GUS

1. Anesthesia for Genitourinary
Surgery: Introduction
Urological procedures account for 10–20% of
most anesthetic practices.
Patients undergoing genitourinary
procedures may be of any age, but most are
elderly and many have coexisting medical
illnesses, particularly
renal dysfunction.

2. Cystoscopy
Preoperative Considerations
Cystoscopy is the most commonly performed
urological procedure.
Indications for cystoscopy include hematuria,
recurrent urinary infections, renal calculi, and
urinary obstruction.
Bladder biopsies, retrograde pyelograms,
resection of bladder tumors, extraction or laser
lithotripsy of renal stones, and placement or
manipulation of ureteral catheters (stents) can
also be performed through the cystoscope

3. Anesthetic management varies with the age and
gender of the patient and the purpose of the
procedure.
General anesthesia is necessary for children.
Topical anesthesia in the form of viscous lidocaine
with or without sedation is used for diagnostic
studies in most women, because of a short urethra.
Operative cystoscopies involving biopsies,
cauterization, or manipulation of ureteral catheters
require regional or general anesthesia.
Most males prefer regional or general anesthesia
even for diagnostic studies.

4. Intraoperative Considerations
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 patients can result in iatrogenic
injuries.
Two persons are required to safely move the patient's legs
simultaneously up or down.
Straps around the ankles or special holders support the legs in
position
The leg supports should be padded, and t he legs should hang
freely.

5. c
• Injury to the common peroneal nerve, resulting in
loss of dorsi flexion of the foot, may result if the
lateral thigh rests on 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.
• It should be noted that the most common nerve
injury associated with the lithotomy position
involves the brachial plexus.

6. The lithotomy position. A: Strap stirrups. B:
Bier–Hoff stirrups. C: Allen stirrups.

7. The lithotomy position is associated with major physiological
alterations.
Functional residual capacity decreases, predisposing patients
to atelectasis and hypoxia.
This effect is accentuated by the head-down (Trendelenburg)
position (> 30°).
Elevation of the legs increases venous return acutely and may
exacerbate congestive heart failure.
Mean blood pressure often increases, but cardiac output does
not change significantly.
Conversely, rapid lowering of the legs acutely decreases
venous return and can result in hypotension.

8. Choice of Anesthesia
General Anesthesia
• Because of the short duration (15–20 min) and the
outpatient setting of most cystoscopies, general
anesthesia is usually used.
• Most patients are apprehensive about the procedure
and prefer to be asleep. Any anesthetic technique
suitable for outpatients may be used.
• 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.
A laryngeal mask airway (LMA) is often used.

9. Regional Anesthesia
• Both epidural and spinal blocks can provide
satisfactory anesthesia.
• However, satisfactory sensory blockade may
require 15–20 min for epidural anesthesia
compared with 5 min for spinal anesthesia.
• Consequently, most clinicians prefer spinal
anesthesia, particularly for procedures lasting
more than 30 min with elderly and high risk
patients.

10. c
• A sensory level to T10 provides excellent
anesthesia for nearly all cystoscopic procedures.
• Regional anesthesia, however, does not abolish
the obturator reflex (external rotation and
adduction of the thigh secondary to stimulation
of the obturator nerve by electrocautery current
through the lateral bladder wall).
• The reflex (muscle contraction) is reliably blocked
only by muscle paralysis during general
anesthesia.

11. Transurethral Surgery of the Prostate
• Preoperative Considerations
• Benign prostatic hypertrophy frequently leads to
symptomatic bladder outlet obstruction in men
older than 60 years.
• Indications of surgery include moderate to
severe lower urinary tract symptoms (LUTS) in
patients who do not respond to or decline
medical therapy, persistent gross hematuria,
recurrent urinary infections, renal insufficiency,
or bladder stones.

12. One of several operations may be selected to remove the
hypertrophied and hyperplastic prostatic tissue:
transurethral resection of the prostate (TURP), transurethral
electrovaporization, transurethral incision, transurethral laser
techniques, suprapubic (transvesical) prostatectomy, perineal
prostatectomy, or retropubic prostatectomy.
All require general or regional anesthesia.
Some less invasive procedures, such as transurethral
microwave treatments, may be performed with just topical
anesthesia.
The transurethral approach for surgery is nearly always
selected for patients with prostate gland volumes less than
40–50 mL.

13. c
• An alternative approach is chosen if the
prostate is over 80 mL.
• Patients with advanced prostatic carcinoma
may also present for transurethral resections
to relieve symptomatic urinary obstruction.
Regardless of its cause, long-standing
obstruction can lead to impaired renal
function.

14. x
• Patients undergoing prostate surgery should be
carefully evaluated for coexistent cardiac and
pulmonary disease as well as renal dysfunction
• Because of their age these patients have a relatively
high (30–60%) prevalence of both cardiovascular and
pulmonary disorders.
• TURP is reported to carry a 0.2–6% mortality rate,
which correlates best with the American Society of
Anesthesiologists' (ASA) physical status scale.
• Common causes of death include myocardial infarction,
pulmonary edema, and renal failure.

15. 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 .
Although experience is more limited with other
transurethral prostate procedures, their complication
rate (and possible efficacy) may be less

16. Major Complications Associated with TURP.
• Hemorrhage
• TURP syndrome
• Bladder perforation
• Hypothermia
• Septicemia
• Disseminated intravascular coagulation

17. TURP Syndrome
• Transurethral prostatic resection often opens the
extensive network of venous sinuses in the prostate and
potentially allows systemic absorption of the irrigating
fluid.
• The absorption of large amounts of fluid (2 L or more)
results in a constellation of symptoms and signs
commonly referred to as the TURP syndrome .
• This syndrome presents intraoperatively or
postoperatively as headache, restlessness, confusion,
cyanosis, dyspnea, arrhythmias, hypotension, or
seizures.
• Moreover, it can be rapidly fatal.
• The manifestations are primarily those of circulatory
fluid overload, water intoxication, and, occasionally,
toxicity from the solute in the irrigating fluid.

18. Manifestations of the 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)

19. c
• 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
absorption can readily result in acute water intoxication.
• Water irrigation is generally restricted to transurethral
resection of bladder tumors only.
• For TURP, slightly hypotonic nonelectrolyte irrigating
solutions such as glycine 1.5% (230 mOsm/L) or a
mixture of sorbitol 2.7% and mannitol 0.54% (195
mOsm/L) are most commonly used.
• Less commonly used solutions include sorbitol 3.3%,
mannitol 3%, dextrose 2.5–4%, and urea 1%.

20. v
• Because all these fluids are still hypotonic,
significant absorption of water can
nevertheless occur.
• Solute absorption can also occur because the
irrigation fluid is under pressure.
• High irrigation pressures (bottle height)
increase fluid absorption

21. v
• Absorption of irrigation fluid appears to be
dependent on the duration of the resection as
well as the height (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.

22. c
• 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.

23. c
• Toxicity may also arise from absorption of the solutes
in these fluids.
• Marked hyperglycinemia has been reported with
glycine solutions and is thought to contribute to
circulatory depression and central nervous system
toxicity.
• Plasma glycine concentrations in excess of 1000 mg/L
have been recorded (normal is 13–17 mg/L).
• Glycine is known to be an inhibitory neurotransmitter
in the central nervous system and has also been
implicated in rare instances of transient blindness
following TURP.

24. c
• Blood ammonia levels in some patients
exceeded 500 mol/L (normal is 5–50 mol/L).
• The use of large amounts of sorbitol or
dextrose irrigating solutions can lead to
hyperglycemia, which can be marked in
diabetic patients.
• Absorption of mannitol solutions causes
intravascular volume expansion and
exacerbates fluid overload.

25. c
• Treatment of TURP syndrome depends on early
recognition and should be based on the severity
of the symptoms.
• The absorbed water must be eliminated, and
hypoxemia and hypoperfusion must be avoided.
Most patients can be managed with fluid
restriction and a loop diuretic.
• Symptomatic hyponatremia resulting in seizures
or coma should be treated with hypertonic saline
.

26. f
• The amount and rate of hypertonic saline
solution (3% or 5%) needed to correct the
hyponatremia to a safe level should be based
on the patient's serum sodium concentration
• Hypertonic saline solution should not be given
at a rate faster than 100 mL/h so as not to
exacerbate circulatory fluid overload.

27. Hypothermia
• Large volumes of irrigating fluids at room
temperature can be a major source of heat loss in
patients.
• Irrigating solutions should be warmed to body
temperature prior to use to prevent hypothermia.
• Postoperative shivering associated with
hypothermia is particularly undesirable, as it can
dislodge clots and promote postoperative
bleeding

28. Bladder Perforation
• The incidence of bladder perforation during
TURP is estimated to be approximately 1
Perforation may result from the resectoscope
going through the bladder wall or from over
distention of the bladder with irrigation fluid.
• Most bladder perforations are extraperitoneal
and are signaled by poor return of the irrigating
fluid.
• Awake patients will typically complain of nausea,
diaphoresis, and retropubic or lower abdominal
pain.

29. Coagulopathy
• Disseminated intravascular coagulation (DIC) has
on rare occasions been reported following TURP
and is thought to result from the release of
thromboplastins from the prostate into the
circulation during surgery.
• Up to 6% of patients may have evidence of
subclinical DIC.
• A dilutional thrombocytopenia can also develop
during surgery as part of the TURP syndrome from
absorption of irrigation fluids.

30. Septicemia
• The prostate is often colonized with bacteria and
may harbor chronic infection.
• Extensive surgical manipulation of the gland
together with the opening of venous sinuses can
allow entry of organisms into the bloodstream.
• Bacteremia following transurethral surgery is not
uncommon and can lead to septicemia or septic
shock .
• Prophylactic antibiotic therapy (most commonly
gentamicin, levofloxacin, or cephazolin) prior to
TURP may decrease the likelihood of bacteremic
and septic episodes.

31. Choice of Anesthesia
• Either spinal or epidural anesthesia with a T10
sensory level provides excellent anesthesia
and good operating conditions for TURP.
• When compared with general anesthesia,
regional anesthesia appears to reduce the
incidence of postoperative venous
thrombosis; it is also less likely to mask
symptoms and signs of the TURP syndrome or
bladder perforation.

32. Monitoring
• Evaluation of mental status in the awake patient is the
best monitor for detection of early signs of the TURP
syndrome and bladder perforation.
• A decrease in arterial oxygen saturation may be an
early sign of fluid overload.
• Some studies have reported perioperative ischemic
electrocardiographic changes in up to 18% of patients.
• Temperature monitoring should be used during long
resections to detect hypothermia.
• Blood loss is particularly difficult to assess because of
the use of irrigating solutions, so it is necessary to rely
on clinical signs of hypovolemia Blood loss averages
about 3–5 mL/min of resection (usually 200–300 mL
total) but is rarely life-threatening.

33. c
• Transient, postoperative decreases in
hematocrit may simply reflect hemodilution
from absorption of irrigation fluid.
• About 2.5% of patients require intraoperative
transfusion; factors associated with
transfusion include a procedure whose
duration is longer than 90 min and resection
of greater than 45 g of prostate tissue.

34. Lithotripsy
• The treatment of kidney stones has changed
significantly over the past two decades from primarily
open surgical procedures to less invasive or completely
noninvasive techniques.
• Stones in the bladder and lower ureters are now
usually treated with cystoscopic procedures, including
flexible and rigid ureteroscopy, stone extraction, stent
placement, and intracorporeal lithotripsy (laser or
electrohydraulic).
• Laser lithotripsy typically utilizes a holmium:YAG laser.
In contrast, stones in the upper two-thirds of the
ureters or kidneys are treated with extracorporeal
shock wave lithotripsy (ESWL) or percutaneous
nephrolithotomy.

35. c
• The latter is reserved for large stones (> 2 cm)
and involves techniques similar to
ureteroscopy; however, application is via a
percutaneous sheath over the kidney in the
prone position.
• Some stones (eg, cystine, uric acid, and
calcium oxalate monohydrate) are particularly
hard and are more likely to require
retreatment.

36. c
Schematic representation of a newer
tubless lithotripsy unit.
Schematic representation of an older tub lithotripsy unit
(Dornier HM3).

37. Preoperative consideration
• 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./ extracorporeal shock wave lithotripsy/
(ESWL
• Shock waves can damage the internal
components of pacemaker and ICD devices
• . The manufacturer should be contacted as to the
best method for managing the device (eg,
reprogramming or applying a magnet).

38. Effects of Immersion
• Immersion into a heated water bath (36–37°C) initially results
in vasodilation that can transiently lead to hypotension.
• Arterial blood pressure, however, subsequently rises as
venous blood is redistributed centrally from the hydrostatic
pressure of water on the legs and abdomen.
• Systemic vascular resistance (SVR) rises and cardiac output
often decreases.
• The sudden increase in venous return and SVR can precipitate
congestive heart failure in patients with marginal cardiac
reserve.
• Moreover, the increase in intrathoracic blood volume
significantly reduces functional residual capacity (30–60%)
and predisposes some patients to hypoxemia.

39. Choice of Anesthesia
• Pain during lithotripsy is from dissipation of a small amount
of energy as shock waves enter the body through the skin.
• The pain is therefore localized to the skin and
proportionate to the intensity of the shock waves.
• Older lithotripsy with units employing a water bath
(Dornier HM3) requires 1000–2400 relatively high intensity
shock waves (18–22 kV) that most patients do not tolerate
without either regional or general anesthesia.
• In contrast, newer lithotripsy units that are coupled directly
to the skin utilize 2000–3000 lower intensity shock waves
(10–18 kV) that usually require only light sedation.

40. Regional Anesthesia
• Continuous epidural anesthesia is commonly
used for ESWL using a water bath.
• A T6 sensory level ensures adequate anesthesia,
as renal innervation is derived from T10 to L2.
• Supplementation of the block with fentanyl, 50–
100 mg epidurally, is often useful.
• As little air as possible should be used with the
loss of resistance technique during insertion
large amounts of air in the epidural space can
dissipate shock waves and theoretically may
promote injury to neural tissue.

41. x
• Supplemental oxygen by face mask or nasal cannula is
also useful in avoiding hypoxemia.
• Spinal anesthesia can also be used satisfactorily, but
because of the potential for an increased incidence of
postdural puncture headache in a seated patient and
less control over the sensory level with spinal
anesthesia, epidural anesthesia is usually preferred.
• Regional anesthesia greatly facilitates positioning and
monitoring.
• Prior intravascular volume expansion with 1000–1500
mL of lactated Ringer's injection may help prevent
severe postural hypotension following the onset of
neuraxial anesthesia, positioning in the hydraulic chair,
and immersion in the warm bath.

42. v
• A major disadvantage of regional anesthesia is the
inability to control diaphragmatic movement.
• Excessive diaphragmatic excursion during spontaneous
ventilation can move the stone in and out of the wave
focus and may prolong the procedure.
• This problem can be partially solved by asking the
patient to breathe in a more rapid but shallow
respiratory pattern.
• Bradycardia from high sympathetic blockade also
prolongs the procedure when shock waves are coupled
to the ECG.

43. General Anesthesia
• General endotracheal anesthesia allows control
of diaphragmatic excursion during tub lithotripsy
(Dornier HM3) and is preferred by many patients.
• The procedure is complicated by the inherent
risks associated with placing a supine
anesthetized patient in a chair, elevating and then
lowering the chair into a water bath to houlder
depth, and then reversing the sequence at the
end.

44. c
• A light general anesthetic technique in
conjunction with a muscle relaxant is preferable
• . The muscle relaxant ensures patient immobility
and control of diaphragmatic movement.
• As with regional anesthesia, intravenous fluid
loading with 1000 mL of lactated Ringer's
injection is generally advisable prior to moving
patients upright into the hydraulic chair to
prevent postural hypotension.

45. f
• Monitored Anesthesia Care
• Intravenous sedation is usually adequate for
low-energy lithotripsy.
• Low-dose propofol infusions together with
midazolam and opioid supplementation may
be used.

46. Monitoring
• Electrocardiograph pads should be attached securely
with waterproof dressing prior to immersion.
• Even with R wave–riggered shocks, supraventricular
arrhythmias can still occur and may require
treatment.
• Changes in functional residual capacity with
immersion mandate close monitoring of oxygen
saturation, particularly in patients at high risk for
developing hypoxemia.
• The temperature of the bath and the patient should
be monitored to prevent hypothermia or
hyperthermia.

47. c
• Intravenous mannitol may also act as a radical
free scavenger and helps establish an osmotic
diuresis after reperfusion.
• Nephrectomy is performed only in the presence
of intractable hypertension or chronic infection.
• Immuno suppression is started on the day of
surgery with combinations of corticosteroids,
cyclosporine (or tacrolimus), and azathioprine (or
mycophenolate mofetil).

48. Fluid Management
• Intravenous fluid therapy is typically generous.
Following the initial intravenous fluid bolus
(above), an additional 1000–2000 mL of
lactated Ringer's injection is usually given with
a small dose of furosemide (10–20 mg) to
maintain brisk urinary flow and flush stone
debris and blood clots.
• Patients with poor cardiac reserve require
more conservative fluid therapy.

49. Noncancer Surgery on the Upper
Ureter & Kidney
• Laparoscopic techniques are increasingly utilized in
urology.
• Advantages include shorter hospital stays, faster
recovery and less pain.
• Laparoscopic procedures include live donor
nephrectomy, nephrectomy, partial nephrectomy, and
pyeloplasty.
• Both transperitoneal and retroperitoneal approaches
have been developed.
• A hand-assisted technique employs an additional
larger incision that allows the surgeon to insert one
hand for tactile sensation and dissection.

50. Renal Transplantation
• The success of renal transplantation, which is largely due to
advances in immunosuppressive therapy, has greatly
improved the quality of life for patients with end-stage
renal disease.
• With modern immunosuppressive regimens, cadaveric
transplants have achieved almost the same 3-year graft
survival rates (80–90%) as living related donor grafts.
• In addition, restrictions on candidates for renal
transplantation have gradually decreased.
• . Infection and cancer are the only remaining absolute
contraindications
• Advanced age (> 60 years) and severe cardiovascular
disease are relative contraindications.

51. Preoperative Considerations
• Preoperative optimization of the patient's medical
condition with dialysis is mandatory.
• Current organ preservation techniques allow ample
time (24–48 h) for preoperative dialysis of cadaveric
recipients.
• Living-related transplants are performed electively
with the donor and recipient anesthetized
simultaneously but in separate rooms.
• The recipient's serum potassium concentration should
be below 5.5 mEq/L, and existing coagulopathies
should be corrected

52. Intraoperative Considerations
• The transplant is carried out by placing the
donor kidney retroperitoneally in the iliac fossa
and anastomosing the renal vessels to the iliac
vessels and the ureter to the bladder.
• Prior to temporary clamping of the iliac vessels,
heparin is administered.
• Injection of a calcium channel blocker (verapamil)
into the arterial circulation of the graft just prior
to revascularization helps protect the kidney from
reperfusion injury.

53. Choice of Anesthesia
. Spinal and epidural anesthesia have been
successfully employed, most transplants are done
under general anesthesia.
• All general anesthetic agents, including enflurane
and sevoflurane, have been employed without
any apparent detrimental effect on graft function;
nonetheless, these two agents are best avoided .
• Atracurium, cisatracurium, and rocuronium may
be the muscle relaxants of choice, as they are not
primarily dependent on renal excretion for
elimination.
• Similarly, vecuronium may be used with only
modest prolongation of its effects.

54. Monitoring
• Central venous pressure monitoring is very useful in
ensuring adequate hydration but avoiding fluid overload.
• Normal saline or half-normal saline solutions are commonly
used.
• A urinary catheter is placed preoperatively.
• A brisk urine flow following the arterial anastomosis
generally indicates good graft function.
• The diuresis that follows may resemble nonoliguric renal
failure .
• If the graft ischemic time was prolonged, an oliguric phase
may precede the diuretic phase, in which case fluid therapy
must be adjusted appropriately.
• The judicious use of furosemide or additional mannitol may
be indicated in such cases.

55. c
• Hyperkalemia has been reported after release of the
vascular clamp following completion of the arterial
anastomosis, particularly in small patients and pediatric
patients.
• Release of potassium contained in the preservative
solution has been implicated in those cases.
• Washout of the preservative solution with ice-cold
lactated Ringer's solution just prior to the vascular
anastomosis may help avoid this problem.
• Serum electrolyte concentrations should be monitored
closely after completion of the anastomosis.
• Hyperkalemia may be suspected from peaking of the T
wave on the ECG.

56. Suggested Reading
• Battillo JA, Hendler MA: Effects of patient
positioning during anesthesia.
• In: Anesthesia for Urological Surgery.
• Lebowitz RW (editor). Int Anesthesiol Clin
1993;31:67. [PMID: 8440533]
• Dobson PM, Caldicott LD, Gerrish SP, et al:
Changes in hemodynamic variables during
transurethral resection of the prostate:
Comparison of general and spinal anaesthesia.
• Br J Anaesth 1994;72:267. [PMID: 8130043

57. c
• Web Site
• http://www.auanet.org/guidelines/
• This site includes clinical guidelines of the
American Urological Association.