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OF ENDOSCOPIC UROLOGIC
PROCEDURES
CYSTOSCOPY
URETEROSCOPY
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
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
Integrity of capsule
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
TECHNIQUES:
Subarachnoid block
Epidural block
Caudal block
Saddle block
Pulse oximetry
Temperature
Mentation
Blood loss
S. electrolytes (serial)
EtCO2 if GA is used
INTRAOPERATIVE CONSIDERATIONS
Lithotomy position
TURP syndrome
Bladder perforation
Hypothermia
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
Bipolar resectoscope
Vaporization methods
Local vasoconstrictors
TURP SYNDROME - MANAGEMENT
Notify surgeon and terminate surgery.
Ensure oxygenation
Restrict fluids
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.
Hypothermia
Hypotension
Haemorrhage
Septicaemia
TURP syndrome
Bladder spasm
Clot retention
A guide wire inserted through the needle and Dilators passed over
the wire
HAEMORRHAGE
FLUID ABSORPTION
INJURY TO PLEURA
SEPTICEMIA
ANAESTHETIC TECHNIQUE
INTRATHORACIC COMPLICATIONS
Most often injured organ during PCNL : lung and pleura.
Risk of injury increases with more superior punctures.
Approach Incidence
Subcostal 0.5%
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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