Anesthetic management of urologic patients requires confidence with the management of elderly patients who typically have multiple comorbidities.
Surgical positioning is often complex and exposes the patient to the risk of severe complications.
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.
Urologic cancer requires highly invasive surgeries that have a high risk of complications. Patients undergoing these procedures require thorough physiologic monitoring and proactive hemodynamic, respiratory, and analgesic management.
Despite an unclear clinical benefit, the use of minimally invasive and robotic surgery in urology is increasing rapidly. These procedures may require prolonged pneumoperitoneum and head-down positioning, introducing a new set of clinical challenges to anesthesiologists.
The perioperative management of urologic patients is often complicated by their advanced age and their multiple comorbidities. Urologic surgery includes procedures with broad complexity, ranging from endoscopies to major abdominal operations. In addition, recent years have seen the expansion of this specialty, which now incorporates minimally invasive, laparoscopic, and robotic techniques. Anesthesiologists must have background knowledge of the indications, technical aspects, and complications of the procedures used in urologic surgery in order to formulate a sound anesthetic plan.
The kidneys are located in the retroperitoneal space between T12 and L4 along the medial borders of the psoas muscles. Positioned inferior to the liver, the right kidney lies slightly lower than the left. The kidneys are surrounded by the perirenal fat and enclosed in the perirenal or Gerota fascia. The adrenal glands lie on top of each kidney, also contained by Gerota fascia. Diaphragmatic movement transmits to the kidneys, causing a physiologic excursion of 4 to 5 cm with each respiration. Upon section, the kidney is composed of a cortex and a medullary section. The medulla is divided into several pyramids whose tips, named papillae, are indented with the minor calices. The latter converge in the major calices and then drain into the renal pelvis, which tapers into the ureter.
Each kidney receives its blood supply from a single renal artery, although occasional variants with multiple arteries are encountered. The renal arteries originate just inferior to the superior mesenteric vein and enter the kidney at its hilum. The right artery crosses the midline behind the vena cava. The renal veins run in front of the arteries, the left vein crossing the midline anterior to the aorta. The lymphatic circulation of the kidney drains into lymph nodes located in the lumbar region.
The kidneys receive vegetative innervation (Fig. 61-1) from the renal plexus, which receives fibers mainly from the celiac plexus and the vagus nerve. Sympathetic vasoconstrictor and afferent fibers originate from T8 to L1. For this reason, kidney pain is typically perceived in the costovertebral angle and below the 12th rib. Anesthesia for kidney surgery requires effective blockade of the nerve roots between T8 and L3 ...