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ANAESTHETIC MANAGEMENT

OF ENDOSCOPIC UROLOGIC
PROCEDURES

DR. RICHA JAIN

University College of Medical Science & GTB Hospital, Delhi


ENDOSCOPIC UROLOGIC PROCEDURES

Endoscopic urologic procedures are performed on kidneys,


ureters, urinary bladder, prostate, urethra.

CYSTOSCOPY
URETEROSCOPY

TRANSURETHRAL RESECTION OF BLADDER


TUMOUR (TURBT)
TRANSURETHRAL RESECTION OF PROSTATE
(TURP)
PERCUTANEOUS NEPHROLITHOTRIPSY ( PCNL)
ANATOMIC CONSIDERATIONS
The sensory nerve supply to genitourinary organs
is primarily thoracolumbar and sacral outflow
thus, well adapted for regional anesthesia.
PAIN CONDUCTION PATHWAYS
ORGAN SYMPATHETIC PARASYMPATHETIC SPINAL LEVEL
OF PAIN
CONDUCTION

KIDNEY T8 L1 CN X (VAGUS) T10 L1

URETER T10 L2 S2 S4 T10 L2

BLADDER T11 L2 S2 S4 T11 L2(DOME)


S2 S4(NECK)
PROSTATE T11 L2 S2 S4 S2 S4

PENIS L1, L2 S2 S4 S2 S4
CYSTOSCOPY
CYSTOSCOPY
The most common urologic
procedure
Indications
Diagnostic
Hematuria
Recurrent urinary infections
Urinary obstruction
Bladder biopsies
Retrograde pyelograms
Therapeutic
Resection of bladder tumors,
Extraction or laser lithotripsy of
renal stones,
Placement or manipulation of
ureteral catheters (stents) .
ANAESTHETIC MANAGEMENT
Varies with age, the indication of the procedure
and patient preference
General anesthesia - children.
Topical anesthesia with or without sedation
diagnostic studies.
Regional or general anesthesia operative
cystoscopies.
TRANSURETHRAL
RESECTION OF BLADDER
TUMOUR (TURBT)
TURBT
For diagnosing and treating bladder cancers
PROCEDURE
o Patient laid in lithotomy position.
o Cystoscope or resectoscope is introduced into the
bladder.
o The tumor is identified & resected.
o Coagulating current is used to cauterize the base of
the tumor.
o Typical duration of procedure: around 1 h.
ANAESTHETIC CONSIDERSTIONS
Preoperative Considerations
Bladder tumor is usually seen in older populations who
may have pre-existing medical problems.
Pt may have hematuria, urinary infection.
Intraoperative Concerns
Lithotomy positioning
Bladder perforation.
Bleeding.
Obturator reflex.
Stimulation of the obturator nerve by electrocautery may
cause the thigh muscles to contract violently, leading to
bladder perforation.
This reflex may be eliminated by blocking neuromuscular
transmission using a muscle relaxant during GA or by
obturator nerve block.
TURBT CHOICE OF ANAESTHESIA

Anaesthetic technique regional or general anesthesia.


Neuraxial regional block preferred.

Anaesthetic level to T10 is required.

GA is indicated when patient requires ventilatory or


haemodynamic support.
TRANSURETHRAL
RESECTION OF
PROSTATE (TURP)
TURP - INTRODUCTION
The current gold standard surgical treatment for
benign prostatic hyperplasia (BPH).
TURP is the 2nd most common procedure in men over
65 yrs of age.

BPH affects 50% of males at 60 years and 90% of 85-


year-olds, so TURP is most commonly performed on
elderly patients, a population group with a high
incidence of cardiac, respiratory and renal disease.

TURP carries unique complications because of the


need to use large volumes of irrigating fluid for the
endoscopic resection.
ANATOMY OF PROSTATE
LOCATION: in the pelvis, below neck
of urinary bladder
SHAPE : inverted cone
SIZE : 4x3x2 cm
Weight : 8 gm
5 LOBES:
BPH median, anterior, 2 lateral
Prostatic carcinoma posterior,
lateral
Composed of glandular tissue in
fibromuscular stroma.
2 capsules:
True formed by condensation of
prostatic tissue
False formed by visceral layers of
pelvic fascia.
ANATOMY OF PROSTATE
NERVE SUPPLY BLOOD SUPPLY
Sympathetic supply Arterial supply
T11-L2 Inferior vesical artery
Inferior hypogastric Middle rectal artery
plexus
Internal pudendal
Parasympathetic artery
supply Venous supply
S2,3,4 Vesical plexus
Pelvic splanchnic Internal pudendal
nerve veins
Vertebral venous
plexus
TURP - PROCEDURE

Performed in the lithotomy position


using a resectoscope, through which a
diathermy loop is passed.
The prostatic tissue is resected in
small strips under direct vision using
the diathermy loop.
The bladder is continuously irrigated
with fluid.
At end of the procedure, a three-
lumen catheter is inserted and
irrigation is continued for up to 24 h
after operation.
The procedure usually takes 3090
min.
IRRIGATION FLUIDS

Uses Characteristics of
distends bladder and Ideal irrigation fluid:
prostatic urethra 1. Transparent
flushes out blood and 2. Isotonic
tissue debris 3. Electrically inert
improves visibility 4. Non hemolytic
5. Inexpensive
6. Not metabolizable
7. Rapidly excretable
8. Non toxic
9. Easy to sterilise
SOLUTION OSMOLALITY ADVANTAGES DISADVANTAGES
(mOsm/kg)
DISTILLED 0 (hypo) Electrically inert Hemolysis
WATER Improved Hemoglobinuria
visibility Hemoglobinemia
Inexpensive Hyponatremia
GLYCINE 220 (iso) Less likelihood of Transient
(1.5%) TURP syndrome postoperative visual
GLYCINE 175 (hypo) syndrome,
(1.2%) Hyperammonemia,
Hyperoxaluria
NORMAL 308 (iso) Less incidence of Ionized, cannot be
SALINE TURP syndrome used with cautery
(0.9%)
RINGER 273 (iso) Ionized, cannot be
LACTATE used with cautery
SOLUTION OSMOLALITY ADVANTAGES DISADVANTAGES
(mOsm/kg)
MANNITOL 275 (iso) Isomolar Osmotic diuresis,
(5%) solution Acute intravascular
Not metabolized expansion
SORBITOL 165 (hypo) Same as glycine Hyperglycemia,
(3.5%) Lactic acidosis
Osmotic diuresis
GLUCOSE 139 (hypo) Hyperglycemia
(2.5%)
UREA 167 (hypo) Increases blood urea
(1%)
CYTAL 178 (iso) Expensive, not easily
(sorbitol 2.7% available
+mannitol
0.54%)
FACTORS AFFECTING AMOUNT AND
RATE OF FLUID ABSORPTION

Size of gland (25ml/gm of prostate)


Number and size of open sinuses

Hydrostatic pressure of irrigating fluid

Duration of procedure (@ 20-30 ml/min)

Integrity of capsule

Venous pressure at irrigant-blood interface

Vascularity of diseased prostate


PREOPERATIVE CONSIDERATIONS
Patients for TURP are frequently elderly with coexistent diseases.
- cardiac disease 67%
- cardiovascular disease 50%
- abnormal electrocardiogram (ECG) 77%
- chronic obstructive pulmonary disease 29%
- diabetes mellitus 8%

Occasionally, patients are dehydrated and depleted of essential


electrolytes (long-term diuretic therapy and restricted fluid
intake).

Long standing urinary obstruction can lead to impaired renal


function and chronic urinary infection.
About 30% of TURP patients have infected urine preoperatively
PREOPERATIVE EVALUATION

History and examination of all organ systems

INVESTIGATIONS
Hb, TLC, DLC, platelet count
Blood sugar
Blood urea, S. Creatinine, S. Electrolytes
Urine R/M
ECG
Chest X-ray
Blood grouping and cross matching
PREOPERATIVE PREPARATION
Optimization of pre-existing co-morbid conditions
Consideration of ongoing drug therapy

Antibiotic prophylaxis (in case of urinary tract


infection or urinary obstruction)
Arrangement of blood
CHOICE OF ANAESTHESIA
Regional anaesthesia is the technique of choice for TURP.

Advantages of regional over general anaesthesia


1. Allows monitoring of mentation and early signs of TURP syndrome
and bladder perforation
2. Promotes peripheral vasodilation , reducing circulatory overload
3. Reduces blood loss, requiring fewer transfusions
4. Avoids effects of general anaesthesia on pulmonary pathology
5. Good early post-operative analgesia
6. Reduced incidence of post-operative DVT/PE
7. Neuroendocrine and immune response are better preserved
8. Lower cost

General anaesthesia preferred when regional is contraindicated.


REGIONAL ANAESTHESIA

TECHNIQUES:
Subarachnoid block
Epidural block
Caudal block
Saddle block

Level of sensory block


T10 dermatome level to eliminate discomfort
caused by bladder distention
T9 dermatome level enable to elicit capsular sign
(pain on perforation of prostatic capsule)
REGIONAL ANAESTHESIA

Subarachnoid block is preferred.


Advantages of SAB over epidural anaesthesia:
Technically easier to perform
Dense motor blockade
No sacral sparing
Lower incidence of PDPH
MONITORING
ECG
Blood pressure

Pulse oximetry

Temperature

Mentation

Blood loss

S. electrolytes (serial)

EtCO2 if GA is used
INTRAOPERATIVE CONSIDERATIONS

Lithotomy position
TURP syndrome

Bladder perforation

Hypothermia

Transient bacterial septicemia

Hemorrhage and coagulopathy

Main challenges: blood loss


and TURP syndrome
LITHOTOMY POSITIONING
Both lower limbs raised
together, flexing the hips
and knees simultaneously.
Ensure proper padding at
edges and angulations.
While lowering, legs
brought together at knees
and then lowered slowly to
prevent stress on spine
and sudden fall in BP.
LITHOTOMY POSITIONING
Physiologic changes Problems with
with lithotomy lithotomy position
Decreased FRC Injury to nerves
Increased venous Injury to fingers
return on elevation of Compression of major
legs vessels at joints
Decreased venous Lower extremity
return following Compartment syndrome
lowering of legs Aggravation of preexisting
Exaggeration of lower back pain
hypotension with SAB
TURP SYNDROME
Rapid absorption of a large-volume irrigation solution.
Can occur 15 min after resection or upto 24 hrs postop.
Incidence : 1 8%
Characterized by intravascular volume shifts and
plasma-solute (osmolarity) effects:
Circulatory overload
Water intoxication
Hyponatremia
Hypoosmolality
Hyperglycinemia
Hyperammonemia
Hemolysis
MECHANISM OF TURP SYNDROME
TURP SYNDROME WATER INTOXICATION

Cause : cerebral edema


Signs and symp:

Somnolence, restlessness, seizures, coma


CNS decerebrate posture, clonus, +ve
babinskis reflex
Eyes papilloedema, dilated and non reactive
pupils
EEG low voltage b/l.
TURP SYNDROME - HYPONATREMIA

Cause : excessive absorption of Na free irrigation fluid


During TURP, S.Na falls by 3 to 10 meq/l.
SIGNS AND SYMPTOMS OF Acute Hyponatremia
Nausea
Vomiting
Irritability
Mental confusion
Cardiovascular collapse
Pulmonay edema
Seizures
MANIFESTATIONS OF HYPONATREMIA
SERUM Na+ CNS CVS ECG
(mEq/l) changes changes Changes

120 Confusion Hypotension wide QRS


Restlessness bradycardia complex

115 Somnolence Cardiac Bradycardia


Nausea depression Wide QRS
complex
Elevated ST
segment
110 Seizures CHF Ventricular
Coma tachycardia or
fibrillation
TURP SYNDROME - HYPERGLYCINEMIA

Glycine, a non essential amino acid, is an inhibitory


neurotransmitter in spinal cord and retina.

Metabolized in liver by oxidative deamination to


ammonia and glyoxylic and oxalic acid.

When absorbed in large amounts, has direct toxic


effects on heart and retina.

Manifestations of glycine toxcity: nausea, headache,


malaise, weakness, visual distubances ( transient
blindness), seizures, encephalopathy.
TURP SYNDROME - HYPERAMMONEMIA
Excessive absorption of
glycine may lead to
hyperammonemia (blood
NH3> 500mmol/L).

S/S: nausea, vomiting,


comatose for 10-12 hrs
and awakens when
blood NH3 < 150
mmol/L.

Explanation : arginine
deficiency
TURP SYNDROME CLINICAL FEATURES
System Signs and Symptoms Cause
Neurologic Nausea, restlessness, visual Hyponatremia and
disturbances, confusion, hypoosmolality
somnolence, seizures,coma,death Hyperglycinemia
Hyperammonemia

Cardiovascular Hypertension, reflex bradycardia, Rapid fluid absorption


pulmonary edema, CVS collapse
Hypotension Third spacing
ECG changes(wide QRS, elevated Hyponatremia
ST segments, vent arrhythmia)
Respiratory Tachypnea, oxygen desaturation, Pulmonary edema
cheyne- stokes breathing
Hematologic Disseminated intravascular Hyponatremia and
hemolysis hypoosmolality
Renal Renal failure Hypotension, hemolysis,
hyperoxaluria
Metabolic Acidosis Deamination of glycine
MEASUREMENT OF FLUID ABSORPTON

1. Volume absorbed = (preoperative Na+/


postoperative Na+ ) ECF - ECF
2. Volumetric fluid balance (diff. b/w amt of
irrigation fluid used and volume recovered.)
3. Gravimetry (measure rise in body weight)
4. CVP monitoring
5. Breath ethanol measurement
6. Isotopes
TURP SYNDROME - PREVENTION
Early diagnosis and prompt treatment
Correction of fluid and electrolyte abnormalities
preoperatively
Cautious adminstration of IV fluids

Limitation of hydrostatic pressure of irrigation


fluid to 60cm
Restrict duration of TURP to 1 hr

Bipolar resectoscope

Vaporization methods

Local vasoconstrictors
TURP SYNDROME - MANAGEMENT
Notify surgeon and terminate surgery.
Ensure oxygenation

Restrict fluids

Pulmonary edema : intubate and IPPV

Bradycardia, hypotension: atropine, adrenergic agents

Seizures : BZD, thiopentone, phenytoin, i.v.Mg2+

Invasive monitoring of arterial and CVP

Send blood sample for electrolytes, arterial blood gas


analysis.
TURP SYNDROME - MANAGEMENT
Treat mild symptoms (if S. Na+ > 120 mEq/L)
with fluid restriction and loop diuretic
(furosemide)
Treat severe symptoms (if S. Na+ <120 mEq/L)
with 3% NaCl IV at rate < 100 ml/ hr.
BLADDER PERFORATION
Incidence 1%
Causes
Trauma by surgical instrument
Overdistention of bladder with irrigation fluid

Manifestation
Early sign : sudden decrease in return of irrigation solution
from bladder
Extraperitoneal perforations : pain in periumbilical,
inguinal or suprapubic region
Intraperitoneal : generalised abdominal pain, shoulder tip
pain, abdo rigidity
BLOOD LOSS
Difficult to quantify blood loss.
Visual estimation of haemorrhage may be difficult due to
dilution with irrigation fluid.
Usual warning signs (tachycardia, hypotension) masked by
overhydration and effects of regional anaesthesia.

Blood loss can be estimated on the basis of


Resection time (2-5ml/min)
Size of prostate (7-20ml/g)
No. of open venous sinuses

Intraoperative BT should be based on preop Hb, duration


and difficulty of resection and clinical assessment of pt
condition.
COAGULOPATHY
Causes of excessive bleeding
Dilutional thrombocytopenia
DIC as a result of release of prostatic particles rich in
thromboplastin into blood
Local release of fibrinolytic agents (plasminogen and
urokinase)

Treatment administration of FFP, platelets


blood transfusion
HYPOTHERMIA
Continuous fluid irrigation causes loss of temp @1oC/hr.

Elderly patients have reduced thermoregulatory capacity.


Unintentional hypothermia is asso. with a significantly higher
incidence of postoperative MI.
Postoperative shivering asso. with hypothermia may dislodge
clots and promote postoperative bleeding.

Monitor body temp of patient to maintain normothermia.


Appropriate measures to reduce heat loss are: warming
blankets, heated irrigation solution and warm I/V fluids.
BACTEREMIA AND SEPTICEMIA
INCIDENCE 6-7%
Causes
Release of bacteria from prostatic tissue
Preoperative indwelling urinary catheter
Preoperative UTI

C/F chills, fever, tachycardia


T/T antibiotic, supportive care
POSTOPERATIVE COMPLICATIONS

Hypothermia
Hypotension

Haemorrhage

Septicaemia

TURP syndrome

Bladder spasm

Clot retention

Deep vein thrombosis

Postoperative cognitive impairment


PERCUTANEOUS
NEPHROLITHOTOMY
AND NEPHROLITHOTRIPSY
(PCNL)
PERCUTANEOUS NEPHROLITHOTOMY

The procedure of choice for removing complex and


large renal stones.
Imp. Indications of PCNL :
Stone size >/= 2.5 cm.
Stones resistant to ESWL
Staghorn stones in lower calyx

Advantages of percutaneous method


Lower morbidity and mortality
Faster convalescence
Small incision
Minimum operative and postoperative complications.
ANATOMICAL CONSIDERATIONS

Kidneys are retroperitoneal


organs, located in
paravertebral gutters.
Right kidney lies adjacent to
12th rib, liver, duodenum and
hepatic flexure of colon.
Left kidney is related to 11th
and 12th ribs, stomach,
pancreas, spleen and splenic
flexure of colon.
Superior pole in direct contact
with diaphragm.
PCNL : PROCEDURE

PCNL consists of gaining


percutaneous access to the
kidney collecting system
and performing stone
disintegration, usually
with ultrasonic or
pneumatic lithotripters.
PERCUTANEOUS APPROACHES
Subcostal /Intercostal approach
Intercostal puncture is made
over lateral portion of rib but medial to viscera
during expiration
A hollow needle placed into the renal collecting system under
fluoroscopy

A guide wire inserted through the needle and Dilators passed over
the wire

After tract dilation, a working sheath is left in place

Nephroscope inserted to directly visualize stone

Small stone grasped under direct vision


Larger stones fragmented by ultrasound or electrohydraulic probe

A nephrostomy tube is left to drain the system


INTRAOPERATIVE COMPLICATIONS

HAEMORRHAGE

INJURY TO RENAL PELVIS

FLUID ABSORPTION

INJURY TO PLEURA

INJURY TO ADJACENT ORGANS

SEPTICEMIA
ANAESTHETIC TECHNIQUE

PCNL can be performed under general or regional


anesthesia.
General anesthesia is preferred.
Patient is laid in prone/ lateral oblique position.
ANAESTHETIC CONSIDERATIONS

POSITION - Prone / lateral oblique position

INTRATHORACIC COMPLICATIONS
Most often injured organ during PCNL : lung and pleura.
Risk of injury increases with more superior punctures.

Approach Incidence
Subcostal 0.5%

Supra-12th rib 1.5 12%

Supra 11th rib 23.1%


ANAESTHETIC CONSIDERATIONS
Close coordination of percutaneous access puncture
and tract dilation with respiration is essential to
minimise pleural injury.
Monitoring of airway pressure, ETCO2 , SpO2
required.
Fluoroscopic monitoring of chest during procedure
is a sensitive means of timely diagnosis of
pneumothorax or hydrothorax.
A chest X-Ray recommended in the recovery room.
ANAESTHETIC CONSIDERATIONS
Acute anemia
due to blood loss or hemodilution .
Repeat Hb measurement should be considered in the
perioperative period.

Fluid absorption
due to high pressure fluid irrigation in presence of venous
injury or collecting system perforation.
Can lead to hypothermia, TURP syndrome, sepsis.
ANAESTHETIC CONSIDERATIONS
Hypothermia
due to large amount of fluids administered for
irrigation.
Causes shivering, peripheral vasoconstriction and
delayed drug clearance.
Prevention by use of warmed intravenous and
irrigation fluids.

Septicemia
All patients have urine cultures done preoperatively
with administration of an appropriate antibiotic
REFERENCES
Millers Anesthesia 7th Editon. Anesthesia and renal and
genitourinary system.
Baraschs Clinical Anesthesia 5th Edition. The renal system
and anesthesia for urologic surgery.
Yao and Artusios Anesthesiology problem oriented patient
management. 6th Edition.
Clinical anesthesiology by Morgan and Mikhail. 4th Edition.
Anesthesia for genitourinary surgery.
Vsevold Rozentsveig. Anesthetic considerations during
percutaneus nephrolithotomy. Journal of Clinical
Anesthesia 2007:19,351-355.
Dietrich Gravenstein. Transurethral resection of prostate
(TURP) syndrome: a review of pathophysiology and
management. Anesth Analg 1997;84:438-46.
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