A. Cystoscopy and ureteroscopy are performed to diagnose and treat lesions of the lower (urethra, prostate, and bladder) and upper (ureter and kidney) urinary tracts.

1. Warmed irrigation fluids are used to improve visualization and to remove blood, tissue, and stone fragments.

a. Electrolyte solutions (normal saline and lactated Ringer’s) are isotonic and do not cause hemolysis upon intravascular absorption. Because of ionization, they cannot safely be used for procedures involving monopolar electrocautery. However, these solutions can be used with newer, bipolar electrocautery.

b. Sterile water has optimal visibility and is nonconductive. However, intravascular absorption can cause hemolysis and hyponatremia/hyposmolality.

c. Nonelectrolyte solutions of glycine, sorbitol, and mannitol have good visibility and are nonconductive. Near isotonicity minimizes hemolysis, although large volume absorption may cause hyponatremia (see section 3.a.1).

2. Anesthesia

a. Depending on the patient and procedure, anesthesia for cystoscopy/ureteroscopy can range from topical lubrication alone to monitored anesthesia care, regional, and/or general anesthesia (GA). Placement of a rigid cystoscope (particularly in males) and distention of the bladder and ureters can be quite stimulating. Postoperative pain is minimal.

b. If regional anesthesia is used, a T6 level is required for upper tract instrumentation, whereas a T10 level is adequate for lower tract surgery.

c. GA can be effective with short-acting intravenous (IV) and inhaled anesthetics. Transient muscle relaxation may be required.

d. Lithotomy position is most common.

B. Transurethral resection of the bladder (TURB) is performed to diagnose and treat lesions of the bladder (anesthetic considerations are similar to TURP—see below). Muscle relaxation should be considered as inadvertent simulation of the obturator nerve, deep to the lateral bladder wall, may result in leg adduction, thus risking damage to the bladder.

C. Transurethral resection of the prostate (TURP) is performed to relieve urinary obstruction due to benign prostatic hypertrophy (BPH). This procedure uses a modified cystoscope (resectoscope) with a wire loop connected to an electrocautery unit for resection of tissue and coagulation of bleeding vessels. Alternatives to TURP include medical management (α-blockers and hormonal therapies) and newer minimally invasive techniques including laser ablation, microwave thermotherapy, and prostatic stents.

1. During surgery, large prostatic venous sinuses can be opened, which allow irrigant to be absorbed. The quantity of fluid absorbed depends on the following factors:

a. Irrigant hydrostatic pressure, proportional to the height of the irrigant above the patient.

b. Surgical technique: duration of exposed sinuses, irrigation flow rate, and cystoscope size.

c. Number and size of venous sinuses opened (influenced by prostate size).

d. Peripheral venous pressure (lower pressure favors increased absorption).

a. If GA is used, it is essential to prevent coughing or patient movement, which can cause increased bleeding or bladder/prostatic capsule perforation. Positive-pressure ventilation may decrease irrigant absorption by raising venous pressure.

b. Advantages of regional anesthesia may include an atonic bladder (improved surgical visualization) and elimination of bladder spasms (more rapid hemostasis postoperatively). Awake patients may report symptoms that allow earlier detection of the TURP syndrome or bladder perforation.

c. Spinal anesthesia can be achieved with an iso- or hyperbaric solution of local anesthetic with or without opioid, providing adequate anesthesia with minimal hemodynamic effects. A T10 sensory level is recommended to counteract pain from bladder distention. Lower venous pressures associated with neuraxial blockade may reduce bleeding but increase irrigant absorption.

d. Methods for monitoring fluid absorption intraoperatively may include volumetric fluid balance, gravimetric weighing, and measurement of exhaled ethanol when a known amount of ethanol is added to the irrigating fluid.

a. TURP syndrome refers to a collection of neurologic and cardiovascular signs and symptoms caused by excessive irrigant absorption. It may appear early (direct intravascular absorption) or after several hours (absorption from retroperitoneal and perivesicular spaces).

1. Central nervous system symptoms include nausea, agitation, confusion, visual changes, seizures, and coma. These symptoms likely are multifactorial and have been attributed to hyponatremia/hyposmolality leading to cerebral edema, hyperglycinemia, and hyperammonemia (glycine is hepatically metabolized to ammonia) associated with glycine solutions and concomitant sedating medications.

2. Cardiovascular symptoms include hypertension/hypotension, bradycardia, dysrhythmias, pulmonary edema, and cardiac arrest likely secondary to pronounced fluid shifts and associated electrolyte disturbances. Hypervolemia initially occurs with fluid absorption, followed by rapid redistribution of the irrigant to the interstitium.

3. Treatment involves notifying the surgeon, completing the procedure as quickly as possible, and maintaining hemodynamic stability. There is disagreement in the literature about the most appropriate therapy. Fluid restriction and diuresis with furosemide have been advocated to treat volume overload, reserving hypertonic saline for severe symptoms or hyponatremia (serum sodium <120 mmol/L). Others suggest that the diuretic strategy may exacerbate intravascular volume depletion and
hyponatremia and recommend early use of hypertonic saline (with slow correction of hyponatremia to minimize the risk of central pontine myelinolysis), reserving diuresis for acute pulmonary edema. Any therapy should be guided by regular measurements of serum sodium and osmolality.

1. Extraperitoneal perforation is more common and manifests as suprapubic fullness, abdominal spasm, or pain in the suprapubic, inguinal, or periumbilical regions.

2. Intraperitoneal perforation presents as upper abdominal pain or referred pain from the diaphragm to the shoulder. This may result in hypertension, tachycardia, and abdominal distention, followed by hypotension and cardiovascular collapse.

c. Bacteremia may occur due to absorption of bacteria through prostatic venous sinuses, commonly associated with indwelling urinary catheters or with subclinical or partially treated prostatitis.

d. Blood loss and coagulopathy. Assessing blood loss is extremely difficult during a TURP because of irrigant dilution. Continuous postoperative bleeding may result from surgical bleeding, dilutional thrombocytopenia, disseminated intravascular coagulation, or the release of fibrinolytic enzymes from the prostate. Hemodynamic responses to blood loss may be masked by hypervolemia from irrigant absorption.

D. Laser resection of prostate is a newer clinical approach to treating BPH with less perioperative morbidity. Hemostatic properties of laser limit tissue penetration and create a practically bloodless field. They provide an alternative for seriously ill patients (TURP morbidity 18%) and those on oral anticoagulants. Bladder irritation (transient), delayed gross hematuria, and transient dysuria are common complications. The procedure time is relatively short in duration. General, regional (subarachnoid or sacral canal block), or possibly even local anesthesia (for selected patients) may be safely performed.

1. The Holmium (yttrium-aluminum-garnet = YAG) laser is a 60- to 80-W high-power pulse laser with a wavelength = 2,140 nm. The high absorption by water limits tissue penetration. It is used for the enucleation of the prostate. Holmium laser preserves the histologic architecture of the prostate facilitating detection of prostate cancer.

2. The KTP (potassium titanyl phosphate) is a 60- to 80-W high-power laser through a crystal with a wavelength = 532 nm. It is highly absorbed by oxyhemoglobin, potentially creating a bloodless field, and is poorly absorbed by water. It is used for the enucleation of the prostate in a procedure known as “Photoselective Vaporization of Prostate” (PVP) that is less technically demanding than the Holmium laser is. PVP is as effective as TURPs (2- to 4-year follow-up) for relief of BPH symptoms and has less perioperative morbidity, postoperative bladder irrigation, catheterization time, incidence of sexual dysfunction, and hospital stay. A disadvantage is that it alters prostatic histology samples.