6CYSTOSCOPY The most common urologic procedure Indications Diagnostic HematuriaRecurrent urinary infectionsUrinary obstructionBladder biopsiesRetrograde pyelogramsTherapeuticResection of bladder tumors,Extraction or laser lithotripsy of renal stones,Placement or manipulation of ureteral catheters (stents) .
7Anaesthetic management Varies with age, the indication of the procedure and patient preferenceGeneral anesthesia - children.Topical anesthesia with or without sedation –diagnostic studies.Regional or general anesthesia – operativecystoscopies.General AnaesthesiaPatient preferenceShort duration (15-20 min) and outpatient settingRegional AnaesthesiaA sensory level upto T10 is adequate.Subarachnoid block preferred.
8TRANSURETHRAL RESECTION OF BLADDER TUMOUR (TURBT)
9TURBT For diagnosing and treating bladder cancers PROCEDURE 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.
10Anaesthetic considerstions Preoperative ConsiderationsBladder tumor is usually seen in older populations who may have pre-existing medical problems.Pt may have hematuria, urinary infection.Intraoperative ConcernsLithotomy positioningBladder 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.
11TURBT – 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.GA for abolishing obturator reflex
13TURP - INTRODUCTIONThe 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 85- year-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.
14ANATOMY OF PROSTATELOCATION: in the pelvis, below neck of urinary bladderSHAPE : inverted coneSIZE : 4x3x2 cmWeight : 8 gm5 LOBES:BPH – median, anterior, 2 lateralProstatic carcinoma – posterior, lateralComposed of glandular tissue in fibromuscular stroma.2 capsules:True – formed by condensation of prostatic tissueFalse – formed by visceral layers of pelvic fascia.
16TURP - PROCEDUREPerformed 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 three- lumen catheter is inserted and irrigation is continued for up to 24 h after operation.The procedure usually takes 30–90 min.
17IRRIGATION FLUIDS Uses Characteristics of Ideal irrigation fluid: distends bladder and prostatic urethraflushes out blood and tissue debrisimproves visibilityCharacteristics of Ideal irrigation fluid:TransparentIsotonicElectrically inertNon hemolyticInexpensiveNot metabolizableRapidly excretableNon toxicEasy to sterilise
18SOLUTIONOSMOLALITY (mOsm/kg)ADVANTAGESDISADVANTAGESDISTILLED WATER0 (hypo)Electrically inertImproved visibilityInexpensiveHemolysisHemoglobinuriaHemoglobinemiaHyponatremiaGLYCINE (1.5%) GLYCINE (1.2%)220 (iso)175 (hypo)Less likelihood of TURP syndromeTransient postoperative visual syndrome,Hyperammonemia,HyperoxaluriaNORMAL SALINE (0.9%)308 (iso)Less incidence of TURP syndromeIonized, cannot be used with cauteryRINGER LACTATE273 (iso)
19SOLUTIONOSMOLALITY (mOsm/kg)ADVANTAGESDISADVANTAGESMANNITOL (5%)275 (iso)Isomolar solutionNot metabolizedOsmotic diuresis, Acute intravascular expansionSORBITOL (3.5%)165 (hypo)Same as glycineHyperglycemia,Lactic acidosisOsmotic diuresisGLUCOSE (2.5%)139 (hypo)HyperglycemiaUREA(1%)167 (hypo)Increases blood ureaCYTAL(sorbitol 2.7% +mannitol 0.54%)178 (iso)Expensive, not easily available
20Factors affecting amount and rate of fluid absorption Size of gland (25ml/gm of prostate)Number and size of open sinusesHydrostatic pressure of irrigating fluidDuration of procedure ml/min)Integrity of capsuleVenous pressure at irrigant-blood interfaceVascularity of diseased prostate
21PREOPERATIVE 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
22PREOPERATIVE EVALUATION History and examination of all organ systemsINVESTIGATIONSHb, TLC, DLC, platelet countBlood sugarBlood urea, S. Creatinine, S. ElectrolytesUrine R/MECGChest X-rayBlood grouping and cross matching
23PREOPERATIVE PREPARATION Optimization of pre-existing co-morbid conditionsConsideration of ongoing drug therapyAntibiotic prophylaxis (in case of urinary tract infection or urinary obstruction)Arrangement of blood
24CHOICE OF ANAESTHESIARegional anaesthesia is the technique of choice for TURP.Advantages of regional over general anaesthesiaAllows monitoring of mentation and early signs of TURP syndrome and bladder perforationPromotes peripheral vasodilation , reducing circulatory overloadReduces blood loss, requiring fewer transfusionsAvoids effects of general anaesthesia on pulmonary pathologyGood early post-operative analgesiaReduced incidence of post-operative DVT/PENeuroendocrine and immune response are better preservedLower costGeneral anaesthesia preferred when regional is contraindicated.
25REGIONAL ANAESTHESIA TECHNIQUES: Level of sensory block Subarachnoid blockEpidural blockCaudal blockSaddle blockLevel of sensory blockT10 dermatome level – to eliminate discomfort caused by bladder distentionT9 dermatome level – enable to elicit capsular sign (pain on perforation of prostatic capsule)
26REGIONAL ANAESTHESIA Subarachnoid block is preferred. Advantages of SAB over epidural anaesthesia:Technically easier to performDense motor blockadeNo sacral sparingLower incidence of PDPH
27MONITORING ECG Blood pressure Pulse oximetry Temperature Mentation Blood lossS. electrolytes (serial)EtCO2 if GA is used
28INTRAOPERATIVE CONSIDERATIONS Lithotomy positionTURP syndromeBladder perforationHypothermiaTransient bacterial septicemiaHemorrhage and coagulopathyMain challenges: blood loss and TURP syndrome
29LITHOTOMY 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.
30LITHOTOMY POSITIONING Physiologic changes with lithotomyDecreased FRCIncreased venous return on elevation of legsDecreased venous return following lowering of legsExaggeration of hypotension with SABProblems with lithotomy positionInjury to nervesInjury to fingersCompression of major vessels at jointsLower extremity Compartment syndromeAggravation of preexisting lower back pain
31TURP 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 overloadWater intoxicationHyponatremiaHypoosmolalityHyperglycinemiaHyperammonemiaHemolysis
33TURP SYNDROME – WATER INTOXICATION Cause : cerebral edemaSigns and symp:Somnolence, restlessness, seizures, comaCNS – decerebrate posture, clonus, +ve babinski’s reflexEyes – papilloedema, dilated and non reactive pupilsEEG – low voltage b/l.
34TURP SYNDROME - HYPONATREMIA Cause : excessive absorption of Na free irrigation fluidDuring TURP, S.Na falls by 3 to 10 meq/l.SIGNS AND SYMPTOMS OF Acute HyponatremiaNauseaVomitingIrritabilityMental confusionCardiovascular collapsePulmonay edemaSeizures
35Manifestations of hyponatremia SERUM Na+(mEq/l)CNS changesCVSchangesECG Changes120ConfusionRestlessnessHypotension bradycardiawide QRS complex115SomnolenceNauseaCardiac depressionBradycardiaWide QRS complexElevated ST segment110SeizuresComaCHFVentricular tachycardia or fibrillation
36TURP 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.
37TURP SYNDROME - HYPERAMMONEMIA Excessive absorption of glycine may lead to hyperammonemia (blood NH3> 500mmol/L).S/S: nausea, vomiting, comatose for hrs and awakens when blood NH3 < 150 mmol/L.Explanation : arginine deficiency
38TURP SYNDROME – CLINICAL FEATURES SystemSigns and SymptomsCauseNeurologicNausea, restlessness, visual disturbances, confusion, somnolence, seizures,coma,deathHyponatremia and hypoosmolality Hyperglycinemia HyperammonemiaCardiovascularHypertension, reflex bradycardia, pulmonary edema, CVS collapseHypotensionECG changes(wide QRS, elevated ST segments, vent arrhythmia)Rapid fluid absorptionThird spacingHyponatremiaRespiratoryTachypnea, oxygen desaturation, cheyne- stokes breathingPulmonary edemaHematologicDisseminated intravascular hemolysisHyponatremia and hypoosmolalityRenalRenal failureHypotension, hemolysis, hyperoxaluriaMetabolicAcidosisDeamination of glycineThird spacing (d/t hyponatremia, hypoosmolality) Hyponatremia and hypoosmolality causing cerebral edema and increased ICP, hyperglycinemia (inhibitory neurotransmitter, potentiates NMDA receptor activity), Deamination of glycine to glyoxylic acid and ammonia
39MEASUREMENT OF FLUID ABSORPTON Volume absorbed = (preoperative Na+/ postoperative Na+ ) ECF - ECFVolumetric fluid balance (diff. b/w amt of irrigation fluid used and volume recovered.)Gravimetry (measure rise in body weight)CVP monitoringBreath ethanol measurementIsotopes
40TURP SYNDROME - PREVENTION Early diagnosis and prompt treatmentCorrection of fluid and electrolyte abnormalities preoperativelyCautious adminstration of IV fluidsLimitation of hydrostatic pressure of irrigation fluid to 60cmRestrict duration of TURP to 1 hrBipolar resectoscopeVaporization methodsLocal vasoconstrictors
41TURP SYNDROME - MANAGEMENT Notify surgeon and terminate surgery.Ensure oxygenationRestrict fluidsPulmonary edema : intubate and IPPVBradycardia, hypotension: atropine, adrenergic agentsSeizures : BZD, thiopentone, phenytoin, i.v.Mg2+Invasive monitoring of arterial and CVPSend blood sample for electrolytes, arterial blood gas analysis.
42TURP 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.
43BLADDER PERFORATION Incidence – 1% Causes Manifestation Trauma by surgical instrumentOverdistention of bladder with irrigation fluidManifestationEarly sign : sudden decrease in return of irrigation solution from bladderExtraperitoneal perforations : pain in periumbilical, inguinal or suprapubic regionIntraperitoneal : generalised abdominal pain, shoulder tip pain, abdo rigidity
44BLOOD 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 ofResection time (2-5ml/min)Size of prostate (7-20ml/g)No. of open venous sinusesIntraoperative BT should be based on preop Hb, duration and difficulty of resection and clinical assessment of pt condition.
45COAGULOPATHY Causes of excessive bleeding Dilutional thrombocytopeniaDIC as a result of release of prostatic particles rich in thromboplastin into bloodLocal release of fibrinolytic agents (plasminogen and urokinase)Treatment – administration of FFP, platelets blood transfusion
46HYPOTHERMIA 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.
47BACTEREMIA AND SEPTICEMIA INCIDENCE – 6-7%CausesRelease of bacteria from prostatic tissuePreoperative indwelling urinary catheterPreoperative UTIC/F – chills, fever, tachycardiaT/T – antibiotic, supportive care
49PERCUTANEOUS NEPHROLITHOTOMY AND NEPHROLITHOTRIPSY (PCNL)
50PERCUTANEOUS NEPHROLITHOTOMY The procedure of choice for removing complex and large renal stones.Imp. Indications of PCNL :Stone size >/= 2.5 cm.Stones resistant to ESWLStaghorn stones in lower calyxAdvantages of percutaneous methodLower morbidity and mortalityFaster convalescenceSmall incisionMinimum operative and postoperative complications.
51ANATOMICAL 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.
52PCNL : PROCEDUREPCNL consists of gaining percutaneous access to the kidney collecting system and performing stone disintegration, usually with ultrasonic or pneumatic lithotripters.
53PERCUTANEOUS APPROACHES Subcostal /Intercostal approachIntercostal puncture is madeover lateral portion of rib but medial to visceraduring expiration
54After tract dilation, a working sheath is left in place A hollow needle placed into the renal collecting system under fluoroscopyA guide wire inserted through the needle and Dilators passed over the wireAfter tract dilation, a working sheath is left in placeNephroscope inserted to directly visualize stoneSmall stone grasped under direct visionLarger stones fragmented by ultrasound or electrohydraulic probeA nephrostomy tube is left to drain the system
55INTRAOPERATIVE COMPLICATIONS HAEMORRHAGEINJURY TO RENAL PELVISFLUID ABSORPTIONINJURY TO PLEURAINJURY TO ADJACENT ORGANSSEPTICEMIA
56ANAESTHETIC TECHNIQUE PCNL can be performed under general or regional anesthesia.General anesthesia is preferred.Patient is laid in prone/ lateral oblique position.
57ANAESTHETIC CONSIDERATIONS POSITION - Prone / lateral oblique positionINTRATHORACIC COMPLICATIONSMost often injured organ during PCNL : lung and pleura.Risk of injury increases with more superior punctures.ApproachIncidenceSubcostal0.5%Supra-12th rib1.5 – 12%Supra – 11th rib23.1%
58ANAESTHETIC 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.
59ANAESTHETIC CONSIDERATIONS Acute anemiadue to blood loss or hemodilution .Repeat Hb measurement should be considered in the perioperative period.Fluid absorptiondue to high pressure fluid irrigation in presence of venous injury or collecting system perforation.Can lead to hypothermia, TURP syndrome, sepsis.
60ANAESTHETIC CONSIDERATIONS Hypothermiadue 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.SepticemiaAll patients have urine cultures done preoperatively with administration of an appropriate antibiotic
61REFERENCESMiller’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,Dietrich Gravenstein. Transurethral resection of prostate (TURP) syndrome: a review of pathophysiology and management. Anesth Analg 1997;84: