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  • image Next to the supine position, the lithotomy position is the most commonly used position for patients undergoing urological and gynecological procedures. Failure to properly position and pad the patient can result in pressure sores, nerve injuries, or compartment syndromes.

  • image The lithotomy position is associated with major physiological alterations. Functional residual capacity decreases, predisposing patients to atelectasis and hypoxia. Elevation of the legs drains blood into the central circulation acutely, and mean blood pressure and cardiac output may increase. Conversely, rapid lowering the legs from the lithotomy or Trendelenburg position acutely decreases venous return and can result in hypotension.

  • image Because of the short duration (15–20 min) and outpatient setting of most cystoscopies, general anesthesia is often chosen, commonly employing a laryngeal mask airway.

  • image Both epidural and spinal blockade with a T10 sensory level provide excellent anesthesia for cystoscopy. However, when neuraxial regional anesthesia is chosen, most anesthesiologists prefer spinal to epidural anesthesia because of its more rapid onset of dense sensory blockade.

  • image Manifestations of 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.

  • image Absorption of TURP irrigation fluid is dependent on the duration of the resection and the pressure of the irrigation fluid.

  • image When compared with general anesthesia, regional anesthesia for TURP may reduce the incidence of postoperative venous thrombosis. It is also less likely to mask symptoms and signs of TURP syndrome or bladder perforation.

  • image Patients with a history of cardiac arrhythmias and those with a pacemaker or implantable cardioverter 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.

  • image Patients who are undergoing retroperitoneal lymph node dissection and who have received bleomycin preoperatively are at increased risk for developing postoperative pulmonary insufficiency. These patients may be particularly at risk for oxygen toxicity and fluid overload and for developing acute respiratory distress syndrome postoperatively.

  • image For patients undergoing kidney transplantation, the preoperative serum potassium concentration should be below 5.5 mEq/L, and existing coagulopathies should be corrected. Hyperkalemia has been reported after the release of the vascular clamp following completion of the arterial anastomosis, particularly in pediatric and other small patients. The release of potassium contained in the preservative solution has been implicated as the cause of this phenomenon.

Urological procedures range in impact and risk from simple outpatient cystoscopy to radical cystectomy and nephrectomy for renal cell carcinoma with vena caval thrombosis. Patients undergoing genitourinary procedures may be of any age, but many are older adults with coexisting medical illnesses, including chronic kidney disease. The impact of anesthesia on kidney function is discussed in Chapter 31. This chapter reviews the anesthetic management of common urological procedures. Lithotomy and steep head-down (Trendelenburg) positions are used in many of these procedures. Moreover, advances in preoperative patient optimization, perioperative management, ...

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