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Improved survival rates for patients with urological cancer following radical surgical resections have resulted in an increase in the number of procedures performed for prostatic, bladder, testicular, and renal cancer. The desire for accelerated, less-complicated recovery with smaller, less painful incisions has prompted development of laparoscopic pelvic and abdominal operations, including radical prostatectomy, cystectomy, pelvic lymph node dissection, nephrectomy, and adrenalectomy. Robotic-assisted technology has increasingly been applied to these procedures over the past decade.
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Many urological procedures are carried out with the patient in a hyperextended supine position to facilitate exposure of the pelvis during pelvic lymph node dissection, retropubic prostatectomy, or cystectomy (Figure 32–3). The patient is positioned supine with the iliac crest over the break in the operating table, and the table is extended such that the distance between the iliac crest and the costal margin increases maximally. Care must be taken to avoid putting excessive strain on the patient’s back. The operating room table is also tilted head-down to make the operative field horizontal. In the frog-leg position, a variation of the hyperextended supine position, the knees are also flexed and the hips are abducted and externally rotated.
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Preoperative Considerations
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Adenocarcinoma of the prostate is the most common nonskin cancer in men and is second only to lung cancer as the most common cause of cancer deaths in men older than 55 years. Approximately one in six men will be diagnosed with prostate cancer in their lifetime. Management varies from surveillance to radical surgery. Important variables include the grade and stage of the malignancy, the patient’s age, the concentration of prostate-specific antigen (PSA), and the presence of medical comorbidity. Transrectal ultrasound is used to guide transrectal biopsies. Clinical staging is based on the Gleason score of the biopsy specimens, magnetic resonance imaging (MRI) to determine whether there is tumor migration to regional lymph nodes, and bone scan.
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Intraoperative Considerations
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Patients with prostate cancer may present to the operating room for open radical retropubic prostatectomy with lymph node dissection, robot-assisted laparoscopic prostatectomy with pelvic lymph node dissection, salvage prostatectomy (following failure of radiation therapy), cryoablation, or bilateral orchiectomy for hormonal therapy.
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A. Radical Retropubic Prostatectomy
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Radical retropubic prostatectomy is usually performed with pelvic lymph node dissection through a lower midline abdominal incision. It may be curative for localized prostate cancer or occasionally used as a salvage procedure after failure of radiation. The prostate is removed en bloc with the seminal vesicles, ejaculatory ducts, and part of the bladder neck. A “nerve-sparing” technique may be used to help preserve sexual function. Following prostatectomy, the remaining bladder neck is anastomosed directly to the urethra over an indwelling urinary catheter. The surgeon may ask for intravenous administration of indigo carmine for visualization of the ureters, and this dye can be associated with hypertension or hypotension.
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Radical retropubic (open) prostatectomy may be accompanied by significant operative blood loss. Most centers use direct arterial blood pressure monitoring, and central venous pressure monitoring may also be employed. Other centers routinely utilize noninvasive cardiac output monitoring (eg, LiDCOrapid or FloTrac/Vigileo). Operative blood loss varies considerably from center to center, with mean values less than 500 mL common. Factors influencing blood loss include prostate size, duration of operation, and the skill and experience of the surgeon. Blood loss and operative morbidity and mortality are similar in patients receiving general anesthesia and those receiving regional anesthesia. Neuraxial anesthesia requires a T6 sensory level, but these patients typically do not tolerate regional anesthesia without deep sedation because of the hyperextended supine position. The combination of a prolonged Trendelenburg position together with administration of large amounts of intravenous fluids may rarely produce edema of the upper airway. The risk of hypothermia should be minimized by utilizing a forced-air warming blanket and an intravenous fluid warmer.
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Postoperative complications include hemorrhage, deep venous thrombosis (perhaps with pulmonary embolus), injuries to the obturator nerve, ureter, and rectum, and urinary incontinence and impotence. Extensive surgical dissection around the pelvic veins increases the risk of intraoperative venous air embolism and postoperative thromboembolic complications. An enhanced recovery approach to perioperative care should be standard. Although epidural anesthesia may reduce the incidence of postoperative deep venous thrombosis following open prostatectomy, this beneficial effect may be negated by the routine use of warfarin or fractionated heparin prophylaxis postoperatively, and in the era of enhanced recovery is less often used. Ketorolac and acetaminophen can be used as analgesic adjuvants and have been reported to decrease opioid requirements, improve analgesia, and promote earlier return of bowel function.
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B. Robot-Assisted Laparoscopic Radical Prostatectomy
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Robot-assisted laparoscopic radical prostatectomy with pelvic lymph node dissection differs from most other laparoscopic procedures by the frequent use of steep (>30°) Trendelenburg position for surgical exposure. Patient positioning, duration of procedure, need for abdominal distention, and desirability of increasing minute ventilation require use of general endotracheal anesthesia. Nitrous oxide is usually avoided to prevent bowel distention. Most laparoscopic prostatectomies are performed with robotic assistance, and the majority of radical prostatectomies in the United States are now performed via robot-assisted laparoscopy. When compared with open retropubic prostatectomy, laparoscopic robot-assisted prostatectomy is associated with a longer procedure time but with less blood loss and fewer blood transfusions, lower postoperative pain scores and lower opioid requirements, less postoperative nausea and vomiting, and shorter hospital length of stay. The steep Trendelenburg position can lead to head and neck tissue edema and to increased intraocular pressure. Complications reported to be associated with such positioning include upper airway edema and postextubation respiratory distress, postoperative visual loss involving ischemic optic neuropathy or retinal detachment, and brachial plexus injury. The surgeon should be routinely advised as to the length of time during which steep Trendelenburg positioning is maintained, and some centers have abandoned the routine use of this positioning entirely.
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Most clinicians use a single large-bore intravenous catheter. The risk of hypothermia should be minimized by utilizing a forced-air warming blanket and an intravenous fluid warmer. Adequate postoperative analgesia is provided by ketorolac or acetaminophen, or both, and supplemented as needed with opioids. Postoperative epidural analgesia is not warranted because of relatively low postoperative pain scores and because patients may be discharged 24 h after surgery.
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C. Bilateral Orchiectomy
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Bilateral orchiectomy may be performed for hormonal control of metastatic prostate cancer. The procedure is relatively short (20–45 min) and is performed through a single midline scrotal incision. Although bilateral orchiectomy can be performed with local or regional anesthesia, most patients and many clinicians prefer general anesthesia, usually administered via a laryngeal mask airway, or spinal anesthesia.
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Preoperative Considerations
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Bladder cancer occurs at an average patient age of 65 years with a 3:1 male to female ratio. Transitional cell carcinoma of the bladder is second to prostate adenocarcinoma as the most common malignancy of the male genitourinary tract. The association of cigarette smoking with bladder carcinoma results in coexistent coronary artery and chronic obstructive pulmonary disease in many of these patients. Underlying kidney impairment, when present, may be age related or secondary to urinary tract obstruction. Staging includes cystoscopy and computed tomography (CT) or MRI scans. Intravesical chemotherapy is used for superficial tumors, and transurethral resection of bladder tumors (TURBT) is carried out via cystoscopy for low-grade, noninvasive bladder tumors. Some patients may receive preoperative radiation to shrink the tumor before radical cystectomy. Urinary diversion is usually performed immediately following cystectomy.
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Intraoperative Considerations
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A. Transurethral Bladder Resection
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Bladder tumors may occur at various sites within the bladder, and laterally located tumors may lie in proximity to the obturator nerve. In such cases, if spinal anesthesia is administered or if general anesthesia is administered without use of a muscle relaxant, use of the cautery resectoscope may result in stimulation of the obturator nerve and adduction of the legs. Urologists rarely derive amusement from having their ear struck by the patient’s knee; thus, in contrast to TURP, TURBT procedures are more commonly performed with general anesthesia and neuromuscular blockade. TURBT, unlike TURP, is rarely associated with absorption of significant amounts of irrigating solution.
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B. Radical Cystectomy
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With radical cystectomy, all anterior pelvic organs—including the bladder, prostate, and seminal vesicles—are removed in men; the bladder, uterus, cervix, ovaries, and part of the anterior vaginal vault may be removed in women. Pelvic node dissection and urinary diversion are also carried out. Radical cystectomy is associated with the greatest risk of perioperative morbidity and mortality of all major urological procedures, especially in the elderly patient population. However, continuous improvements in neoadjuvant chemotherapy and enhanced recovery after surgery programs have been associated with progressively lower rates of perioperative morbidity and mortality as well as higher rates of 1- and 5-year survival. When compared with open radical cystectomy, robot-assisted radical cystectomy is associated with reduced perioperative complications, less blood loss and transfusion, and shorter hospital length of stay.
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Duration of radical cystectomy is typically 4 to 6 h and blood transfusion is frequently utilized. General endotracheal anesthesia with a muscle relaxant provides optimal operating conditions. Controlled hypotensive anesthesia may reduce intraoperative blood loss and transfusion requirements in open cystectomy, and some surgeons also believe it improves surgical visualization. However, maintenance of mean arterial pressure below 55 to 65 mm Hg may be associated with increased risk of acute kidney injury and stroke. Continuous epidural anesthesia can facilitate the induced hypotension, decrease general anesthetic requirements, and facilitate postoperative analgesia. Optimized intraoperative fluid administration (using noninvasive cardiac output monitoring) may decrease blood transfusion requirements, postoperative complications, and hospital length-of-stay. Continuous epidural infusion or transversus abdominis plane (TAP) block is frequently used for postoperative analgesia.
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Many clinicians will place an arterial catheter along with two large-bore intravenous lines. Urinary output is correlated with the progress of the operation, as the urinary collection path is interrupted at an early point during most of these procedures. As with all lengthy operative procedures, the risk of hypothermia is minimized by use of a forced-air warming blanket and intravenous fluid warming.
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Urinary diversion (ie, implanting the ureters into a segment of bowel) is usually performed immediately following radical cystectomy. The selected bowel segment is either left in situ, such as in ureterosigmoidostomy, or divided with its mesenteric blood supply intact and attached to a cutaneous stoma or urethra. Moreover, the isolated bowel can either function as a conduit (eg, ileal conduit) or be reconstructed to form a continent reservoir (neobladder). Conduits may be formed from ileum, jejunum, or colon.
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Major anesthetic goals for urinary diversion procedures include keeping the patient well hydrated and maintaining a brisk urinary output once the ureters are opened. Neuraxial anesthesia often produces unopposed parasympathetic activity due to sympathetic blockade, which results in a contracted, hyperactive bowel that makes construction of a continent ileal reservoir technically difficult. Papaverine (100–150 mg as a slow intravenous infusion over 2–3 h), glycopyrrolate (1 mg), or glucagon (1 mg) may alleviate this problem.
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Prolonged contact of urine with bowel mucosa (slow urine flow) may produce significant metabolic disturbances. Hyponatremia, hypochloremia, hyperkalemia, and metabolic acidosis can occur following construction of jejunal conduits. In contrast, colonic and ileal conduits may be associated with hyperchloremic metabolic acidosis. The use of temporary ureteral stents and maintenance of high urinary flow help alleviate this problem in the early postoperative period.
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Preoperative Considerations
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Testicular tumors are classified as either seminomas or nonseminomas. The initial treatment for all tumors is radical (inguinal) orchiectomy, and subsequent management depends on tumor histology. Retroperitoneal lymph node dissection (RPLND) plays a major role in the staging and management of patients with nonseminomatous germ cell tumors. Low-stage disease is managed with RPLND or in some instances by surveillance. High-stage disease is usually treated with chemotherapy followed by RPLND.
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In contrast to other tissue types, seminomas are very radiosensitive tumors that are primarily treated with retroperitoneal radiotherapy. Chemotherapy is used for patients who relapse after radiation. Patients with large bulky seminomas or those with increased α-fetoprotein levels (usually associated with nonseminomas) are treated primarily with chemotherapy. Chemotherapeutic agents commonly include cisplatin, vincristine, vinblastine, cyclophosphamide, dactinomycin, bleomycin, and etoposide. RPLND is usually undertaken for patients with residual tumor after chemotherapy.
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Patients undergoing RPLND for testicular cancer are typically young (15–35 years old) but are at increased risk for morbidity from the residual effects of preoperative chemotherapy and radiation therapy. In addition to bone marrow suppression, specific organ toxicity may be encountered, such as impaired kidney function following cisplatin, pulmonary fibrosis following bleomycin, and neuropathy following vincristine.
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Intraoperative Considerations
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A. Radical Orchiectomy
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Inguinal orchiectomy can be carried out with regional or general anesthesia. Anesthetic management may be complicated by reflex bradycardia from traction on the spermatic cord.
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B. Retroperitoneal Lymph Node Dissection
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The retroperitoneum is usually accessed through a midline incision, but regardless of the surgical approach, all lymphatic tissue between the ureters from the renal vessels to the iliac bifurcation is removed. With the standard RPLND, all sympathetic fibers are disrupted, resulting in loss of normal ejaculation and infertility. A modified technique that may help preserve fertility limits the dissection below the inferior mesenteric artery to include lymphatic tissue only on the ipsilateral side of the testicular tumor.
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Patients receiving bleomycin preoperatively may be particularly at risk for oxygen toxicity and fluid overload. Excessive intravenous fluid administration may promote pulmonary insufficiency or acute respiratory distress syndrome postoperatively and should be avoided. Anesthetic management should include use of the lowest inspired concentration of oxygen compatible with oxygen saturation above 90%. Positive end-expiratory pressure (5–10 cm H2O) may help optimize oxygenation.
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Evaporative and redistributive fluid losses with open RPLND can be considerable as a result of the large wound and the extensive surgical dissection. Retraction of the inferior vena cava during surgery often results in transient arterial hypotension.
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Postoperative pain associated with open RPLND incisions is severe, and continuous epidural analgesia, intrathecal morphine or hydromorphone, or TAP block should be considered. Because ligation of intercostal arteries during left-sided dissections has rarely resulted in paraplegia, it may be prudent to document normal motor function postoperatively prior to institution of epidural analgesia. The arteria radicularis magna (artery of Adamkiewicz), which is supplied by these vessels and is responsible for most of the arterial blood to the lower half of the spinal cord, arises on the left side in most individuals. It should be noted that unilateral sympathectomy following modified RPLND usually results in the ipsilateral leg being warmer than the contralateral one. Patients who have undergone RPLND frequently complain of severe bladder spasm pain in the postanesthesia care unit.
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Preoperative Considerations
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Renal cell carcinoma is the cause of approximately 3% of all adult cancers and 95% of all kidney cancers. It has a peak incidence between the fifth and sixth decades of life, with 2:1 male to female ratio. It is commonly discovered as an incidental finding in the course of evaluating a supposedly unrelated medical problem, such as in an MRI performed for evaluation of low back pain. The classic triad of hematuria, flank pain, and palpable mass occurs in only 10% of patients, and the tumor often causes symptoms only after it has grown considerably in size. Renal cell carcinoma is frequently associated with paraneoplastic syndromes, such as erythrocytosis, hypercalcemia, hypertension, and nonmetastatic hepatic dysfunction. Tumors confined to the kidney may be treated by open or laparoscopic partial or total nephrectomy, or by percutaneous cryoablation or radiofrequency ablation. Palliative surgical treatment may involve more extensive tumor debulking. In approximately 5% to 10% of patients, the tumor extends into the renal vein and inferior vena cava as a thrombus (Figure 32–4), and in some cases approaches or enters the right atrium. Staging includes CT or MRI scans and an arteriogram. Preoperative arterial embolization may shrink the tumor mass and reduce operative blood loss.
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Preoperative evaluation of the patient with renal carcinoma should focus on tumor staging, kidney function, the presence of coexisting systemic diseases, and anesthetic management needs dictated by the scope of anticipated surgical resection. Preexisting kidney function impairment depends upon tumor size in the affected kidney as well as coexisting systemic disorders such as hypertension, diabetes, and coronary artery disease. Smoking is a well-established risk factor for renal cell carcinoma, and these patients have a high incidence of underlying coronary artery and chronic obstructive lung disease. Although some patients present with erythrocytosis, the majority are anemic.
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Intraoperative Considerations
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A. Percutaneous Cryoablation or Radiofrequency Ablation
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Relatively small kidney tumors without metastasis are commonly ablated by interventional radiologists using percutaneous cryoprobes or radiofrequency probes with ultrasonography or CT guidance. This may be performed on an outpatient or 23-h stay basis. Routine American Society of Anesthesiologists (ASA) monitors are used, and general endotracheal anesthesia with muscle relaxation is usually employed to minimize the risk of patient movement during the procedure. An indwelling urinary catheter is typically used if the procedure duration is anticipated to be more than approximately 2 to 3 h. Precautions must be taken for patients with pacemakers or ICDs who are undergoing radiofrequency ablation (see Chapter 21). The patient is typically placed in the lateral decubitus or prone position. The patient may experience significant postoperative pain of limited duration requiring intravenous analgesia.
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B. Radical Nephrectomy
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The operation may be carried out via an anterior subcostal, flank, or (rarely) midline incision. Hand-assisted laparoscopic technique is often utilized for partial or total nephrectomy associated with a smaller tumor mass. Many centers prefer a thoracoabdominal approach for large tumors, particularly when a tumor thrombus is present. The kidney, adrenal gland, and perinephric fat are removed en bloc with the surrounding (Gerota) fascia. General endotracheal anesthesia is used, often in combination with epidural anesthesia.
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This operation has the potential for extensive blood loss because these tumors are very vascular and often very large. Two large-bore intravenous lines with an indwelling peripheral arterial catheter are typically used. Transesophageal echocardiography (TEE), esophageal Doppler, or peripheral pulse wave analysis (Lidco or Vigileo) are often used for hemodynamic monitoring. TEE should be used for all patients with vena cava thrombus. Retraction of the inferior vena cava may be associated with transient arterial hypotension. Only brief periods of controlled hypotension should be used to reduce blood loss because of the potential for acute kidney injury in the contralateral kidney. Reflex vasoconstriction in the unaffected kidney can also result in postoperative kidney dysfunction.
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If combined general–epidural anesthesia is employed, administration of epidural local anesthetic may be postponed until the risk of significant operative blood loss has passed. As with all lengthy operative procedures, the risk of hypothermia should be minimized by utilizing core temperature monitoring, a forced-air warming blanket and intravenous fluid warming. The postoperative course of subcostal, flank, or midline incision for open nephrectomy is extremely painful, and epidural analgesia is very useful in minimizing discomfort and accelerating convalescence.
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C. Radical Nephrectomy with Excision of Tumor Thrombus
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Because of the degree of physiological trespass and potential for major blood loss associated with this operation, the anesthetic management can be challenging. A thoracoabdominal approach allows the use of cardiopulmonary bypass when necessary.
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Surgery can significantly prolong and improve quality of life, and in some patients, metastases may regress after resection of the primary tumor. A preoperative ventilation-perfusion scan may detect preexisting pulmonary embolization of the thrombus. Intraoperative TEE is helpful in determining whether the uppermost margin of the tumor thrombus extends to the diaphragm, above the diaphragm, into the right atrium, or even across the tricuspid valve. TEE can also be used to confirm the absence of tumor in the vena cava, right atrium, and right ventricle after successful surgery.
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The presence of a large thrombus (level II, III, or IV) complicates anesthetic management. Problems associated with massive blood transfusion should be anticipated (see Chapter 51). Central venous catheterization should be performed cautiously to prevent dislodgement and embolization of tumor thrombus extending into the right atrium. An increased central venous pressure is typical with significant caval thrombus and reflects the degree of venous obstruction. Pulmonary artery catheters risk dislodgement of right atrial tumor thrombus, and provide no useful information that cannot be obtained from TEE.
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Complete obstruction of the inferior vena cava markedly increases operative blood loss because of dilated venous collaterals. Patients are also at significant risk for potentially catastrophic intraoperative pulmonary embolization of the tumor. Tumor embolization may be heralded by sudden supraventricular arrhythmias, arterial desaturation, and profound systemic hypotension. TEE is critical in this situation. Cardiopulmonary bypass may be used when the tumor cannot be pulled back from the right atrium into the cava. Heparinization and hypothermia greatly increase surgical blood loss.