Chapter 56: Anesthetic Considerations for Genitourinary and Renal Surgery

KEY POINTS

1. Anesthetic management of urologic patients requires confidence with the management of elderly patients who typically have multiple comorbidities.

2. Surgical positioning is often complex and exposes the patient to the risk of significant complications.

3. Most endourologic procedures can be safely accomplished with either general or regional anesthesia. The anesthetic plan can be tailored to patient characteristics and individual preferences.

4. Urologic cancer requires highly invasive operations that have a high risk of complications. Patients undergoing these procedures require thorough physiologic monitoring and proactive hemodynamic, respiratory, and analgesic management.

5. New oral anticoagulant use is on the rise for a variety of conditions that afflict this patient population. Evidence-based guidelines regarding the perioperative management of these drugs and the use of neuraxial anesthesia are not established at present. Careful consideration and knowledge of up-to-date literature should be used in the decision to perform neuraxial procedures in these instances.

6. Recent enhanced-recovery-after-surgery (ERAS) pathways have shown effectiveness in reducing the morbidity of major operations such as radical cystectomies. ERAS pathways often include (among other things) standardized anesthesia plans, regional anesthesia, goal-directed/restrictive fluid management strategies, and effective pain control.

7. The transversus abdominis plane (TAP) block is a fast, simple, and relatively low risk regional technique that allows sensory blockade of the anterior abdominal wall after major abdominal surgery. It shows potential as an adjunct in a multi-modal approach to postoperative pain management in these patients.

8. Bleomycin is a chemotherapeutic agent that is often used to treat recurrent and advanced-stage testicular cancer. Postoperative acute respiratory distress syndrome has been reported in these patients, likely due to pulmonary toxicity of bleomycin triggered by increased amounts of inspired oxygen. Care should be taken to limit the admixture of oxygen in these patients as much as possible.

9. The use of minimally invasive and robotic surgery in urology continues to increase rapidly, both in the United States and worldwide. These procedures may require prolonged pneumoperitoneum and head-down positioning, which introduce additional clinical challenges for anesthesia providers.