- The lithotomy position is the most commonly
used position for patients undergoing urological and gynecological
procedures. Failure to properly position patients can result in
- The lithotomy position is associated with major
physiological alterations. Functional residual capacity decreases,
predisposing patients to atelectasis and hypoxia. Elevation of the
legs increases venous return acutely. Mean blood pressure often
increases, but cardiac output does not change significantly. Conversely,
rapid lowering of the legs acutely decreases venous return and can
result in hypotension. Blood pressure measurements should
always be taken immediately after the legs are lowered.
- Because of the short duration (15–20
min) and the outpatient setting of most cystoscopies, general anesthesia
is usually used.
- Both epidural and spinal blocks can provide satisfactory
anesthesia. A sensory level to T10 provides excellent anesthesia
for nearly all cystoscopic procedures.
- Manifestations of the TURP (transurethral resection
of the prostate) syndrome are primarily those of circulatory fluid
overload, water intoxication, and, occasionally, toxicity from the
solute in the irrigating fluid.
- Absorption of irrigation fluid appears to be
dependent on the duration of the resection as well as the height
(pressure) of the irrigation fluid.
- When compared with general anesthesia, regional
anesthesia appears to reduce the incidence of postoperative venous
thrombosis; it is also less likely to mask symptoms and signs of
the TURP syndrome or bladder perforation.
- Patients with a history of cardiac arrhythmias
and those with a pacemaker or internal cardiac defibrillator (ICD)
may be at risk for developing arrhythmias induced by shock waves
during extracorporeal shock wave lithotripsy (ESWL). Shock waves
can damage the internal components of pacemaker and ICD devices.
- Patients who are undergoing retroperitoneal lymph
node dissection and who are receiving bleomycin preoperatively are
at increased risk for developing postoperative pulmonary insufficiency. These
patients appear to be particularly sensitive to oxygen toxicity
and fluid overload, and are at increased risk for developing acute
respiratory distress syndrome postoperatively. Excessive intravenous
fluid administration may also be contributory.
- The serum potassium concentration should be
below 5.5 mEq/L and existing coagulopathies should be corrected
in patients undergoing renal transplantation. Hyperkalemia has been
reported after release of the vascular clamp following completion
of the arterial anastomosis, particularly in small patients and
pediatric patients. Release of potassium contained in the preservative
solution has been implicated in those cases.
Urological procedures account for 10–20% of
most anesthetic practices. Patients undergoing genitourinary procedures
may be of any age, but most are elderly and many have coexisting
medical illnesses, particularly renal dysfunction. Anesthetic management
of patients with renal impairment is discussed in Chapter
32, and the effects of anesthesia on renal function are discussed
in Chapter 31. This chapter reviews the anesthetic
management of common urological procedures. Use of the lithotomy
position, the transurethral approach, and extracorporeal shock waves
(lithotripsy) complicates many of these procedures. Moreover, advances
in surgical technique allow more patients to undergo radical procedures
for urological cancer, urinary diversion with bladder reconstruction, and