- Innervation of GU Structures
- Mitomycin Bladder Instillation
- Trans-Urethral Prostatectomy
- Embryologic Development
Brian Jumper requests that we restrict IV Fluids on patients for bladder instillation of mitomycin as increases in urine output decrease the effectiveness of the therapy.
-adapted from Miller 2012
-adapted from Miller 2012
The most common malignancy of the kidney is renal cell carcinoma; 85% to 90% of all solid renal masses are renal cell carcinoma. Because renal cell carcinoma is refractory to chemotherapy and radiation therapy, surgical resection or ablation can offer curative treatment of localized disease (Table 65-17). More recently, resection of the ipsilateral adrenal gland has been reserved for patients with large upper pole lesions or when the adrenal is enlarged or appears abnormal. Partial nephrectomy (nephron-sparing surgery) is considered for patients with small lesions or bilateral tumors or for patients at risk because of other diseases, such as diabetes or hypertension.
In 5% to 10% of patients, the tumor extends into the renal vein and the inferior vena cava and right atrium. Tumor extension into the inferior vena cava and atrium occurs more frequently with right-sided renal cell carcinoma. Several problems can occur in these patients, ranging from circulatory failure as a result of complete occlusion of the vena cava by tumor to acute pulmonary embolization of tumor fragments during surgery. To operate on these patients safely, the extent of the lesion must be defined preoperatively. Cardiopulmonary bypass is often required in these cases to prevent tumor embolization, and necessary with tumor thrombus extension into the upper portion of the hepatic vena cava or when venous return is significantly compromised.
Right heart catheterization is potentially hazardous because of the danger that a part of the tumor may be dislodged and embolize. Some anesthesiologists use a central venous pressure catheter inserted through left internal jugular or external jugular vein so as not to place it beyond the superior vena cava. Central venous pressure in such cases may not reflect intravascular volume accurately because venous return through the inferior vena cava is impaired by the thrombus, and transesophageal echocardiography may be of value. This decrease in venous return also predisposes the patient to hypotension during induction of anesthesia. Venous obstruction leads to dilation of the epidural veins and the development of abdominal wall and retroperitoneal collaterals. The emphasis is on appropriate preoperative preparation, which is possible only when the full extent of the lesion has been defined.
Dr. Beaule would like to have her patients who are scheduled for HAND-ASSISTED NEPHRECTOMY to be consented/considered for TAP blocks. This does not apply to laparoscopic/robotic radical nephrectomy or radical nephroureterectomy.
Laser prostatectomy has found renewed interest among urologists and is being conducted in several centers. Based on initial experience, it promises to replace conventional TURP in the near future. The neodymium: yttrium-aluminum-garnet (Nd-YAG) laser has been replaced by holmium and potassium-titanyl-phosphate (KTP) lasers. These lasers produce varying degrees of coagulation and vaporization of prostate tissue.
The main advantages over conventional TURP include minimal blood loss (50 to 70 mL) and minimal fluid absorption, which should nearly eliminate these two major complications of TURP; however, other potential complications are introduced, including coagulation through the prostatic fossa and sloughing of prostatic debris in the postoperative period, with subsequent urinary obstruction and urinary retention.[100-104] Protective eyewear and a means to evacuate the smoke plume are needed. In critically ill patients, caudal anesthesia has been successfully used for laser prostatectomy because the use of continuous irrigation combined with minimal bleeding obviates the need for copious irrigation and minimizes bladder distention.
In a systematic review of randomized, controlled trials evaluating the efficacy and safety of laser prostatectomy techniques versus TURP for symptomatic benign prostatic obstruction, the authors observed that TURP provided slightly greater improvement in urinary symptoms and flow. Laser procedures resulted in fewer transfusions and strictures and shorter hospitalizations. Reoperation was required more often after laser procedures.
Traditional monopolar electrode and previously described laser TURP therapies are currently being challenged with new urethral prostate resection techniques. Bipolar electrode resection and next-generation prostate lasers are proving to be alternative surgical therapies for benign prostatic hyperplasia resection.
An advantage of bipolar electrode resection is that normal saline can be used to avoid morbidity associated with hypo-osmolar bladder irrigants such as glycine.
Laser therapy delivers vaporization energy creating a thin resecting coagulation treatment zone that also can be created using normal saline bladder irrigation.
Both treatments are promoted to prevent excessive prostatic bleeding, extend rather than limit resection time, and reduce hospital stay. Hanson and associates reviewed the anesthetic implications of the newer prostate laser resection therapies. The described advantages included minimal bladder irrigating fluid absorption, a minimized risk of TURP syndrome, potential to perform the procedure on anticoagulated patients, delivery in an outpatient setting, and less emphasis on describing regional as the preferred anesthetic technique.
-adapted from Miller 2012
Diagnosis & Management of Glycine Toxicity (U. of Michigan, pdf)
Diagnosis & Management of TURP (Water Intoxication) Syndrome (U. of Michigan, pdf)
Congenital Heart Defects, Neural Tube Defects, Others