Urologic Procedures – Flashcards
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What patient positioning is used to perform a Cystoscopy?
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Lithotomy
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What are typical nerve injury sites for patients in LITHOTOMY position?
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1. Common Peroneal Nerve injury 2. Saphenous Nerve injury 3. Obturator Nerve injury 4. Femoral Nerve injury 5. Sciatic Nerve stretching
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What is Common Peroneal Nerve injury caused by in the Lithotomy position?
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Lateral thigh resting on strap support
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What movement is lost with Common Peroneal Nerve injury?
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Loss of DORSIFLEXION of Foot
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What is Saphenous Nerve injury caused by in the Lithotomy position?
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Legs resting against MEDIALLY placed strap support
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How does a Saphenous Nerve injury in the Lithotomy position present itself?
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NUMBNESS along MEDIAL CALF
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What causes Obturator and Femoral Nerve injury along with Sciatic Nerve stretching in the Lithotomy position?
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Excess FLEXION of THIGH against GROIN
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What serious condition can develop in the lower extremities with prolonged time in the Lithotomy position?
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Compartment Syndrome
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Because of the short duration of the procedure, what anesthetic technique is often used with CYSTOSCOPY?
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General Anesthesia
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How long does the sensory blockade take with an EPIDURAL vs SPINAL for a CYSTOSCOPY?
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15-20 Min for Epidural 5 Min for Spinal
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What sensory level of blockade is needed with a CYSTOSCOPY?
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T10
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What reflex is not able to be abolished using REGIONAL Anesthesia techniques for a CYSTOSCOPY?
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OBTURATOR Reflex is not abolished
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What is the OBTURATOR Reflex?
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EXTERNAL ROTATION and ADDUCTION of the THIGH from ELECTROCAUTERY Stimulation of the OBTURATOR NERVE through the LATERAL Bladder Wall
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How is the OBTURATOR Reflex blocked?
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OBTURATOR Reflex is only blocked by MUSCLE PARALYSIS during GENERAL Anesthesia
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What does TURP stand for?
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Transurethral Resection of Prostate
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What does TURBT stand for?
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Transurethral Resection of Bladder Tumor
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What population of patients normally undergo a TURP or TURBT?
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ELDERLY with BENIGN or MALIGNANT Prostate or Bladder Lesion
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What are 3 factors that determine the TURP or TURBT technique?
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1. Time 2. Use of Laser 3. Size of the Mass
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What are the major serious complications of TURP?
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1. Hemorrhage 2. TURP Syndrome 3. Bladder Perforation 4. Hypothermia 5. Septicemia 6. DIC
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What is opened in the prostate during resection?
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A NETWORK of Venous Sinuses
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What the risk from the irrigating fluid during TURP?
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There is potential of SYSTEMIC ABSORPTION of large amounts of irrigating fluid
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What is TURP SYNDROME?
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The ABSORPTION of >/= 2 L of IRRIGATING FLUID
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When do Symptoms of TURP SYNDROME appear (intraop or postop)?
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EITHER, signs can occur INTRAOP or POSTOP
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What are the Symptoms of TURP SYNDROME?
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1. Headache 2. Restlessness 3. Confusion 4. Cyanosis 5. Dyspnea 6. Arrhythmias 7. Hypotension 8. Seizure
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How dangerous is TURP SYNDROME?
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Can be QUICKLY FATAL
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How does TURP SYNDROME manifest itself?
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1. Fluid Overload 2. HYPOnatremia 3. HYPO-osmolality 4. Hemolysis 5. Water Intoxication 6. Solute Toxicity
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What are the Solute Toxicities in TURP SYNDROME (and what are the solutes used that cause them)?
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1. HYPERglycinemia (glycine) 2. HYPERammonemia (glycine) 3. HYPERglycemia (sorbitol) 4. Intravascular Volume Expansion (mannitol)
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At what Na+ Concentration do signs of HYPOnatremia evidence themselves in TURP SYNDROME?
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<120 mEq/L
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What eye condition can glycine cause?
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Transient BLINDNESS
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What is the Treatment for TURP SYNDROME?
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1. Early recognition of Symptoms 2. Fluid RESTRICTION and LOOP DIURETICS
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What is used to Treat the Symptomatic HYPOnatremia with Coma and Seizures in TURP SYNDROME?
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HYPERTONIC Saline
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What is the caution with using HYPERTONIC Saline to correct severe HYPOnatremia in TURP SYNDROME?
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Correct SLOWLY!!!
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What can result from rapid correction of severe HYPOnatremia using HYPERTONIC Saline?
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CENTRAL PONTINE MYELINOSIS
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What is CENTRAL PONTINE MYELINOSIS?
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DEMYELINATION of the PONS, causing PERMANENT NEUROLOGICAL DAMAGE
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At what rates should severe HYPOnatremia be corrected with HYPERTONIC Saline?
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</= 0.5 mEq/L/HR for MILD Symptoms </= 1.0 mEq/L/HR for MODERATE Symptoms </= 1.5 mEq/L/HR for SEVERE Symptoms
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What are 2 complications related to the large volume of room temperature irrigating fluid administered during TURP?
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1. HYPOthermia 2. Bladder Perforation
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What are 4 symptoms AWAKE patients present with a Bladder Perforation from TURP?
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1. Nausea 2. Diaphoresis 3. Retropubic Pain 4. Lower Abdominal Pain
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What should be suspected when TURP patients exhibit sudden HYPOtension or HYPERtension with BRADYcardia?
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Bladder Perforation
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What types of perforation often present with sudden, unexplained HYPO/HYPERtension during TURP?
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1. LARGE EXTRAperitoneal Perforations, and 2. MOST INTRAperitoneal Perforations
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What can cause DIC during a TURP?
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The Release of THROMBOPLASTINS from the Prostate into circulation during surgery
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What other platelet condition can develop from TURP?
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DILUTIONAL Thrombocytopenia
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What is important to remember about blood loss monitoring in a TURP?
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Blood Loss can be difficult to assess
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What is the average blood loss during a TURP?
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3-5mL/min average during resection time (200-300mL total avg)
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What 2 factors are associated with the need to transfuse blood during a TURP?
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1. Procedure lasting > 90 MIN 2. Resection of > 45 g of Prostate Tissue
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What anesthetic techniques are used for TURP?
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SPINAL or GENERAL Anesthesia
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Which anesthesia technique used for TURP makes it easier to detect signs of HYPERvolemia and Bladder Perforation?
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SPINAL Anesthesia
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What level of sensory block is needed with SPINAL Anesthesia on a TURP patient?
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T10 Sensory Level Block
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What type of fibers carry the pain impulses from the Bladder NECK and Prostate in TURP?
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AFFERENT PARAsympathetic Fibers
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Where do the AFFERENT Parasympathetic Fibers originate that carry the pain impulses of the Bladder NECK and Prostate in TURP?
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2nd & 3rd Sacral Roots with the Pelvic Splanchnic Nerves
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What type of fibers carry the pain impulses from the Bladder in TURP?
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Sympathetic Nerve Fibers
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Where do the SYMPATHETIC Fibers originate that carry the pain impulses of the Bladder in TURP?
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HYPOgastric Plexus derived from the T11-L2 Nerve Roots
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Which pain impulses are harder to block, from the bladder neck & prostate or from the bladder?
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The Bladder Neck and Prostate b/c PARAympathetic Fibers are more difficult to block than the Sympathetic
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What is the only NONinvasive Urinary Stone Treatment?
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Extracorporeal Shock-Wave Lithotripsy (ESWL)
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How does an ESWL break up renal calculi?
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Uses 100s-1000s of High-Energy ULTRASONIC or PNEUMATIC Shock Waves to fragment the renal calculi into small particles
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What sized renal stones can be treated with ESWL?
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Stones < 10-20mm
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What location of renal stones can be treated with ESWL?
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Mid to Proximal Ureter
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How does an ESWL deliver the shock waves to break up the renal calculi?
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1. External source delivers pulses of energy into a fluid chamber 2. Generates a SHOCK WAVE which is transmitted unimpeded through the fluid and patient's soft tissue 3. The SHOCK WAVE encounters an abrupt CHANGE in ACOUSTIC DENSITY from the body tissue to the stone
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What is the Shock Wave in ESWL syncronized to?
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The R wave of the patient's ECG
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Why is the Shock Wave in ESWL syncronized to R Waves of the ECG?
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To reduce the incidence of Cardiac Dysrhythmias, mostly PACs and PVCs (it reduces the incidence, but doesn't totally eliminate them...)
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What is the risk of a Pacemaker or Internal Cardiac Defibrillator (AICD) with ESWL treatment?
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Shock Wave Induced Arrhythmia
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What precaution should be taken with patients with an AICD?
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Turn the AICD off before the ESWL procedure
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Why is there a bleeding risk associated with ESWL treatment?
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Any structure in the abdominal region may be perforated, ruptured, or otherwise damaged by the Shock Waves in ESWL
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What are ABSOLUTE Contraindications of ESWL Treatment?
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1. Pregnancy 2. Abnormal Coagulation 3. Weight >275lbs 4. Aortic Aneursym >6cm 5. Active UTI
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What are RELATIVE Contraindications of ESWL Treatment?
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1. Aortic Aneursym <6cm 2. Spinal Tumors 3. Uncontrolled Arrhythmias 4. Metal Instrumentation in the LUMBAR Spine
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Is ESWL by immersion in heated water bath still used today?
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NO, but may still be on certification exam
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What CV changes are produced in ESWL by immersion in heated water bath?
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1. Hypotension 2. Vagal Response 3. Increased Central Venous PRESSURE 4. Increased Central Venous VOLUME
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What causes the HYPOtension and VAGAL Response in ESWL by immersion in heated water bath?
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VasoDILATION
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What medications should the anesthesia provider have available to treat the CV responses common in ESWL by immersion in heated water bath?
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GLYCOPYROLATE or ATROPINE
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What are the RESPIRATORY Effects of ESWL by immersion in heated water bath?
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1. REDUCED FRC 2. REDUCED Tidal Volume 3. REDUCED Vital Capacity 4. V/Q MISMATCH
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What causes the risk for HYPOthermia with ESWL by immersion in heated water bath?
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1. Heat is transferred from the patient to the water 2. General and Epidural Anesthesia cause VasoDILATION and LOSS of SHIVERING response
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What water temperature is maintained during ESWL by immersion in heated water bath?
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35-37 Degrees C
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What is noteworthy about the EKG Leads used with ESWL by immersion in heated water bath?
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Waterproof EKG Leads are required
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Why are WATERPROOF EKG Leads required with ESWL by immersion in heated water bath?
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The R Wave is used to trigger the SHOCK WAVES, so the EKG reading must be of good quality
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At what point in the Cardiac Cycle is the Shock Wave set to trigger?
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20 MILLIseconds after the R Wave, which is during the ABSOLUTE REFRACTORY Period of the VENTRICLE
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At what ratio is the timing of the shock wave triggered by the Heart Rate?
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1:1; unless the HR is > 120, then it is 1:2
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What medications can be used to increase the heart rate and the Shock Wave rate?
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GLYCOPYRROLATE
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What is important about lead placement in ESWL by immersion in heated water bath?
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Leads should not be placed in the path of the shock wave
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What is important about placement of the BP cuff and Pulse Oximeter in ESWL by immersion in heated water bath?
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Make sure the BP cuff and Pulse Oximeter stays out of the water
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What anesthetic techniques can be used with ESWL?
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GENERAL SPINAL EPIDURAL MAC
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What level of sensory block is needed with REGIONAL Anesthesia on an ESWL patient?
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T6 Level with IV Sedation
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What special precautions should be taken with EPIDURAL Anesthesia with an ESWL by immersion in heated water bath?
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Epidural Catheter must be protected from H2O with watertight plastic occlusive dressing
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How are Shock Waves generated in Non-Immersion ESWL?
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By ELECTROMAGNET thru SELF-CONTAINED Water Filled Cushions
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Is Non-Immersion ESWL MORE painful or LESS painful than Water Immersion ESWL?
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LESS Painful than Water Immersion
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What anesthetic technique is used for Non-Immersion ESWL?
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MAC or SEDATION GENERAL ANESTHESIA, if a poor candidate for MAC
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How is the patient positioned for Non-Immersion ESWL?
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1. Supine 2. Prone
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Why is it important to alert the patient before the start of the shocks?
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So the patient doesn't move
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What is used to enhance contact with Non-Immersion ESWL?
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Water or Gel (Patient may be cold and wet)
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What sized kidney stones can be removed with PERCUTANEOUS Nephrolithotomy?
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</= 25mm Kidney Stones
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What are the anesthetic and post-surgical requirements for patients undergoing PERCUTANEOUS Nephrolithotomy?
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Requires GENERAL Anesthesia and POST-OP HOSPITALIZATION
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By what method are kidney stones removed with PERCUTANEOUS Nephrolithotomy?
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Removed/Pulverized via rigid operating SCOPE inserted in the LOWER CALYX of the Kidney under Fluoroscopy
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What is placed directly on the stones to pulverize them with PERCUTANEOUS Nephrolithotomy?
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1. Laser probes 2. Electrohydrualic probes 3. Ultrasound probes
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What position is a patient placed for PERCUTANEOUS Nephrolithotomy?
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1. Prone 2. Supine
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What are the 2 separate procedures that may be required with PERCUTANEOUS Nephrolithotomy?
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1. Access via NEPHROSTOMY established in Radiology Suite 2. NEPHROLITHOTOMY Procedure
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What are the MAJOR Complications to PERCUTANEOUS Nephrolithotomy?
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1. Septicemia 2. Bleeding 3. Pelvic or Ureteral Tears 4. Pneumothorax 5. Hemothorax 6. Anaphylaxis secondary to Contrast Dye
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What are the MINOR Complications to PERCUTANEOUS Nephrolithotomy?
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1. Pain 2. Fever 3. Urinary Tract Infection 4. Renal Colic
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What is ROBOTIC Assisted Laparoscopic Prostatectomy used for?
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Removal of Urinary Obstruction secondary to BPH or Malignant Tumor
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What are the benefits to ROBOTIC Assisted Laparoscopic Prostatectomy?
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1. Spares Nerves 2. Less Blood Loss 3. Shorter Hospital Stay
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How is ROBOTIC Assisted Laparoscopic Prostatectomy able to be so precise?
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Allows 3-D image of prostate with magnification
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What anesthetic technique is used for ROBOTIC Assisted Laparoscopic Prostatectomy?
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GENERAL Anesthesia with Muscle Paralysis
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What ventilator settings are most appropriate for patients undergoing ROBOTIC Assisted Laparoscopic Prostatectomy?
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Pressure Control Ventilation with SMALLER Tidal Volumes and INCREASED Respiration Rate to maintain ETCO2
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In what general situations is Pressure Control Ventilation a good choice?
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1. Obese Patients 2. COPD 3. Trendelenberg Position
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What additional monitoring may be required with ROBOTIC Assisted Laparoscopic Prostatectomy?
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Arterial Line, due to: 1. Length of Case 2. CV Status
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How should IV fluids be maintained with ROBOTIC Assisted Laparoscopic Prostatectomy?
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IV Fluids kept to MINIMUM until END of Case when ANASTOMOSIS is COMPLETE
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Why are IV Fluids kept to MINIMUM until END of Case in ROBOTIC Assisted Laparoscopic Prostatectomy?
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1. Minimizes risk of urine spilling into abdomen until urethra is anastomosed to bladder neck 2. Excess UOP affects surgeon's view
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Can a urethral catheter be used for bladder drainage in ROBOTIC Assisted Laparoscopic Prostatectomy?
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Yes, but at the end of the case. (If catheter is in place during the procedure, will move it in and out of the bladder during the anastomosis to the bladder neck)
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What patient positioning is used for ROBOTIC Assisted Laparoscopic Prostatectomy?
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LITHOTOMY Position and STEEP TRENDELENBERG
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How are arms positioned during ROBOTIC Assisted Laparoscopic Prostatectomy?
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Padded and tucked at the sides
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What is the duration of ROBOTIC Assisted Laparoscopic Prostatectomy surgery?
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3 - 6 HRS
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What are the RESPIRATORY Effects of STEEP TRENDELENBERG and PNEUMOPERITONEUM?
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1. DECREASED FRC 2. DECREASED Pulmonary Compliance 3. DECREASED Lung Volume 4. IMPAIRED Movement of Lungs & Diaphragm
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What negative effects result from the RESPIRATORY changes brought on by STEEP TRENDELENBERG and PNEUMOPERITONEUM?
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1. Hypoxia 2. HYPERcapnia 3. Atelectasis
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What Ventilatory Settings can be used to maximize Tidal Volume and minimize Peak Inspiratory Pressures?
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1. PCV 2. PCV-VG 3. SIMV PCV-VG
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What are the CARDIOVASCULAR Effects of STEEP TRENDELENBERG and PNEUMOPERITONEUM?
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1. DECREASED CO 2. DECREASED Venous Return 3. INCREASED CVP 4. INCREASED PCWP
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What potential negative effects can result from the CARDIOVASCULAR changes brought on by STEEP TRENDELENBERG and PNEUMOPERITONEUM?
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1. Myocardial ISCHEMIA 2. Dysrhythmias
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What are potential negative CARDIOVASCULAR effects of PNEUMOPERITONEUM?
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1. BRADYcardia 2. Asystole
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What is the cause of the potential negative CARDIOVASCULAR effects of PNEUMOPERITONEUM?
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VAGAL Stimulation initiates the CELIAC Reflex
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What are the RENAL Effects of STEEP TRENDELENBERG and PNEUMOPERITONEUM?
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1. DECREASED Blood Flow to the Kidneys 2. DECREASED GFR 3. ADH & ALDOSTERONE Release due to DECREASED UOP
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What are the CEPHALIC Effects of STEEP TRENDELENBERG and PNEUMOPERITONEUM?
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1. FACIAL Edema 2. EYELID Edema 3. CONJUNCTIVAL Edema 4. INCREASED ICP 5. INCREASED INTRAOCCULAR Pressure
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What can result from EXTRAPERITONEAL Insufflation in ROBOTIC Assisted Laparoscopic Prostatectomy?
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1. SUB-Q Emphysema 2. HYPERcarbia causing ACIDOSIS 3. CO2 Gas EMBOLISM 4. Arterial HYPOXEMIA 5. Migration of ET Tube 6. BAROtrauma resulting in Pneumothorax
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What are Complications of ROBOTIC Assisted Laparoscopic Prostatectomy?
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1. Stimulation of CELIAC Reflex 2. INCREASED Cardiac Workload causing Myocardial ISCHEMIA 3. RETINOPATHY from prolonged Trendelenberg Position 4. AIRWAY Edema from prolonged Trendelenberg Position 5. CEREBRAL Edema from prolonged Trendelenberg Position 6. Acute MASSIVE Hemorrhage 7. Unintentional Surgical Trauma to Bowel, Bladder, Abdominal Organs, or Vascular Structures
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What are INDIGO CARMINE and METHYLENE BLUE used for?
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Determine URETERAL INTEGRITY
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How are INDIGO CARMINE and METHYLENE BLUE eliminated from the body?
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Both are excreted by Kidneys approximately 10 MIN after IV Administration
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How do INDIGO CARMINE and METHYLENE BLUE determine URETERAL INTEGRITY?
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DYE is Detected in Urine if: 1. Damage Occurred or 2. REANASTOMOSIS is Necessary
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What is the choice of using INDIGO CARMINE or METHYLENE BLUE determined by?
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1. Hospital Formulary 2. Surgeon Preference
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What affect on Blood Pressure are there with INDIGO CARMINE and METHYLENE BLUE use?
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Mild, usually SHORT LIVED Increase in BP
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What causes the mild, short-lived Increase in BP with INDIGO CARMINE and METHYLENE BLUE use?
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INHIBITION of Nitric Oxide (NO), which is a POTENT VasoDILATOR
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What happens to SpO2 with INDIGO CARMINE and METHYLENE BLUE use?
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Artificially DECREASE due to the Blue Color of the Dyes
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What is the dosage for METHYLENE BLUE use?
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1-2 mg/Kg, SLOW IV Push (0.1-0.2 mL/Kg)
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What is METHYLENE BLUE used to treat?
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METHEMOGLOBINEMIA, but can Cause or Exacerbate it as well
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What is the dosage for INDIGO CARMINE use?
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40 mg IV (in a 5mL Ampule)
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Which is preferred, INDIGO CARMINE or METHYLENE BLUE?
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INDIGO CARMINE (less risk of side effects)
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What is a CV effect of INDIGO CARMINE?
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MILD VasoPRESSOR Effect
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What are the side effects of METHYLENE BLUE?
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1. METHEMOGLOBINEMIA with Large Doses 2. HTN 3. Dysrhythmias 4. HYPERthermia 5. Anaphylaxis
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What are the side effects of INDIGO CARMINE?
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1. METHEMOGLOBINEMIA with Large Doses 2. HTN 3. BRADYcardia
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What are Anesthetic Concerns for ROBOTIC Assisted Laparoscopic Prostatectomy?
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1. Warming Blankets and Fluid Warmers 2. Pre-op Lab Values Checked 3. Type & Crossmatch Blood Pre-op 4. Facial Swelling requires careful AIRWAY ASSESSMENT PRIOR To Extubation 5. There are difficulties inherent in PROLONGED TRENDELENBURG Position
