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 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

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 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.

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

Sympathetic supply T11-L2 Inferior hypogastric

plexus 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

NERVE SUPPLY BLOOD SUPPLY

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 three-lumen catheter is inserted and irrigation is continued for up to 24 h after operation.

The procedure usually takes 30–90 min.

IRRIGATION FLUIDS

Characteristics of Ideal irrigation fluid:1. Transparent2. Isotonic3. Electrically inert4. Non hemolytic5. Inexpensive6. Not metabolizable7. Rapidly excretable8. Non toxic9. Easy to sterilise

Uses distends bladder and

prostatic urethra flushes out blood

and tissue debris improves visibility

SOLUTION OSMOLALITY (mOsm/kg)

ADVANTAGES DISADVANTAGES

DISTILLED WATER

0 (hypo) Electrically inertImproved visibilityInexpensive

HemolysisHemoglobinuriaHemoglobinemiaHyponatremia

GLYCINE (1.5%) GLYCINE (1.2%)

220 (iso)

175 (hypo)

Less likelihood of TURP syndrome

Transient postoperative visual syndrome,Hyperammonemia,Hyperoxaluria

NORMAL SALINE (0.9%)

308 (iso) Less incidence of TURP syndrome

Ionized, cannot be used with cautery

RINGER LACTATE

273 (iso) Ionized, cannot be used with cautery

SOLUTION OSMOLALITY (mOsm/kg)

ADVANTAGES DISADVANTAGES

MANNITOL (5%)

275 (iso) Isomolar solutionNot metabolized

Osmotic diuresis, Acute intravascular expansion

SORBITOL (3.5%)

165 (hypo) Same as glycine

Hyperglycemia, Lactic acidosisOsmotic diuresis

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

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 anaesthesia1. Allows monitoring of mentation and early signs of TURP

syndrome and bladder perforation2. Promotes peripheral vasodilation , reducing circulatory

overload 3. Reduces blood loss, requiring fewer transfusions4. Avoids effects of general anaesthesia on pulmonary pathology5. Good early post-operative analgesia6. Reduced incidence of post-operative DVT/PE7. Neuroendocrine and immune response are better preserved8. 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

coagulopathyMain 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, comaCNS – decerebrate posture, clonus, +ve

babinski’s reflexEyes – papilloedema, dilated and non

reactive pupilsEEG – 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 ConfusionRestlessness

Hypotension bradycardia

wide QRS complex

115 SomnolenceNausea

Cardiac depression

Bradycardia Wide QRS complexElevated 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, pulmonary edema, CVS collapseHypotension ECG changes(wide QRS, elevated ST segments, vent arrhythmia)

Rapid fluid absorption

Third spacingHyponatremia

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. Volume absorbed = (preoperative Na+/ postoperative Na+ ) ECF - ECF

2. Volumetric fluid balance (diff. b/w amt of irrigation fluid used and volume recovered.)

3. Gravimetry (measure rise in body weight)4. CVP monitoring5. Breath ethanol measurement6. 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

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.

.

THANK YOU …