Between the years 2004 and 2008, the median age at diagnosis of cancer of the prostate was 67 years. Less than 10% of cases are diagnosed before age 54 years, 31% of cases occur in men between 55 and 64 years, and approximately 60% of new cases occur in men 65 years and older [1]. Because prostate cancer is a disease of older men, preoperative assessment should focus on optimizing comorbid disease processes that are prevalent in this patient population.

The most common complication of radical urologic surgery is hemorrhage. Extensive bleeding can occur during radical prostatectomy if the hypogastric veins are inadvertently lacerated during pelvic lymph node dissection, and significant blood loss may occur during transection of the dorsal venous complex. Estimated blood loss associated with radical retropubic prostatectomy is commonly reported between 550 and 800 ml, though higher estimates are infrequently reported [20, 21]. Autologous blood donation has been recommended before elective procedures in which there is a high likelihood for blood transfusion [22]. More recently, the practice of preoperative autologous donation has been challenged as being cumbersome and expensive. Further, a review of transfusion practices suggests that nearly half of the autologous units of blood are discarded [23]. There are a number of alternative practices which aim to minimize intraoperative blood loss and salvage unavoidable operative blood losses.

Acute normovolemic hemodilution has been suggested as a less expensive and more convenient alternative to predonation of autologous blood [24, 25]. Additionally, the use of controlled hypotension (targeted mean arterial blood pressure of 50 mmHg) in appropriate patients has been advocated as an effective and less costly alternative to acute normovolemic hemodilution [26]. Cell salvage in radical prostatectomy provides yet another means to avoid allogenic blood transfusion. In one study, patients who underwent radical prostatectomy with cell salvage (CS) received approximately 300 cc of salvaged blood product, and none of these patients required allogenic blood transfusion. Additionally, the patients assigned to CS, when compared to patients who were assigned to the predonation of autologous blood group, had higher pre- and postoperative hematocrits and showed no differences in cancer recurrence rates at 24 and 36 months [27]. While concerns regarding the theoretical risk of cancer dissemination have limited the use of red cell salvage in many cancer surgeries, several studies addressing this question have been conducted in the urologic field. In particular, multiple studies examined biochemical cancer recurrence rates in patients who underwent radical retropubic prostatectomy with and without the use of cell salvage [28–31]. These investigations demonstrated that intraoperative red blood salvage did not increase the risk of early biochemical relapse or tumor dissemination. Finally, prophylactic hemostatic sutures may be placed strategically prior to nerve-sparing dissection and mobilization of the prostate in an effort to minimize intraoperative blood loss [32].

One of the most common causes of nonsurgical death in patients undergoing surgery is deep vein thrombosis (DVT) and resultant pulmonary thromboembolism [33]. Patients undergoing prostatectomy possess multiple, widely recognized risk factors for development of DVT, namely, malignancy, surgery, immobility, and increasing age. Careful measures, therefore, must be taken to prevent DVT; in fact, DVT prophylaxis has been identified by a number of organizations as a marker of good quality of patient care. Without prophylaxis, the risk of DVT is estimated to be 32% for patients undergoing open radical prostatectomy [34]. With the use of various prophylactic measures, studies of radical prostatectomy series have reported rates of DVT and PTE ranging from 0.8% to 6.2%.

In 2009, the Board of Directors of the American Urological Association (AUA) and the Practice Guidelines Committee of the AUA convened a panel to develop a Best Practice Statement for the prevention of DVT in patients undergoing urologic surgery [33]. The panel recommends therapeutic options based on consideration of patient-specific predisposing risk factors for increased development of DVT and the specific risk category to which a particular urologic procedure belongs. For open urologic surgery, the panel recommends routine use of mechanical prophylaxis (graduated compression stockings and/or intermittent pneumatic compression) and, commonly, pharmacologic prophylaxis (low-dose unfractionated heparin or low molecular weight heparin). When managing patients at risk for heparin-induced thrombocytopenia, the use of argatroban may be considered. Always, when determining the initiation of pharmacologic prophylaxis, risk of bleeding must be weighed against the risk of thromboembolic complication.

Patients who have undergone percutaneous coronary intervention with stent placement present a unique preoperative challenge to both the urologist and the anesthesiologist. Following cardiac stent placement, patients almost universally take combination antiplatelet therapy, commonly consisting of clopidogrel and aspirin, for extended duration. Thus, the operative team must carefully consider the delicate balance of prevention of perioperative thrombotic cardiovascular event(s) and perioperative hemorrhage. The American College of Cardiology/American Heart Association recommends combination therapy for at least 4 weeks for bare-metal stents and at least 12 months for drug-eluting stents. Knowledge of the type of stent employed and the time interval between stent placement and prostate surgery will guide determination of appropriate management of antiplatelet therapy during the perioperative period. Consultation with the patient’s cardiologist is highly recommended [35].

Regional, general, or a combined regional/general technique can adequately provide anesthesia for radical retropubic prostatectomy. Choice of anesthesia technique may affect perioperative variables such as volume of blood loss, quality of postoperative pain control, and length of hospital stay. One randomized, controlled trial compared patients who underwent radical prostatectomy under combined epidural/general anesthesia to patients who underwent the same surgery under general anesthesia alone. Patients assigned to the combined epidural/general anesthesia group lost significantly less blood and received significantly fewer blood transfusions [36]. Another study randomized patients undergoing radical prostatectomy to general anesthesia (IV induction with propofol and maintenance with isoflurane plus fentanyl) or to (L2/3 or L3/4) spinal anesthesia (bupivacaine plus fentanyl). Significantly less intraoperative blood loss occurred in the spinal anesthesia group; additionally, the spinal anesthesia group had significantly lower pain scores in the recovery room and experienced significantly faster recovery of bowel function [37]. The groups did not differ significantly, however, in postoperative pain scores on postoperative day 1. In a prospective study that investigated anesthetic choice on volume of blood loss in patients undergoing combined epidural/general anesthesia with deliberate hypotension versus patients undergoing general anesthesia alone, it was found that the combined anesthesia technique with controlled hypotension was associated with significantly less intraoperative blood loss. In the epidural group, deliberate hypotension was achieved with a target mean arterial pressure of 55–60 mmHg. Of clinical importance, the epidural group received significantly fewer blood transfusions [38].

It is well recognized that regional anesthesia reduces the stress response to surgical stimulation. A recent study evaluated the effect of epidural opioid and local anesthetic on the perioperative stress response in elderly patients undergoing RRP. Patients received epidural with saline, epidural with local anesthetic, or epidural with local anesthetic combined with opioid. Stress response was gauged by glucose, insulin, cortisol, norepinephrine, and prolactin concentrations which were measured over 48 h postoperatively. Epidural ropivacaine blunted the perioperative stress responses in elderly patients undergoing RRP, and the combination of epidural ropivacaine and sufentanil was associated with the most pronounced attenuation of the stress [39]. The ability to blunt the stress response in elderly patients undergoing RRP has important implications for decreasing risk for adverse cardiac events.

The incidence of perioperative hypothermia (body temperature less than 36 °C) is high, especially during open surgeries lasting more than 1 h. The consequences of poorly regulated temperature range from increased infectious complications, coagulation disorders, and morbid cardiac events to prolonged hospitalization and increased costs [40]. The intraoperative use of forced-air warming blankets in patients undergoing radical prostatectomy has been shown to reduce postanesthetic recovery time [41]. Increasing the operating room temperature and warming of irrigation fluids are additional adjunctive therapies to be considered.

Postoperative pain control presents a significant clinical challenge for the perioperative team. Current anesthesia practice commonly focuses on the intraoperative management of pain when, in fact, comprehensive anesthesia care should include consideration of intraoperative, noxious stimuli and should also preemptively strike at postoperative pain. In that postoperative pain may prolong recovery and lead to the development of chronic pain syndromes [42], it is paramount that postoperative pain needs be addressed judiciously and efficiently. Recommendations for treating postoperative pain emphasize the use of multimodal, opioid-sparing therapy [43]. Multimodal analgesia is most effective when combined with some form of regional local anesthetic block [39]. RRP represents a major abdominal surgery. Today, hospital stay after RRP averages 2–3 days compared to routine hospitalizations of 5–7 days only a decade ago. Improvements in postoperative pain management have played a role in this accomplishment [44].

One retrospective review of 100 patients who underwent RRP by the same surgeon examined the impact of multimodal analgesia on the perioperative experience. At the completion of the prostate surgery, all patients received wound infiltration with local anesthetic, ketorolac, and opioids. Half of the patients underwent, in addition to the cited medications, a single preoperative oral dose of a COX-2 inhibitor and preoperative bilateral paravertebral blocks at T10–T12. Patients who received multimodal analgesia had significantly better pain scores and used only half of the morphine required by the control group; these differences continued from the PACU through the hospital course. Additionally, the patients who received multimodal analgesia had significantly shorter hospital stays, by approximately 9 h [45]. Finally, for postoperative patients unable to take pain medications by mouth, an intravenous formulation of acetaminophen was approved for use in the United States in 2010 and may be used as a component in multimodal approach to postoperative pain management.

Intrathecal analgesia is another technique which may impact postoperative pain management and recovery of functional status after RRP. One prospective randomized clinical trial investigated the effect of preoperative intrathecal analgesia on recovery from RRP [46]. The investigators studied 100 patients, half of whom had general anesthesia followed by IV opioid analgesia, and the other half had general anesthesia preceded by placement of preoperative intrathecal analgesia including local anesthetic, clonidine, and morphine. All patients received postoperative supplemental morphine as needed. Pain was well controlled throughout the study in both groups. Patients who received intrathecal analgesia had decreased pain scores and decreased supplemental morphine use on the first postoperative day, but an increased incidence of pruritus. Duration of hospital stay was significantly reduced in the intrathecal analgesia group (from 2.8 to 2.1 days). There were no differences between groups at 12 weeks postoperatively.

Another randomized study including 50 patients examined the efficacy of intrathecal morphine with and without clonidine for postoperative analgesia after RRP [47]. Three groups were studied: intrathecal morphine, intrathecal morphine and clonidine, and intravenous patient-controlled analgesia (PCA). All patients received morphine PCA for rescue analgesia. Results revealed that intrathecal morphine provided a significant reduction in the morphine requirement in the first 48 h after radical prostatectomy. The addition of clonidine to intrathecal morphine reduced intraoperative opioid use, prolonged the time until first request for PCA rescue, and further prolonged analgesia at rest and with coughing.

In addition to influencing perioperative variables such as intraoperative blood loss, attenuated perioperative stress response, postoperative pain control, and shortened hospital stay, anesthetic technique has recently been examined for its possible influence on cancer recurrence rates. A small number of such studies have investigated anesthetic technique and outcomes in RRP surgery. One retrospective study reviewed the records of patients who underwent radical open prostatectomy surgery and had either general anesthesia with epidural analgesia or general anesthesia with opioid analgesia. This study reported a substantially smaller risk of biochemical cancer recurrence in patients who received epidural analgesia compared to those who received opioid analgesia [48]. Similarly, the effect of anesthetic technique on disease progression and long-term survival was studied. Patients undergoing open radical prostatectomy surgery with extended pelvic lymph node dissection received either general anesthesia plus intraoperative and postoperative thoracic epidural analgesia or general anesthesia combined with ketorolac-morphine analgesia. Combined general anesthesia with epidural analgesia was associated with a reduced risk of clinical cancer progression compared with general anesthesia and IV analgesia. No significant difference was found between groups with respect to biochemical recurrence-free survival, cancer-specific survival, or overall survival [49].

The proposed influence of anesthetic technique on cancer recurrence focuses on the effect of anesthesia on host defenses, especially natural killer cells which are the primary defense against cancer [50]. Many anesthetic agents (inhaled agents and opioids in particular) impair immune mediators such as neutrophils, macrophages, T cells, and natural killer cells [51, 52]. Furthermore, morphine is proangiogenic and promotes breast tumor in animal models [53]. The factors supporting a positive effect of regional anesthesia/analgesia are decreased suppression of host immune function, attenuated perioperative stress response, and decreased need for volatile anesthetics and IV opioids. Prospective randomized trials to further investigate the influence of anesthetic technique on cancer recurrence in prostatectomy surgery and other cancer surgeries seem warranted. Anesthesiologists should be aware of these controversial studies, especially in the context of discussing anesthetic options for radical prostatectomy.

Routine monitors are likely sufficient for the majority of patients undergoing radical prostatectomy. Invasive hemodynamic monitoring may be indicated in patients with significant comorbid disease. Adequate venous access must be established as blood loss can be substantial and acute. Urine output is not useful as a monitor of fluid status as the urinary bladder is open during prostatectomy. If volume status must be closely guarded, such as in a patient with diminished cardiac function, a central venous line may be helpful in guiding fluid management, but as stated earlier, is not a reliable method for assessing cardiac preformance related to fluid infusion [11].

Both the Trendelenburg position and the supine position with elevated kidney rest create a potential setup for venous air embolism in that the surgical field is above the level of the heart. Significant venous embolism can therefore occur during RRP. Monitors for detection of venous air embolism (VAE) include measurement of ETCO₂ and ETN₂, precordial Doppler, and transesophageal echocardiography. However, most anesthesiologists routinely use only capnography. If VAE is suspected, management goals include prevention of further entrainment of air and limiting the volume of entrained air. Achievement of these goals requires communication with the surgical team, covering the surgical field with saline-soaked dressings, adjustment of the operative bed to lower the presumed air entry site and eliminate the negative pressure gradient, and examination of the surgical field to identify and eliminate the air entry site.

Patients undergoing RRP may be placed in extreme lithotomy position to optimize access to the perineum. The risk of lower extremity injury has been well described in this position. The peroneal nerve is vulnerable to compression between the head of the fibula and the stirrup. Similarly, the saphenous nerve can be compressed at the medial tibial condyle. The sciatic nerve can also be stretched by hyperflexion of the hip and extension of the knees [54]. Risk factors which increase the incidence of neuropraxia include extremes of body size, duration of surgery greater than 2 h, and tobacco use. Additionally, cases of compartment syndrome and rhabdomyolysis have been reported in patients undergoing urologic procedures in extreme lithotomy position [55, 56].

Renal cell carcinoma (RCC) accounts for 85% of solid tumors of the kidney accounting for approximately 60,000 new cases and 13,000 deaths annually [57]. Intensive study of the biology of RCC has advanced the understanding of its pathogenesis and has led to novel adjuvant therapies such as the use of tyrosine kinase inhibitors. Despite advances in targeted molecular therapy, surgical excision remains the primary curative treatment of kidney cancer [58]. Historically, open radical nephrectomy, with and without ipsilateral adrenalectomy and regional lymphadenectomy, has been the standard for the surgical approach to localized disease [59]. By definition, radical nephrectomy involves excision of the kidney, the ipsilateral adrenal gland, perinephric fat, and surrounding fascia. More recently, however, resection of the ipsilateral adrenal gland is reserved for cases in which the lesion in large and located in the upper pole or when the gland appears abnormal [60].

There is growing evidence demonstrating that renal preservation is critical even in patients in whom contralateral kidney function is normal because there is a higher risk of subsequent chronic renal disease following radical nephrectomy for RRC [61]. As a result, surgical options have expanded to include nephron-sparing surgery, or partial nephrectomy.

Partial nephrectomy involves the complete resection of a localized renal mass with clear surgical margins while preserving as much normal renal parenchyma as possible. Today, nephron-sparing surgery is indicated in patients who have a solitary functional kidney, patients who have bilateral synchronous tumors, patients who have comorbidities that place them at high risk for long-term renal insufficiency or failure (diabetes, hypertension, renovascular disease), and patients who have small (<4 cm) unilateral renal mass of the upper or lower pole and a normal contralateral kidney [62, 63].

Nephron-sparing surgery has demonstrated curative potential equal to that of radical nephrectomy in the treatment of renal cell carcinoma [58]. A matched comparison of 164 patients treated with either radical nephrectomy or partial nephrectomy reported no differences between the two groups in overall survival, cancer-specific survival, complication rate, and development of metastatic disease. Patients who underwent nephron-sparing surgery, however, demonstrated a decreased incidence of chronic kidney disease and a decreased rate of proteinuria at 10-year follow-up [61].

With widespread acceptance of laparoscopy in urologic surgery, minimally invasive techniques have been applied to radical and partial nephrectomy resulting in an alternative to the open approach. The laparoscopic approach to surgery, in general, is associated with decreased morbidity and faster recovery, and with respect to renal cell carcinoma, the laparoscopic approach has shown comparable survival outcomes as the open surgery [64]. Laparoscopic radical nephrectomy, however, has been limited to use in localized, renal cell carcinoma of small size (less that 4 cm) without invasive features and without substantial venous or nodal involvement. Additionally, patients selected for laparoscopic partial nephrectomy represent a lower-risk cohort than those patients selected for open surgery. Patients selected for laparoscopic partial nephrectomy generally have smaller tumors, more favorable tumor biology and location, and superior functional status when compared to patients selected for open surgery. Compared to open partial nephrectomy, laparoscopic partial nephrectomy has been associated with longer warm ischemia times (clamping of renal vessels) and more postoperative complications requiring additional interventions [65]. The impact of longer ischemia time merits further study. It is possible that the longer ischemia time during laparoscopic surgery may partially or completely negate the more favorable long-term renal function associated with (open) nephron-sparing surgery.

While the vast majority of nephrectomies are performed for cancer treatment, this operation may also be performed selectively in the management of patients with autosomal dominant polycystic kidney disease (ADPKD). ADPKD affects approximately 600,000 patients in the United States (12 million worldwide) and is the fourth leading cause of renal failure. ADPKD is responsible for approximately 10% of all end-stage renal disease (ESRD), usually in patients between the ages of 40 and 60 years. By age 60 years, nearly half of patients with ADPKD have ESRD [66]. The disease is characterized by the presence of multiple, variable-sized cysts in both kidneys. Initially, symptoms of ADPKD result directly from the cysts, and patients may experience lumbar pain, recurrent urinary tract infections, hematuria, and arterial hypertension. By the third or fourth decade, the overwhelming number and volume of cysts lead to increasing loss of renal function [67]. Eventually, hemodialysis and/or kidney transplantation are recommended treatments.