ANAESTHETIC MANAGEMENT OF ENDOSCOPIC UROLOGIC PROCEDURES DR. RICHA JAIN

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
S2 – S4
S2 – S4
L1, L2
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
o
o
o
o
Patient laid in lithotomy position.
Cystoscope or resectoscope is introduced into the
bladder.
The tumor is identified & resected.
Coagulating current is used to cauterize the base of
the tumor.
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 85year-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
 Sympathetic supply
T11-L2
 Inferior hypogastric
plexus
BLOOD SUPPLY



Parasympathetic
supply
S2,3,4
 Pelvic splanchnic
nerve

Arterial supply




Inferior vesical artery
Middle rectal artery
Internal pudendal
artery
Venous supply
Vesical plexus
 Internal pudendal
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 threelumen catheter is inserted and
irrigation is continued for up to 24 h
after operation.
The procedure usually takes 30–90
min.
IRRIGATION FLUIDS

Uses



distends bladder and
prostatic urethra
flushes out blood and
tissue debris
improves visibility

Characteristics of
Ideal irrigation fluid:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Transparent
Isotonic
Electrically inert
Non hemolytic
Inexpensive
Not metabolizable
Rapidly excretable
Non toxic
Easy to sterilise
SOLUTION OSMOLALITY ADVANTAGES
(mOsm/kg)
DISADVANTAGES
DISTILLED
WATER
0 (hypo)
Electrically inert
Improved
visibility
Inexpensive
Hemolysis
Hemoglobinuria
Hemoglobinemia
Hyponatremia
GLYCINE
(1.5%)
GLYCINE
(1.2%)
220 (iso)
Less likelihood of Transient
TURP syndrome postoperative visual
syndrome,
Hyperammonemia,
Hyperoxaluria
NORMAL
SALINE
(0.9%)
308 (iso)
RINGER
LACTATE
273 (iso)
175 (hypo)
Less incidence of
TURP syndrome
Ionized, cannot be
used with cautery
Ionized, cannot be
used with cautery
SOLUTION
OSMOLALITY
(mOsm/kg)
ADVANTAGES DISADVANTAGES
MANNITOL
(5%)
275 (iso)
Isomolar
Osmotic diuresis,
solution
Acute intravascular
Not metabolized expansion
SORBITOL
(3.5%)
165 (hypo)
GLUCOSE
(2.5%)
139 (hypo)
Hyperglycemia
UREA
(1%)
167 (hypo)
Increases blood urea
CYTAL
(sorbitol 2.7%
+mannitol
0.54%)
178 (iso)
Expensive, not easily
available
Same as glycine
Hyperglycemia,
Lactic acidosis
Osmotic diuresis
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.
2.
3.
4.
5.
6.
7.
8.

Allows monitoring of mentation and early signs of TURP syndrome
and bladder perforation
Promotes peripheral vasodilation , reducing circulatory overload
Reduces blood loss, requiring fewer transfusions
Avoids effects of general anaesthesia on pulmonary pathology
Good early post-operative analgesia
Reduced incidence of post-operative DVT/PE
Neuroendocrine and immune response are better preserved
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
with lithotomy
Decreased FRC
 Increased venous
return on elevation of
legs
 Decreased venous
return following
lowering of legs
 Exaggeration of
hypotension with SAB


Problems with
lithotomy position





Injury to nerves
Injury to fingers
Compression of major
vessels at joints
Lower extremity
Compartment syndrome
Aggravation of preexisting
lower 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
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
babinski’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+
(mEq/l)
CNS
changes
CVS
changes
ECG
Changes
120
Confusion
Restlessness
Hypotension
bradycardia
wide QRS
complex
115
Somnolence
Nausea
Cardiac
depression
Bradycardia
Wide QRS
complex
Elevated ST
segment
110
Seizures
Coma
CHF
Ventricular
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
disturbances, confusion,
somnolence, seizures,coma,death
Hyponatremia and
hypoosmolality
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,
cheyne- stokes breathing
Pulmonary edema
Hematologic
Disseminated intravascular
hemolysis
Hyponatremia and
hypoosmolality
Renal
Renal failure
Hypotension, hemolysis,
hyperoxaluria
Metabolic
Acidosis
Deamination of glycine
MEASUREMENT OF FLUID ABSORPTON
1.
2.
3.
4.
5.
6.
Volume absorbed = (preoperative Na+/
postoperative Na+ ) ECF - ECF
Volumetric fluid balance (diff. b/w amt of
irrigation fluid used and volume recovered.)
Gravimetry (measure rise in body weight)
CVP monitoring
Breath ethanol measurement
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






Miller’s Anesthesia 7th Editon. Anesthesia and renal and
genitourinary 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
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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