for clinical
improvement and [Na+] >= 125 mmol.l-1.
NB - 3% NaCl = 513 mmol.l-1, 5% NaCl = 855 mmol.l-1.
Mannitol - possible indication, but increases risk of overload.

Risks - CPM, fluid overload \ CVP monitoring indicated if hypertonic saline

used.

(c) Haemolysis

Due to hypotonic irrigant -> RBC haemolysis -> haemoglobinaemia,

haemoglobinuria and anaemia.

Clinical manifestations

Chills, loin pain, pigmenturia, increased BP, bradycardia.

Renal afferent arteriolar constriction due to free Hb -> ATN, esp. if anaemia
and further CVS decompensation occurs.

Management - adequate filling presures, osmotic diuretics, low dose DA

infusion.

(d) Circulatory overload

Increases bleeding due to raised venous pressure.

Changes in central volume with changes in position ie into and out of
lithotomy -> ~ 800 ml sequestered in lower extremity in classical lithotomy
position, less in "modified" lithotomy position ie legs at 45deg..
Irrigant absorption - 15-30 ml.min-1 operating time.
Assessment - pre and postop weight easiest.

Strategies to minimise:

(i) hydrostatic bag pressure <= 50-60 cmH2O - > 70 cmH2O = 2-fold
increased absorption;
(ii) short operating time - < 60-90 minutes;
(iii) minimise intra-vesical pressure -> frequent emptying;
(iv) adequate haemostasis.

(e) Haemorrhage

- difficult to quantify,
- measurement of the irrigant is most effective,
- communication between surgeon and anaesthetist most important
Measurement methods:-
(i) radioactive RBC/albumin labelling,
(ii) changes in electrical conductivity of irrigant,
(iii) colorimetric methods - Hb estimation of sample of all irrigant used
during the case:

Blood loss = Hb (irrigant) g.l-1x vol.(irrigant) ml / Hb(patient) g.l-1

Guessing blood loss will result in over-transfusing.
Average blood loss for TURP ~ 4-500 ml irrespective of anaesthetic.
Open prostatectomy - average 1050 ml; GA results in TWICE the
transfusion rate as regional.
Type of anaesthesia makes little difference in TURP -> ~ 2.6-4.6 ml.min -
1
 blood loss whatever technique used.
Infection increases bleeding, cooled irrigant may decrease bleeding ->
hypothermia.

Fibrinolysis

XS bleeding due to local plasminogen activation by urinary urokinase ->

systemic fibrinolysis in < 1% cases. More common with malignancy.

E-ACA -> plasminogen inhibitor. Theoretical risk of increased systemic

thrombosis. Dose - 1 g.hour-1 for 24 hours.

Bleeding increased by

- large gland,
- infection,
- malignancy -> smaller gland, quicker operation,
- open vs closed,
- duration of surgery - > 60-90 min -> dramatic increase,
- venous pressure,
- attention to haemostasis,
- fibrinolysis.

(f) Hypothermia

- elderly patients, cool irrigant, exposure lower limbs, water spilt on

perineum.

(g) Perforation

- (1% TURPs) - urethral, intraperitoneal, extraperitoneal or capsular with

peri-prostatic extravasation -> 2deg. to over-distension or instrumentation;
- abdominal, suprapubic and/or shoulder tip pain may indicate
intraperitoneal extravasation (if sensory block below T10) -> "shock" like
picture can develop if severe.

(h) Erection

- spinal will not always prevent.

(i) Bacteraemia

- gram negatives from infected urinary tract -> blood cultures is rigors,
fever, hypotension. Treat if any evidence of gram neg. septicaemia.

(j) Electrical hazards

- skin burns if ground plate incorrectly placed.

- pacemaker interference possible.

(k) Adductor spasm

- due to stimulation of obturator nerve as it passes lateral to bladder neck -

can block if problematical.

(l) DVT/PE

Incidence DVT - TURP ~ 6-10%; open - 24-47%.

Morbidity - 0.2%, mortality <0.1%.
TURP - less venous stasis, less pain & earlier mobilisation, less local
trauma.

Prophylaxis - depends on number of risk factors - age, intercurrent illness,

previous DVT, malignancy, obesity, immobility, low CO states, VVs.
- options - TEDs, SC heparin (LMWH), calf stimulators and compressors,
dextrans, regional anaesthetic.

ANAESTHETIC CONSIDERATIONS - TURP

Ideal anaesthetic

- adequate analgesia;
- minimal physiological disturbance;
- no compromise of compensatory mechanisms;
- adequate muscle relaxation;
- minimise drug doses, minimal blood losses;
- permit early recognition of complications.
Spinal anaesthetic

Method of choice. Requires minimal anaesthetic with minimal physiological

insult and low incidence of PDPH. Resp. function preserved, and volume
preload prevents severe hypotension.

Require block from - 

(i) T10 - L3 - Sic via sup. hypogastric plexus -> motor to bladder incl.
internal sphincter, sensation to trigone;
(ii) S2-4 - Psic via pelvic splanchnics -> motor to sphincter urethrae,
sensation to glans, urethra and perineum.

Drugs - (a) heavy lignocaine 5% - 3-4 ml (150-200 mg);

(b) isobaric 0.5% bupiv. - 2-4 ml (10-20 mg);
(c) heavy bupiv. 0.5% - 2-4 ml.
Long duration advantageous - pain free recovery with decreased analgesia
requirements.
If regional C/I - GA using controlled or spontaneous breathing.
Relaxant technique -> better CO2 control, with less bleeding possibly.

Preop. - treat infection, full assessment and optimisation of medical

condition.
High proportions of intercurrent disease, eg., DM, CAD, CAL, CNS,
vascular. Regional anaesthesia well tolerated, and not associated with a
significant increase in perioperative cardiac morbidity.

Monitoring - HR, BP, SpO2, ECG, pigmenturia, conscious level if regional,

RR using capnography in sedated patients and/or those with chronic lung
disease.

Open prostatectomy

- increased blood loss regional vs GA,

- epidural associated with a decrease in the incidence of DVT.

Radical cystectomy

- + loop ileostomy -> long operation with significant blood loss,
- GA/epidural combination used with success; reduced incidence of
DVT/PE.

SURGERY FOR NEPHROLITHIASIS

1. EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY

Most common non-invasive remedy for nephrolithiasis - stones > 20mm ->
too many fragments \ limited to stones < 20mm diameter.
Biplanar fluoroscopy to apply shock waves to the flank, focusing on the
target stone.
Several thousand shocks per treatment -> stone disintegrates.

Side-effects

- haemorrhage,
- blistering of the skin where the shock wave enters,
- renal oedema and haemorrhage into the renal pelves.
Outpatient basis usually.
VT or VF during the vulnerable period of the cardiac cycle during early
development of the technique .
Shock waves now linked to the R-wave.
Ventilation causes the stone to move, \ heart-synchronised ventilation
overcomes ECG and movement problems.
High frequency jet ventilation also used to overcome stone movement.
No differences in morbidity GA vs regional - ie GA with HFJV vs regional
with low volume respiration.
EDB to T4 - T6 required.
Monitoring includes SpO2; NB ear protection.
Modern 2nd generation lithotripters generate shocks through a moistened
gel interface, avoiding immersion in water bath with minimal circulatory
side effects, less pain due to lower power and finer focus.

Patients

all types and ages.

GA may be best technique in terms of - simplicity, speed, patient comfort -
hard table, uncomfortable position and variable length.
Spinals associated with high incidence of PDPH - 45% - reduced to 8%
using prophylactic blood patch.
Sedation possible, but large narcotic requirement with concern about airway
adequacy.
O2 supplementation in all cases.

Pharmacological manipulation of HR - shock synchronised with ECG (R

wave). Higher HR decrease duration of procedure but rates greater than
130/min result in lithotripter reverting to half speed.
Newer machines deliver double shock.

2. PERCUTANEOUS NEPHROLITHIASIS.
For stones not amenable to ESWL.
All patients, ASA I-III, generally healthier than average urology patients.
Epidural is effective for placement of nephrostomy tube under I-I control,
and destroying the stone in the OR.
GA preferable -> lithotomy to prone position.

Prone position - bolster under chest and pelvis -> abdo excursion during
inspiration.
BUT in this procedure - prone decubitus position with bolster under one
side of the abdomen (operated side) to reduce the parenchymal distance
from surface to renal tract, avoiding renal vessels.
In practice respiratory compromise seldom seen.
IVC obstruction possible but uncommon since bolster is unilateral.
IV - same side as operation -> arm is abducted.

Potential problems:
(a) retroperitoneal fluid extravasation if renal pelvis perforated;
(b) bleeding - 6% cases require transfusion -> occasionally need open
haemostasis;
(c) absorption of N/S irrigant from retroperitoneal space in prolonged cases;
(d) thermal control;
(e) sepsis - 6% \ antibiotics routine;
(f) ileus - 2deg. to retroperitoneal fluid (brief duration);
(g) pain - 50% need narcotics in first 24 hours; ketorolac OK for short-term
use;
(h) potential for pneumothorax.

OPERATIONS ON THE KIDNEY INCLUDING

TRANSPLANTATION.

Major problems in patients with renal disease -

(i) HT and cardiac failure,
(ii) Anaemia,
(iii) Coagulopathy,
(iv) Hyperkalaemia/acidosis,
(v) Increased susceptibility to infection.
Lateral decubitus position common with kidney rest.

Hypotension is common - due to

- compression of the great vessels,
- pooling in the extremities,
- decreased VR from the upper body.
Careful volume loading and gentle positioning minimises the BP fall.
ESRF not a major problem provided electrolytes near normal range,
minimal coag. abnormalities, and drug metabolism accounted for - abnormal
Pb, changes in Vd, decreased renal elimination of muscle relaxants and
opioids in particular.
Steroid cover often indicated.

Preop assessment 
- [K+], ECG, CXR,
- coagulation studies,
- Hb, X-match,
- steroids/immunosuppressants yes or no,
- when was last dialysis,
- A-V fistula or shunt location -> avoid IV placement.

Monitoring 
- clinical monitoring - colour, perfusion, mental state (in regional),
- CVP often indicated to avoid fluid overload,
- ECG, SpO2, capnography, PNS, temp, blood loss, HCT, arterial line
indicated if severe preop HT, large volume changes anticipated or if BP
maintenance critical,
- urinary catheter.

Drugs 
- atracurium , vecuronium best relaxants to use,
- morphine and its metabolites renally excreted, \ prolonged t1/2,
- avoid ketorolac.

CONCLUSION

Complex urological cases are often long duration with potential for large
blood losses and transfusion requirements eg - renal tumour resection and
LN clearance with extensive dissection;
- cystectomy and conduit reconstruction - 4-6 hours.

Considerations 
(i) Thermal control - ambient temp. increase,
- warm IV fluids - coils and warmers,
- warming blankets/Bair hugger,
- wrap exposed parts, limit evaporative losses -> bowel bag,
- warm and humidify inspired gases -> Fisher and Paykel humidifier.
(ii) Pressure points and nerve protection - wrap heels and check
periodically,
- brachial plexus at risk with both arms abducted \ abduction < 90deg. with
arms in pronation.
(iii) DVT prophylaxis - calf-compressors, SC heparin, calf stimulators, TED
stockings,
regional -> reduces incidence of DVT effectively.
(iv) Blood loss - fluid requirements always greater than anticipated - 2-4
litres positive often.
- NB Head-down position -> significant upper airway oedema possible \
caution before extubation.
- losses associated with bowel exposure - ~ 10-20 ml.kg.-1hr-1.
- massive transfusion sometimes -> involve haematologist early if
anticipated, monitor clotting and HCT, FFP, platelet replacement if
indicated.

Blood requirements 
TURP - G & H only if consultant surgeon;
- 2 units if registrar;
Open prostatectomy - 2 units X-matched;
Cystectomy - 4 units X-matched;
Nephrectomy with IVC dissection - 6 units minimum.
(v) Technique - ED/GA combination advantageous:-
(a) reduction of blood losses;
(b) greater haemodynamic stability;
(c) DVT risk reduced;
(d) analgesia into postoperative period;
(e) lower concentrations GA agents -> rapid awakening and earlier
extubation.