ANAESTHETIC MANAGEMENT

OF ENDOSCOPIC UROLOGIC P
ROCEDURES
ENDOSCOPIC UROLOGIC PROCEDURES

 Endoscopic urologic procedures are performed on kidneys, u

reters, urinary bladder, prostate, urethra.

 CYSTOSCOPY
 URETEROSCOPY

 TRANSURETHRAL RESECTION OF BLADDER TUM

OUR (TURBT)
 TRANSURETHRAL RESECTION OF PROSTATE (T
URP)
 PERCUTANEOUS NEPHROLITHOTRIPSY ( PCNL)
ANATOMIC CONSIDERATIONS
 The sensory nerve supply to genitourinary organs
is primarily thoracolumbar and sacral outflow th
us, well adapted for regional anesthesia.
PAIN CONDUCTION PATHW
AYS
ORGAN SYMPATHETIC PARASYMPATHETIC SPINAL LEVEL OF PAI
N 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

Cytoscopy
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 re
nal stones,
 Placement or manipulation of uret
eral catheters (stents) .
ANAESTHETIC MANAG
EMENT
 Varies with age, the indication of the procedure a
nd patient preference
 General anesthesia - children.
 Topical anesthesia with or without sedation –
diagnostic studies.
 Regional or general anesthesia – operative
cystoscopies.
TRANSURETHRAL RESEC
TION OF BLADDER TUMO
UR (TURBT)
TURBT
 For diagnosing and treating bladder cancers
 PROCEDURE
o Patient laid in lithotomy position.
o Cystoscope or resectoscope is introduced into the blad
der.
o The tumor is identified & resected.
o Coagulating current is used to cauterize the base of t
he tumor.
o Typical duration of procedure: around 1 h.
Anaesthetic considerstions
 Preoperative Considerations
 Bladder tumor is usually seen in older populations who m
ay 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 th
e thigh muscles to contract violently, leading to bladder perforatio
n.
 This reflex may be eliminated by blocking neuromuscular transmi
ssion using a muscle relaxant during GA or by obturator nerve blo
ck.
T
URBT – 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 hae

modynamic support.
TRANSURETHRAL R
ESECTION OF PROS
TATE (TURP)
TURP - INTRODUCTION
 The current gold standard surgical treatment for be
nign prostatic hyperplasia (BPH).
 TURP is the 2nd most common procedure in men ov
er 65 yrs of age.

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

-year-olds, so TURP is most commonly performed o
n elderly patients, a population group with a high i
ncidence 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, la
teral
 Composed of glandular tissue in fibro
muscular stroma.
 2 capsules:
 True – formed by condensation of
prostatic tissue
 False – formed by visceral layers o
f pelvic fascia.
ANATOMY OF PROSTATE
NERVE SUPPLY BLOOD SUPPLY
 Sympathetic supply  Arterial supply
 T11-L2  Inferior vesical artery
 Inferior hypogastric pl  Middle rectal artery
exus
 Internal pudendal arte
 Parasympathetic supp ry
ly  Venous supply
 S2,3,4  Vesical plexus
 Pelvic splanchnic nerv  Internal pudendal vei
e ns
 Vertebral venous plex
us
TURP - PROCEDURE

 Performed in the lithotomy position u

sing a resectoscope, through which a
diathermy loop is passed.
 The prostatic tissue is resected in sm
all strips under direct vision using th
e diathermy loop.
 The bladder is continuously irrigated
with fluid.
 At end of the procedure, a three-lum
en catheter is inserted and irrigation
is continued for up to 24 h after opera
tion.
 The procedure usually takes 30–90 m
in.
IRRIGATION FLUIDS

 Uses  Characteristics of Idea

 distends bladder and p l irrigation fluid:
rostatic urethra 1. Transparent
 flushes out blood and t 2. Isotonic
issue 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 (mO ADVANTAGES DISADVANTAGES
sm/kg)
DISTILLED WA 0 (hypo) Electrically inert Hemolysis
TER Improved visibility Hemoglobinuria
Inexpensive Hemoglobinemia
Hyponatremia
GLYCINE (1.5% 220 (iso) Less likelihood of T Transient postoperative
) GLYCINE (1.2 URP syndrome visual syndrome,
%) 175 (hypo) Hyperammonemia,
Hyperoxaluria
NORMAL SALI 308 (iso) Less incidence of TU Ionized, cannot be used
NE (0.9%) RP syndrome with cautery

RINGER LACTA 273 (iso) Ionized, cannot be used

TE with cautery
SOLUTION OSMOLALITY (mOs ADVANTAGES DISADVANTAGES
m/kg)

MANNITOL (5%) 275 (iso) Isomolar solution Osmotic diuresis, Acute

Not metabolized intravascular expansion

SORBITOL (3.5% 165 (hypo) Same as glycine Hyperglycemia,

) Lactic acidosis
Osmotic diuresis
GLUCOSE (2.5% 139 (hypo) Hyperglycemia
)

UREA 167 (hypo) Increases blood urea

(1%)

CYTAL 178 (iso) Expensive, not easily av

(sorbitol 2.7% + ailable
mannitol 0.54%
)
FACTORS AFFECTING AMOUNT
AND RATE OF FLUID ABSORPTI
ON

 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 el

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

 Long standing urinary obstruction can lead to impaired renal fun

ction 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 inf

ection 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 syn
drome and bladder perforation
2. Promotes peripheral vasodilation , reducing circulatory overl
oad
3. Reduces blood loss, requiring fewer transfusions
4. Avoids effects of general anaesthesia on pulmonary patholog
y
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 cause
d 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 to
gether, flexing the hips an
d knees simultaneously.
 Ensure proper padding at
edges and angulations.
 While lowering, legs broug
ht together at knees and t
hen lowered slowly to prev
ent stress on spine and su
dden fall in BP.
LITHOTOMY POSITIONING
 Physiologic changes w  Problems with lithotom
ith lithotomy y position
 Decreased FRC  Injury to nerves
 Increased venous retu  Injury to fingers
rn on elevation of legs  Compression of major vesse
 Decreased venous retu ls at joints
rn following lowering o  Lower extremity Compart
f legs ment syndrome
 Exaggeration of hypot  Aggravation of preexisting l
ension with SAB ower back pain
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 plas
ma-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 babins
ki’s 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 changes CVS ECG Changes
(mEq/l) changes

120 Confusion Hypotension brady wide QRS comple

Restlessness cardia x

115 Somnolence Cardiac depression Bradycardia

Nausea Wide QRS comple
x
Elevated ST segm
ent
110 Seizures CHF Ventricular tachy
Coma cardia or fibrillati
on
TURP SYNDROME - HYPERGLYCINEMIA

 Glycine, a non essential amino acid, is an inhibitory n

eurotransmitter in spinal cord and retina.

 Metabolized in liver by oxidative deamination to amm

onia and glyoxylic and oxalic acid.

 When absorbed in large amounts, has direct toxic effe

cts on heart and retina.

 Manifestations of glycine toxcity: nausea, headache,

malaise, weakness, visual distubances ( transient blin
dness), seizures, encephalopathy.
TURP SYNDROME - HYPERAMMONEMIA
 Excessive absorption of
glycine may lead to hyp
erammonemia (blood N
H3> 500mmol/L).

 S/S: nausea, vomiting,

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

 Explanation : arginine
deficiency
TURP SYNDROME – CLINICAL FEATURES
System Signs and Symptoms Cause
Neurologic Nausea, restlessness, visual disturban Hyponatremia and hypoos
ces, confusion, somnolence, seizures, molality Hyperglycinemia H
coma,death yperammonemia

Cardiovascular Hypertension, reflex bradycardia, pul Rapid fluid absorption

monary edema, CVS collapse
Hypotension Third spacing
ECG changes(wide QRS, elevated ST s Hyponatremia
egments, vent arrhythmia)
Respiratory Tachypnea, oxygen desaturation, che Pulmonary edema
yne- stokes breathing
Hematologic Disseminated intravascular hemolysis Hyponatremia and hypoos
molality
Renal Renal failure Hypotension, hemolysis, hy
peroxaluria
Metabolic Acidosis Deamination of glycine
MEASUREMENT OF FLUID ABSORPTON

1. Volume absorbed = (preoperative Na+/ postoper

ative Na+ ) ECF - ECF
2. Volumetric fluid balance (diff. b/w amt of irrigat
ion 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 fl

uid 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 anal

ysis.
TURP SYNDROME - MANAGEMENT
 Treat mild symptoms (if S. Na+ > 120 mEq/L) wit
h fluid restriction and loop diuretic (furosemide)
 Treat severe symptoms (if S. Na+ <120 mEq/L) wi
th 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, inguin
al or suprapubic region
 Intraperitoneal : generalised abdominal pain, shoulder tip p
ain, 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 co
ndition.
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 blo

od 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 blanke
ts, 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 NEPHROLI
THOTOMY AND NEPHRO
LITHOTRIPSY (PCNL)
PERCUTANEOUS NEPHROLITHOTOMY

 The procedure of choice for removing complex and larg

e 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 or

gans, located in paravertebral
gutters.
 Right kidney lies adjacent to 1
2th rib, liver, duodenum and he
patic flexure of colon.
 Left kidney is related to 11th a
nd 12th ribs, stomach, pancreas,
spleen and splenic flexure of co
lon.
 Superior pole in direct contact
with diaphragm.
PCNL : PROCEDURE

PCNL consists of gaining p

ercutaneous access to the
kidney collecting system a
nd performing stone disint
egration, usually with ultr
asonic or pneumatic lithot
ripters.
PERCUTANEOUS APPROACHES
 Subcostal /Intercostal approach
 Intercostal puncture is made
 over lateral portion of rib but medial to viscera
 during expiration
INTRAOPERATIVE COMPLICATIONS
ANAESTHETIC TECHNIQUE

 PCNL can be performed under general or regional an

esthesia.
 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 m
inimise pleural injury.
• Monitoring of airway pressure, ETCO2 , SpO2 requir
ed.
• Fluoroscopic monitoring of chest during procedure
is a sensitive means of timely diagnosis of pneumo
thorax 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 periop
erative period.

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

 Septicemia
 All patients have urine cultures done preoperatively
with administration of an appropriate antibiotic
REFERENCES
 Miller’s Anesthesia 7th Editon. Anesthesia and renal and ge
nitourinary system.
 Barasch’s Clinical Anesthesia 5th Edition. The renal system
and anesthesia for urologic surgery.
 Yao and Artusio’s Anesthesiology problem oriented patient
management. 6th Edition.
 Clinical anesthesiology by Morgan and Mikhail. 4th Edition.
Anesthesia for genitourinary surgery.
 Vsevold Rozentsveig. Anesthetic considerations during perc
utaneus nephrolithotomy. Journal of Clinical Anesthesia 2
007:19,351-355.
 Dietrich Gravenstein. Transurethral resection of prostate
(TURP) syndrome: a review of pathophysiology and manag
ement. Anesth Analg 1997;84:438-46.
.

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