ANESTHESIA FOR GENITOURINARY

SURGERY

Dr. OSAMA M. AL_QADHAB M.D

ANESTHOLOGIEST & ICU
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Urological procedures account for 10–20% of most
anesthetic practices.
Patients undergoing genitourinary procedures may be of
any age, but many are elderly with coexisting medical
illnesses, commonly
renal dysfunction.
This chapter reviews the anesthetic management of
common
urological procedures. Use of the lithotomy and steep
head-down (Trendelenburg) positions, the transurethral
approach, and extracorporeal shock waves ESWL
(lithotripsy) complicates many of these procedures.
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Cystoscopy
Preoperative Considerations
Cystoscopy is the most commonly performed
urological procedure, and indications for this
investigative or therapeutic operation include
hematuria, recurrent urinary infections, renal
calculi, and urinary obstruction.
Bladder biopsies, retrograde pyelograms,
transurethral resection of bladder tumors,
extraction or laser lithotripsy of renal stones, and
placement or manipulation of ureteral catheters
(stents) are also commonly performed through the
cystoscope .
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Anesthetic management varies with the age and gender

of the patient and the purpose of the procedure.
General anesthesia is usually necessary for children.
Viscous lidocaine topical anesthesia with or without
sedation is satisfactory for diagnostic studies in most
women because of the short urethra.
Operative cystoscopies involving biopsies, cauterization,
or manipulation of ureteral catheters require regional or
general anesthesia.
Many men prefer regional or general anesthesia even
for diagnostic cystoscopy.
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Intraoperative Considerations
A. Lithotomy Position
Next to the supine position, the lithotomy position is the
most commonly used position for patients undergoing
urological and gynecological procedures.
Failure to properly position and pad the patient can
result in
pressure sores,
nerve injuries, or
compartment syndromes.
Two people are needed to safely move the patient’s legs
simultaneously up into, or down from, the lithotomy
position.
Straps around the ankles or special holders support the
legs in lithotomy position ( Figure 31–1 ).
The lithotomy position. A: Strap stirrups. B: Bier–Hoff stirrups. C:
Allen stirrups.
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The leg supports should be padded wherever

there is leg or foot contact, and straps must not
impede circulation.
When the patient’s arms are tucked to the side,
caution must be exercised to prevent the fingers
from being caught between the mid and lower
sections of the operating room table when the
lower section is lowered and raised—many
clinicians completely encase the patient’s hands
and fingers with protective padding to minimize
this risk.
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Injury to the tibial (common peroneal) nerve,

resulting in loss of dorsiflexion of the foot, may
result if the lateral knee rests against the strap
support.
If the legs are allowed to rest on medially placed
strap supports, compression of the saphenous
nerve can result in numbness along the medial
calf.
Excessive flexion of the thigh against the groin
can injure the obturator and, less commonly, the
femoral nerves. Extreme flexion at the thigh can
also stretch the sciatic nerve.
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The most common nerve injuries directly
associated with the lithotomy position involve
the lumbosacral plexus.
Brachial plexus injuries can likewise occur if
the upper extremities are inappropriately
positioned (eg, hyperextension at the axilla).
Compartment syndrome of the lower
extremities with rhabdomyolysis has been
reported with prolonged time in the lithotomy
position, after which lower extremity nerve
damage is also more likely.
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The lithotomy position is associated with major
physiological alterations.
Functional residual capacity ( FRC ) decreases,
predisposing patientsto atelectasis and hypoxia.
This effect is amplified by steep Trendelenburg
positioning (>30°), which is commonly utilized in
combination with the lithotomy position.
Elevation of the legs drains blood into the central
circulation acutely and may thereby exacerbate
congestive heart failure (or treat a relative
hypovolemia).
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Mean blood pressure and cardiac output may

increase.
Conversely, rapid lowering of the legs from the
lithotomy or Trendelenburg position acutely
decreases venous return and can result in
hypotension.
Vasodilation from either general or regional
anesthesia potentiates the hypotension in this
situation, and for this reason, blood pressure
measurement should be taken immediately
after the legs are lowered.
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B. Choice of Anesthesia
1. General anesthesia —
Many patients are apprehensive about the procedure
and prefer to be asleep.
However, any anesthetic technique suitable for
outpatients may be utilized.
Because of the short duration (15–20 min) and
outpatient setting of most cystoscopies, general
anesthesia is often chosen, commonly employing a
laryngeal mask airway.
Oxygen saturation should be closely monitored when
obese or elderly patients, or those with marginal
pulmonary reserve, are placed in the lithotomy or
Trendelenburg position.
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2. Regional anesthesia —
Both epidural and spinal blockade provide
satisfactory anesthesia for cystoscopy. However,
when regional anesthesia is chosen most
anesthesiologists prefer spinal anesthesia
because onset of satisfactory sensory blockade
may require 15–20 min for epidural anesthesia
compared with 5 min or less for spinal
anesthesia.
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2. Regional anesthesia —
Some clinicians believe that the sensory level
following injection of a hyperbaric spinal
anesthetic solution should be well
established(“fixed”) before the patient is moved
into the lithotomy position; however, studies fail
to demonstrate that immediate elevation of the
legs into lithotomy position following
administration of hyperbaric spinal anesthesia
either increases the dermatomal extent of
anesthesia to a clinically significant degree or
increases the likelihood of severe hypotension.
A sensory level to T10 provides excellent
anesthesia for essentially all cystoscopic
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TRANSURETHRAL RESECTION OF THE
PROSTATE (TURP)
● Preoperative Considerations
Benign prostatic hyperplasia (BPH) frequently leads to
bladder outlet obstruction in men older than 60 years.
Although increasingly being treated medically, some men
require surgical intervention.
Transurethral resection of the prostate (TURP) is the
most common surgical procedure performed for bladder
outlet obstruction due to BPH, and indications for TURP
in this setting include obstructive uropathy, bladder
calculi, and recurrent episodes of urinary retention,
urinary tract infections, and hematuria. Patients with
adenocarcinoma of the prostate may also benefit from
TURP to relieve symptomatic urinary obstruction.
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TURP requires regional or general anesthesia,

and patients should be evaluated for
coexistent major organ dysfunction.
Despite advanced age (over half of TURP
patients are older than 70 years) and prevalence
of significant comorbidity in over two
thirds(2/3) of TURP patients, perioperative
mortality and medical morbidity
(most frequently myocardial infarction,
pulmonary edema, and kidney failure) for
this procedure are both less than 1%.
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Intraoperative Considerations
TURP is performed by passing a loop through a special
cystoscope (resectoscope).

Using continuous irrigation and direct visualization,

prostatic tissue is resected by applying a cutting current
to the loop.

Because of the characteristics of the prostate and the

large amounts of irrigation fluid often used,

TURP can be associated with a number of serious

complications ( Table 31–1 )
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Surgical complications associated with TURP
Most common
1- Clot retention
2- Failure to void
3- Uncontrolled acute hematuria
4- Urinary tract infection
5- Chronic hematuria
Less common
1- TURP syndrome
2- Bladder perforation
3- Hypothermia
4- Sepsis
5- Disseminated intravascular coagulation ( DIC )
All of the following are the Most common
Surgical complications associated with TURP
Except :-
A) Uncontrolled acute hematuria
B) Failure to void
C) Urinary tract infection
D) Bladder perforation
E) Clot retention
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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 or decrease in arterial oxygen
saturation may be an early sign of 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
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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 will typically complain of nausea,
diaphoresis, and retropubic or lower 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.
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TURP syndrome SURGERY

Transurethral prostatic resection opens

venous sinuses, leading to possible
systemic absorption of irrigating fluid,
which can be rapidly fatal.
This syndrome presents intraoperatively
or postoperatively.
The incidence of TURP syndrome is less
than 1%.
• Clinical signs : Headache, restlessness,
confusion, arrhythmia, hypotension,
cyanosis, dyspnea, and seizure.
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TURP syndrome SURGERY

The Cardiovascular signs

Hypertension, reflex bradycardia, pulmonary edema,
cardiovascular collapse, hypotension, ECG changes
(wide QRS, elevated ST segments, ventricular
arrhythmias)
The CNS signs
Nausea, restlessness, visual disturbances, confusion,
somnolence, seizures, coma, death.
The Respiratory signs
Tachypnea, oxygen desaturation, Cheyne-Stokes
breathing
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All of the following are the Clinical signs of

the TURP syndrome Except :-
A) Bradycardia
B)Tachycardia
C) Hypotension
D) Hypertension
E) Arrhythmia
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Irrigating fluid: Typically, glycine 1.5% or mixture

of sorbitol 2.7% and mannitol 0.54%. These are
hypotonic 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.
The hypotonicity of these fluids also results in
acute hyponatremia and hypoosmolality, which can
lead to serious neurological manifestations.
Symptoms of hyponatremia usually do not develop
until the serum sodium concentration decreases
below 120 mEq/L. Marked hypotonicity in plasma ([Na
+ ]< 100 mEq/L) may also result in acute intravascular
hemolysis.
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Electrolyte solutions cannot be used for
irrigation during TURP because they disperse the
electrocautery current.
Water provides excellent visibility because its
hypotonicity lyses red blood cells, but significant
water absorption can readily result in acute
water intoxication.
Water irrigation is generally restricted to
transurethral resection of bladder tumors only.
The irrigating fluid for a 55-year-old
otherwise healthy man undergoing
transurethral prostatic resection ;-
(A) can cause hypotension and tachycardia in
the anesthetized patient
(B) should be water
(C) should be isosmolar
(D) should be hypertonic saline
(E) should be a solution of a nonmetabolized
solute
(C) The irrigating fluids should be nonhemolytic and isosmolar. The composition
should not be close to water, since water is hyposmotic. Electrolyte solutions should
not be used because they conduct electricity and therefore interfere with the
electrocautery. (5:1140)
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Absorption of TURP irrigation fluid is dependent
on the duration of the resection and the
pressure of the irrigation fluid. Most resections
last 45–60 min, and, on average,
20 mL/min of the irrigating fluid is absorbed.

Pulmonary congestion or florid pulmonary

edema can readily result from the absorption of
large amounts of irrigation fluid, particularly in
patients with limited cardiac reserve.
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Glycine solution:
Hyperglycinemia is associated circulatory depression,
central nervous system (CNS) toxicity, and transient

blindness. Glycine degradation can lead to

hyperammonemia,

leading to CNS toxicity as well.

Sorbitol and dextrose solutions : Hyperglycemia

Mannitol solution : Fluid overload

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Treatment

Volume overload : Fluid restriction and

furosemide
Symptomatic hyponatremia : Hypertonic saline

Seizure : Midazolam 2 to 4 mg, phenytoin 10 to 20

mg/kg

Altered mental status : Intubation

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Manifestations of TURP syndrome
Hyponatremia
Hypoosmolality
Fluid overload
Congestive heart failure
Pulmonary edema
Hypotension
Hemolysis
Solute toxicity
Hyperglycinemia (glycine)
Hyperammonemia (glycine)
Hyperglycemia (sorbitol)
Intravascular volume expansion (mannitol)
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You are asked to evaluate a patient in the PACU who

has undergone a TURP. On arrival, you find a 76-
year-old agitated man yelling that he can’t see
anything. His past medical history is significant for
smoking, hypertension, and coronary artery disease
with recent stent placement.
The most likely cause of the visual disturbance is :-
A) sorbitol toxicity
B) cortical blindness
C) transient ischemic attack
D) glycine toxicity
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An 82-year-old, 100-kg male with a history of hypertension
and COPD is undergoing a transurethral resection of the
prostate under spinal anesthesia at a T8 level. Thirty
minutes into the procedure he complains that he is
nauseated, and having trouble catching his breath. You
note his blood pressure has increased from 100/ 68 mm Hg
to 152/ 94 mm Hg, his heart rate has decreased from 74 to
56 bpm, and his ECG shows ST elevation in lead II. He is
becoming restless and trying to sit up. The management
of this patient should include
all of the following EXCEPT
A) inform the surgeon
B) check serum sodium, serum osmolality and hemoglobin
C) start an infusion of a hypertonic saline solution
D) administer intravenous furosemide
E) stop the procedure
419. (C) During resection of the prostate, venous sinuses
are opened, and large amounts of irrigation fluid can be
absorbed into the systemic circulation, causing TURP
syndrome. The syndrome has multiple manifestations
characterized by fluid overload, hypoosmolality,
hyponatremia, and neurologic disturbances, with onset
as early as 15 min into the procedure. Symptoms may
include nausea, confusion, hypertension, reflex
bradycardia from volume overload, ECG changes from
myocardial ischemia, desaturation, seizure, visual
changes, and coma. When TURP syndrome is suspected,
the procedure should be stopped; serum sodium,
potassium, and osmolality should be measured, as should
hemoglobin, as a measure of fluid absorption. Presumed
pulmonary edema should be treated with diuresis.
Hyponatremia does not need to be treated aggressively
when it is not accompanied by hypoosmolality, or in the
absence of neurologic symptoms.
An 85-year-old man with no previous medical history
except for cataracts is undergoing a transurethral
resection of the prostate gland under spinal anesthesia.
Twenty minutes into the procedure the patient
becomes restless. Over the next 20 minutes, his blood
pressure increases from 110/70 to 140/90 mm Hg and
his heart rate slows from 90 to 50 beats/min. The
patient is noted to have some difficulty breathing. The
most likely cause of these symptoms in this patient is ;-

A. Volume overload
B. Hyponatremia
C. High spinal
D. Bladder perforation
(A) Large quantities of irrigating fluid can be absorbed
during transurethral resection of the prostate gland
because the open venous sinuses in the prostate allow the
irrigation fluid to be absorbed. On average, from 10 to 30
mL of fluid per minute are absorbed, and during long
cases this can amount to several liters, causing
hypertension, reflex bradycardia, and pulmonary
congestion. Treatment consists of fluid restriction and a
loop diuretic
(e.g., furosemide) when the [Na+] level is greater than 120
mEq/L. Rarely does the amount of fluid absorbed cause
significant hyponatremia ([Na+]
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Lithotripsy
Extracorporeal shock wave lithotripsy (ESWL)
High-energy shocks fragment the stone, allowing it to
pass down the urinary tract. Modern lithotripters
generate shock waves electromagnetically or from
piezoelectric crystals.
Ureteral stents are placed before the procedure to allow
for passage of large stone particles.
Tissue damage occurs if acoustic energy is focused at
air–tissue interfaces (e.g., lung and intestine).
Contraindications :
Bleeding diathesis, pregnancy, obstruction below stone,
and inability to have lung and intestine out of sound
wave focus.
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Preoperative management
There is arrhythmia risk if patient has a pacemaker or
implantable cardioverter-defibrillator or has a history
of arrhythmias. Synchronize shock wave with ECG R-
wave to decrease risk.
The shock waves can also damage these devices; thus,
the device manufacturer should be contacted for best
management plan.
Patients with a history of cardiac arrhythmias and
those with a pacemaker or internal cardiac defibrillator
(ICD) may be at risk for developing arrhythmias
induced by shock waves during ESWL.
Synchronization of the shock waves with the
electrocardiogram (ECG) R wave decreases the
incidence of arrhythmias during ESWL.
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Intraoperative management
Immersion during ESWL can lead to vasodilation with
transient hypotension. Systemic vascular resistance
(SVR) and venous return can increase as blood moves
centrally, causing possible CHF precipitation or
hypoxemia from decreased FRC because of increased
intrathoracic blood volume.
New, low-energy shock waves require light sedation,
but
older water bath lithotripsy requires regional or GA.
Epidural anesthesia for water bath lithotripsy to T6 level
provides adequate coverage. With GA, diaphragmatic
movement can be controlled with neuromuscular
blockade, keeping the stone in the wave focus.
For modern lithotripsy, light sedation is adequate.
Maintain brisk urine output with generous IV fluid and
TO BE CONTINUE