Urology

Harcharan S. Gill MD¹

Benjamin I. Chung MD¹

Ronald G. Pearl MD, PhD²

¹SURGEONS

²ANESTHESIOLOGIST

DIAGNOSTIC TRANSURETHRAL (ENDOSCOPIC) PROCEDURES

SURGICAL CONSIDERATIONS

Description: Many urologic diseases are diagnosed and evaluated endoscopically through the urethra with the use of specialized instruments, such as cystoscopes and resectoscopes. With the patient in a lithotomy position, the cystoscope is introduced into the urethra and advanced under direct vision all the way into the bladder (Figs. 9-1 and 9-2), allowing inspection of the urethra (urethroscopy) and bladder (cystoscopy). If pathology is noted, a biopsy can be obtained easily through the cystoscope. It is also possible to introduce a small catheter into the ureteral orifice and advance it up to the kidney for radiologic evaluation (retrograde pyelography) to collect a urine specimen or to bypass areas of obstruction. If the upper urinary tract needs to be visualized, a ureteroscope is introduced through the urethra into the bladder and through the ureteral orifice into the ureter and advanced up to the kidney, allowing inspection of the ureter (ureteroscopy) and intrarenal collecting system (nephroscopy). These procedures often precede a major surgical operation.

Usual preop diagnosis: Hematuria; hydronephrosis; benign prostatic hypertrophy; cancer of the urethra, prostate, bladder, ureter, and renal pelvis; urinary tract stones; strictures; ureteropelvic junction obstruction; hemorrhagic or interstitial cystitis

Figure 9-1. Cystoscope introduced into bladder via urethra (male anatomy). (Reproduced with permission from Hardy JD: Textbook of Surgery. JB Lippincott: 1988.)

Figure 9-2. Cystoscope introduced into bladder (female anatomy). (Reproduced with permission from Govan DE: Roche Manual of Urologic Procedures. Hoffmann-LaRoche: 1976.)

ANESTHETIC CONSIDERATIONS

See Anesthetic Considerations following Therapeutic Transurethral Procedures (Except TURP), p. 881.

THERAPEUTIC TRANSURETHRAL PROCEDURES (EXCEPT TURP)

SURGICAL CONSIDERATIONS

Description: Therapeutic transurethral procedures, the most common urologic operations, require the use of specialized instruments, such as cystoscopes and resectoscopes. Because of continuously improving instrumentation and fiberoptics, the range and complexity of these operations are widening, and more operations are being done transurethrally now than ever before. These operations are transurethral resection (TUR) of any urethral, prostatic, or bladder pathology; fulguration of bleeding vessels; instillation of chemicals, such as oxychlorosene (Chlorpactin) and formalin, into the bladder; extraction of stones; and incision and dilation of strictures.

With the patient in the lithotomy position, the cystoscope or resectoscope is introduced into the urethra and advanced under direct vision into the bladder, allowing inspection of the urethra and bladder (Figs. 9-1 and 9-2). The pathology is identified. If it is a tumor, it is resected piecemeal with the electrode of the resectoscope, using the cutting current and cauterizing the base of the tumor with the coagulating current. If the pathology is a stone, it is extracted with special forceps or a stone basket. Large stones have to be fragmented, prior to extraction, with a mechanical lithotrite, electrohydraulic probe, ultrasound lithotrite, or laser (holmium or pulsed dye). Chemicals can be instilled through the cystoscope to control interstitial and hemorrhagic cystitis. Bleeding vessels can be coagulated with the electrode. Strictures of the urethra can be dilated or incised with an endoscopic knife. Strictures of the ureter also can be treated endoscopically by dilatation with a balloon catheter or by incision with electrocautery. Balloon catheters with attached cutting electro-wires (Acucise) often are used. A temporary ureteral stent is placed at the end of most endoscopic ureteral surgeries.

Variant procedure or approaches: Occasionally, access to the intrarenal collecting system (renal pelvis and calyces) and upper ureter is easier and more appropriately done by a percutaneous nephrostomy than by a transurethral procedure. The patient is placed in a prone or flank position, a percutaneous stab wound is made at the costovertebral angle, and a tube is introduced into the kidney under fluoroscopic control.

Usual preop diagnosis: Tumors of the urinary tract; stones; interstitial or hemorrhagic cystitis; strictures

▪ SUMMARY OF PROCEDURES

	Transurethral	Percutaneous
Position	Lithotomy	Flank or prone
Incision	None	Stab wound
Special instrumentation	Cystoscope; resectoscope; catheters; stents	Percutaneous nephrostomy kit; nephroscope; urethroscope; catheters; stents
Unique considerations	Use of x-rays, fluoroscopy, and electrocautery	⇚
Antibiotics	Gentamicin 80 mg iv, slowly	⇚
Surgical time	1 h	2-3 h
EBL	100 mL	500 mL
Postop care	Irrigation of tubes and catheters to clear clots and prevent obstruction	⇚
Mortality	< 1%	⇚
Morbidity	Bleeding: 10%	⇚
	Infection: 5%	⇚
	Perforation: 2%	⇚
	Retained stones: 2%	⇚
Pain score	1	3

ANESTHETIC CONSIDERATIONS FOR TRANSURETHRAL PROCEDURES (EXCEPT TURP)

PREOPERATIVE

Patients of all ages may present for ureteral stone extraction. Paraplegics and quadriplegics have a predilection for nephrolithiasis and may present for repeated cystoscopies. Bladder tumors usually are seen in older patients, who may present for cystoscopy or TUR. These patients may have preexisting medical problems, including CAD, CHF, PVD, cerebrovascular diseases, COPD, and/or renal impairment. Preop evaluation should be directed toward the detection and treatment of these conditions prior to anesthesia.

Neurological	Paraplegics and quadriplegics may present for repeated cystoscopies and stone extractions. Note Hx of autonomic hyperreflexia; Sx may include flushing, headache, and nasal stuffiness, associated with voiding or noxious stimuli below the level of spinal cord injury (see below).
Musculoskeletal	Contractures and pressure sores may make positioning difficult in paraplegics or quadriplegics.
Laboratory	Tests as indicated from H&P
Premedication	Sedation prn anxiety (e.g., lorazepam 1-2 mg po 1-2 h before surgery; midazolam 1-2 mg iv in preop area).

INTRAOPERATIVE

Anesthetic technique: Spinal, continuous lumbar epidural, and GA are acceptable, with the choice dependent on type and length of procedure, age, coexisting disease, and patient preference. Simpler transurethral procedures (e.g., cystoscopy) are amenable to topical anesthesia, whereas longer and more complex procedures (e.g., ureteral stone extraction) will require regional or GA (see discussion below regarding autonomic hyperreflexia). Note that many of these procedures are done on an outpatient basis, and the anesthetic should be planned accordingly. For regional anesthesia, a sacral block is required for urethral procedures (T9-T10 level for procedures involving the bladder and as high as T8 for procedures involving the ureters).

Regional anesthesia:

Topical	2% lidocaine jelly
Spinal	0.75% bupivacaine 10-12 mg. For shorter procedures (< 1 h), consider low-dose bupivacaine (0.75%, 7.5 mg); mepivacaine (1.5%, 45 mg); or procaine (10%, 100-150 mg). Lidocaine may be used, but the incidence of transient neurologic symptoms may be as high as 30% for procedures performed in the lithotomy position.
Lumbar epidural	1.5-2.0% lidocaine with epinephrine 5 mcg/mL, 15-25 mL; supplement with 5-10 mL boluses as needed. Supplemental iv sedation.

General anesthesia:

Induction	Standard induction (see p. B-2). ET intubation may not be necessary for shorter procedures; consider LMA. Succinylcholine should be avoided in paralyzed (e.g., paraplegic, quadriplegic) patients 2° ↑ K⁺ → VF or asystole.
Maintenance	Pure inhalation anesthetic (e.g., N₂O, sevoflurane/desflurane) for short cases. IV technique (e.g., propofol 100-200 mcg/kg/min; supplement with N₂O ± volatile anesthetic ± remifentanil. Muscle relaxation is not essential. Long-acting narcotics unnecessary because postop pain is usually minimal.
Emergence	No specific considerations
Blood and fluid requirements	Usually minimal blood loss IV: 18 ga × 1 NS/LR @ 2-4 mL/kg/h
Monitoring	Standard monitors (see p. B-1).
Positioning	[check mark] and pad pressure points [check mark] eyes	* NB: In lithotomy position, peroneal nerve compression at lateral fibular head → foot drop.
Complications	Anticipate ↓ BP upon returning from lithotomy position. Autonomic hyperreflexia (AH): ▼ Severe HTN ▼ Bradycardia ▼ Dysrhythmias ▼ Cardiac arrest	Rx: volume (200-500 mL NS/LR) or ephedrine (5 mg iv) may be necessary. Patients with spinal cord injury level above T10 are at risk for autonomic hyperreflexia (AH) associated with stimulation below the level of transection. Transection levels below T5 may be associated with less severe manifestations. AH can be prevented by GA, spinal, or epidural anesthesia. If AH occurs intraop, it should be treated by deepening the level of anesthesia, and iv antihypertensive agents (e.g., SNP 0.5-5 mcg/kg/min; labetalol 5-10 mg iv; phentolamine 2-5 mg iv), if necessary.

POSTOPERATIVE

Complications	Peroneal nerve injury 2° lithotomy position Fever/bacteremia Bladder perforation	Peroneal nerve injury manifested as foot drop with loss of sensation over dorsum of foot. Seek neurology consultation. Bladder perforation may present as shoulder pain in the awake patient but may go unnoticed in a patient under GA. Sx include unexplained HTN, tachycardia, ↓ BP (rare).
Pain management	Pain usually mild	Rx: morphine 2-4 mg iv q 10-15 min prn, fentanyl 25-50 mcg iv, ketorolac 15-30 mg im or iv

Suggested Readings

1. Gunduz H, Binak DF: Autonomic dysreflexia: an important cardiovascular complication in spinal cord injury patients. Cardiol J 2012; 19(2):215-9.

2. Hambly PR, Martin B: Anesthesia for chronic spinal cord lesions. Anesthesia 1998; 53:273-89.

TRANSURETHRAL RESECTION OF THE PROSTATE (TURP)

SURGICAL CONSIDERATIONS

Description: TURP is one of the most common urologic operations, performed to relieve bladder outlet obstruction by an enlarging prostate gland. It is often preceded by cystoscopy, which is used to evaluate the size of the prostate gland and to rule out any other pathology, such as bladder tumor or stone. The operation is performed with the resectoscope, a specialized instrument having an electrode capable of transmitting both cutting and coagulating currents. Resectoscopes are either single inflow only or continuous flow with an inflow and outflow system. The latter allows the surgeon to maintain low pressure in the bladder and prostatic fossa and thus limit fluid absorption. Two different electrical options are available. The traditional resectoscope is a monopolar system, and this requires a grounding pad and possible interference with electric devices, such as pacemakers. Bipolar resectoscopes have both the active and return electrode fitted in the resectoscope and do not cause any electrical interference with cardiac electrical devices. In addition, the use of bipolar cautery allows saline to be used as an irrigant during surgery.

The resectoscope is introduced into the bladder (Fig. 9-3), and the tissue protruding into the prostatic urethra is resected in small pieces called “chips.” Bleeding vessels are coagulated with the coagulating current. The resection is performed with continuous irrigation using an isotonic solution, such as sorbitol 2.7% with mannitol 0.54% in monopolar resectoscopes and normal saline in bipolar resectoscopes. After the obstructing prostatic tissues are completely resected and bleeding vessels coagulated, the chips are irrigated from the bladder and the resectoscope is removed. An indwelling Foley catheter is introduced into the bladder. The time of transurethral resection should not exceed 2 h because excessive absorption of the irrigating fluid may → dilutional hyponatremia, confusion, seizures, and heart failure. However, this is less of an issue with a continuous flow bipolar resectoscope where saline is used as an irrigant. Although fluid absorption can occur, hyponatremia does not occur with the use of saline. The size of the enlarged prostate or adenoma, therefore, needs to be carefully assessed preop to determine if it is possible to complete the resection within 2 h. If not, an open prostatectomy is performed. This variant approach is discussed under Open Prostate Operations, p. 887.

Variant procedure or approaches: A number of techniques have been developed to avoid the morbidity of TURP. These are either vaporization (electrocautery or laser) or thermocoagulation of the prostate (laser, microwave, radiofrequency). The following techniques are available and approved:

TUVP: Transurethral vaporization of the prostate with a standard resectoscope using a roller ball electrode at 275-300 watts setting.

Laser Ablation: Laser coagulation of the prostate is done with Nd:YAG or Ho:YAG laser through a standard cystoscope. This procedure has been largely replaced by laser ablation with the KTP laser (PVP, green light laser) or diode laser. This wavelength allows vaporization of the prostate tissue with minimal blood loss. This is currently the most popular minimally invasive technique used for treatment of BPH. It can also be done on patients while on anticoagulation or with bleeding disorders. All personnel in the OR, including the patient, must wear protective glasses to protect the eyes from inadvertent exposure from a break in the laser fiber.

TUNA: Transurethral needle ablation of the prostate is done with a special disposable device connected to a radiofrequency generator.

TUMT: Transurethral microwave thermotherapy is done with a catheter that has a microwave antenna attached to it. A microwave generator is needed for this procedure.

All of the above have several advantages over TURP, including shorter surgical time, no blood loss, and reduced risk of fluid absorption and all can be done as outpatient procedures.

Figure 9-3. Transurethral resection of prostate using a resectoscope. (Reproduced with permission from Govan DE: Roche Manual of Urologic Procedures. Hoffmann-LaRoche: 1976.)

Usual preop diagnosis: Benign prostatic hypertrophy; prostate cancer

▪ SUMMARY OF PROCEDURES

	TURP	Thermotherapy
Position	Lithotomy	⇚
Incision	None	⇚
Special instrumentation	Cystoscope; resectoscope; catheters; electrocautery	Cystoscope; resectoscope; catheters; electrocautery (standby); laser equipment
Unique considerations	During resection, the patient should be absolutely still because any movement may lead to perforation or injury to the external sphincter, → postop incontinence.
During laser resection, the patient and all personnel should wear protective eyeglasses.
Antibiotics	Gentamicin 80 mg iv, slowly	⇚
Surgical time	1-2 h (not to exceed 2 h)	1 h
EBL	500 mL	None
Postop care	Irrigation of the Foley catheter to clear it of clots and keep it from being blocked. Determination of serum Na⁺	⇚
Mortality	< 1%	⇚
Morbidity	Significant intraop bleeding: 10% intraop perforation and fluid extravasation, which may require placement of retropubic drain: < 0.5% Postop bleeding, which may necessitate a return to OR for fulguration of bleeding vessels: < 5% Absorption of irrigating fluid, which may → dilutional hyponatremia, mental confusion, and heart failure: 2-5%	Prolonged catheterization: 10% Postop bleeding: 1%
Pain score	1	1

ANESTHETIC CONSIDERATIONS

PREOPERATIVE

Patients presenting for prostate surgery are generally elderly and may have preexisting medical problems, including CAD, CHF, PVD, cerebrovascular disease, COPD, and renal impairment. Preop evaluation should be directed toward the detection and treatment of these conditions before anesthesia.

Respiratory	COPD common in this age group. Patients with > 50 pack-year smoking Hx, or with any respiratory Sx, may need PFTs. For dyspnea with moderate exercise, [check mark] VC, FEV₁, MMEF. If VC < 80%, FEV₁ < 60%, or MMEF < 40% predicted, [check mark] ABG. If ABG and PFT markedly abnormal, consider postponing surgery until patient’s respiratory condition has been optimized. Tests: PFT; CXR; ABG, as indicated from H&P
Cardiovascular	HTN, CAD common in this age group. Assess exercise tolerance by H&P (e.g., should be able to climb a flight of stairs without difficulty or SOB). Tests: ECG; others as indicated from H&P
Neurological	Cerebrovascular disease, Alzheimer’s, and other neurologic problems may be present in this age group. Assess mental status to guide evaluation of any intraop or postop changes.
Renal	Anticipate renal impairment 2° chronic obstruction. Tests: BUN; Cr; electrolytes. If ↑ BUN and ↑ Cr, [check mark] creatinine clearance (nl = 95-140 mL/min).
Musculoskeletal	Various arthritides in this age group may cause problems with positioning for regional anesthesia and surgery.
Endocrine	Increased incidence of DM
Hematologic	Moderate blood loss expected with larger glands. If gland < 80 g, no T&C necessary. Test: Hct
Laboratory	Other tests as indicated from H&P
Premedication	Continue commonly used drugs (e.g., digitalis, β-blockers, NTG) to prevent cardiovascular problems. Sedation prn anxiety (e.g., midazolam 1-2 mg iv before surgery).

INTRAOPERATIVE

Anesthetic technique: Regional or GA. Choice of technique depends on the coexisting disease and the patient’s preference. Regional anesthesia may hold some advantage over GA for TURP in that it allows evaluation of mental status and, thus, earlier detection of TURP syndrome. The incidence of postdural puncture headache is very low in this age group (< 1%). A T9 level is optimal. Continuous lumbar epidural anesthesia has no advantage over spinal anesthesia for TURP, because a sacral block may be less reliable, the procedure is relatively short and supplemental doses are usually not necessary.

Regional anesthesia:

Spinal

0.75% bupivacaine, 12 mg in 7.5% dextrose solution (1.6 mL)

General anesthesia:

Induction	Standard induction (see p. B-2).
Maintenance	Standard maintenance (see p. B-3). Muscle relaxation is not mandatory, although patient movement during the procedure must be avoided.
Emergence	Postop pain is usually not significant. Anticipate ↓ BP when legs are repositioned from lithotomy. Avoid stress on lumbar spine by slowly and simultaneously bringing legs together and returning to supine position.
Blood and fluid requirements	Moderate blood loss (TURP) Minimal blood loss (thermotherapy) IV: 16-18 ga × 1 NS/LR @ 2-4 mL/kg/h	Blood loss can be large (TURP) if venous sinuses are entered; it also can be difficult to quantify because of irrigant. To flush away blood and tissue and to promote visibility during TURP (or thermotherapy), continuous irrigation is used. For monopolar procedures, irrigating fluid must be nonelectrolytic to prevent dispersion of current but near iso-osmotic to prevent hemolysis. For these reasons, sorbitol (2.7%) with mannitol (0.54%) or glycine (1.5%) is added to distilled water to produce solutions that are nearly isotonic.
Monitoring	Standard monitors (see p. B-1).	Regional anesthesia allows monitoring of mental status. Invasive monitoring, if indicated from H&P.
TURP syndrome	Intravascular volume overload Hyponatremia Hypotonicity 2° absorption of irrigant Symptoms include ▼ N/V ▼ Visual disturbances ▼ Mental status changes ▼ Coma ▼ Sz ▼ HTN ▼ Angina ▼ Cardiovascular collapse	Factors that influence the absorption of irrigant include surgical technique (TURP or thermotherapy); hydrostatic pressure of irrigant (height of bag); number of venous sinuses opened; peripheral venous pressure; duration of surgery; and experience of the surgeon. Resections should optimally be limited to 1 h or less. Some CNS manifestations (e.g., visual disturbances, nausea, confusion) are 2° glycine and its metabolites. Rx may include observation, diuresis (e.g., furosemide 5-20 mg iv), and administration of hypertonic saline (e.g., 100 mL of 3% saline over 1-2 h). Serum sodium < 120 is associated with more severe symptoms, and the goal of therapy is to restore sodium to > 120. In milder cases, observation and water restriction may be sufficient.
Positioning	[check mark] and pad pressure points [check mark] eyes	*NB: In lithotomy position, peroneal nerve compression at lateral fibular head → foot drop.
Complications	Bladder perforation TURP syndrome	Bladder perforation may produce shoulder pain in the awake patient. Bladder perforation (and TURP syndrome) may go unnoticed under GA; Sx: ↑ BP, ↑ HR (occasionally ↓ BP).

POSTOPERATIVE

Complications	TURP syndrome Bladder perforation Fever/bacteremia/sepsis Hypothermia	See discussion of TURP syndrome, above.
Pain management	Minimal postop pain	Rx: Morphine 1-4 mg iv prn until comfortable.
Tests	Hct; electrolytes Blood cultures if febrile	Consider serum osmolarity, CXR, ECG in TURP syndrome

Suggested Readings

1. Hawary A, Mukhtar K, Sinclair A, Pearce I: Transurethral resection of the prostate syndrome: almost gone but not forgotten. J Endourol 2009; 23(12):2013-20.

2. Kavanagh LE, Jack GS, Lawrentschuk N: Medscape: prevention and management of TURP-related hemorrhage. Nat Rev Urol 2011; 8(9):504-14.

3. Smith RD, Patel A: Transurethral resection of the prostate revisited and updated. Curr Opin Urol 2011; 21(1):36-41.

4. Teng J, Zhang D, Li Y, et al: Photoselective vaporization with the green light laser vs transurethral resection of the prostate for treating benign prostate hyperplasia: a systematic review and meta-analysis. BJU Int 2013; 111(2):312-23.

5. van Rij S, Gilling PJ: In 2013, holmium laser enucleation of the prostate (HoLEP) may be the new ‘gold standard’. Curr Urol Rep 2012; 13(6):427-32.

6. Wang J, Zhang C, Tan G, Chen Q, Yang B, Tan D: Risk of bleeding complications after preoperative antiplatelet withdrawal versus continuing antiplatelet drugs during transurethral resection of the prostate and prostate puncture biopsy: a systematic review and meta-analysis. Urol Int 2012; 89(4):433-8.

OPEN PROSTATE OPERATIONS

SURGICAL CONSIDERATIONS

Description: Open (in contrast to transurethral or endoscopic) operations on the prostate gland are common. They include simple prostatectomy and radical prostatectomy and are done through either a midline extraperitoneal incision, which extends from the umbilicus to the symphysis pubis, or through a Pfannenstiel’s incision (Fig. 9-4, inset).

Simple prostatectomy: When the benign prostatic hypertrophy or adenoma is too large to be resected transurethrally, it is removed by a simple prostatectomy. The prostate gland is exposed through a retropubic approach (Fig. 9-4A), and the anterior capsule is incised, exposing the adenoma—the central part of the prostate, which is excised, “shelled” out by blunt dissection (Fig. 9-4B), leaving behind the peripheral prostate and all the associated structures. A Foley catheter is left indwelling in the urethra, and the incision in the prostate capsule is closed. In a suprapubic prostatectomy, the incision is made in the bladder and the adenoma shelled from within the bladder.

Radical prostatectomy: The term radical prostatectomy is used because the entire prostate, both seminal vesicles and pelvic nodes, are removed. It is used to differentiate this cancer operation from a simple prostatectomy (used for benign prostatic hypertrophy). Radical prostatectomy can be achieved through a retropubic approach. In radical prostatectomy, all of the prostate gland is removed, together with the bladder neck, the seminal vesicles, and the ampullae of the vas deferens. A limited pelvic lymphadenectomy (Fig. 9-5) also is performed. After the prostate gland and its associated structures are removed, the bladder neck is reduced to 1 cm diameter and anastomosed to the membranous urethra over an indwelling Foley catheter. Most of the blood loss occurs during control of the dorsal vein complex. In early-stage cancers, which nowadays comprise 90% of patients, a nerve sparing procedure is done. This involves preserving potency by preserving the nerves to the corpora cavernosa. More recently, radical
prostatectomy is being done by laparoscopy. This procedure has been popularized with the use of robots. Please see section of robotic urologic surgery.

Figure 9.4. Retropubic prostatectomy: A: A transverse capsulotomy is made between heavy hemostatic stay sutures. B: The cleavage plane between the adenoma and the surgical capsule is developed with scissors. (Reproduced with permission from Fowler JE: Urologic Surgery. Little & Brown: 1990.)

Figure 9-5. Right lateral pelvic wall. Anatomy of pelvic blood vessels and nerves encountered in a pelvic lymph node dissection. (Reproduced with permission from Graham SD Jr: Glenn’s Urologic Surgery. Lippincott Williams & Wilkins: 1998.)

Variant approach: Minimally invasive prostate cancer surgery has expanded with the use of the Da Vinci robotic system. Most laparoscopic radical prostatectomies are done with the assistance of the robot. With the robotic system, the surgeon sits at a console away from the patient and has a three-dimensional view with 10× magnification. A bedside assistant is necessary for instrument change and retraction. See page 922 for special Anesthetic Considerations for Robotic-Assisted Laparoscopic Surgery.

Usual preop diagnosis: Benign prostatic hypertrophy; prostate cancer

▪ SUMMARY OF PROCEDURES

	Simple Prostatectomy	Radical-Retropubic
Position	Supine	⇚; lithotomy → steep Trendelenburg (robotic)
Incision	Extraperitoneal, low midline, or Pfannenstiel’s (Fig. 9-4A, inset)	⇚; multiple port sites (robotic)
Unique considerations	None	⇚; Da Vinci robotic system is used increasingly (> 80%); abdominal insufflation
Antibiotics	Gentamicin 80 mg	cefazolin 1 g iv
Surgical time	1 h	2-3 h (experienced surgeon)
EBL	500 mL	1500 mL (open)
Postop care	Irrigate catheter to clear blood clots and prevent obstruction; frequently, if urine is bloody.	⇚
Mortality	< 1%	⇚
Morbidity	Bleeding: 2%	⇚
	DVT: 2%	⇚
	Infection: 2%	⇚
	PE: 1%	⇚
		Impotence: Non-nerve-sparing: 100% Nerve-sparing: 20-50% Lymphocele: 4%
Pain score	8	8

Figure 9-6. Perineal incisions.

ANESTHETIC CONSIDERATIONS

PREOPERATIVE

Respiratory	COPD common in this age group. Patients with Hx of > 50 pack-year smoking, or with respiratory Sx, may require PFTs. For dyspnea with moderate exercise, check VC, FEV₁, MMEF. If VC < 80%, FEV₁ < 60%, or MMEF < 40% predicted, [check mark] ABG. If ABG and PFT are markedly abnormal, consider postponing surgery until patient’s respiratory condition has been optimized. In robotic surgery, steep Trendelenburg position will compromise pulmonary function. Tests: PFT; CXR; ABG, as indicated from H&P
Cardiovascular	HTN, CAD common in this age group. Assess exercise tolerance by H&P (e.g., should be able to climb a flight of stairs without difficulty or SOB). Transition plans for patients on anticoagulants for coronary stents should be discussed with both the cardiologist and surgeon before surgery. Tests: ECG; others as indicated from H&P
Neurological	Cerebrovascular disease, Alzheimer’s, and other neurologic problems may be present in this age group. Assess mental status to guide evaluation of any intraop or postop changes. In robotic cases, steep Trendelenburg position and CO₂ insufflation → ↓ ICP and ↑ intraocular pressure. A preop neurosurgical consult is recommended for patients with intracranial lesions or VP shunts. Blindness has been reported following robotic prostatectomy.
Renal	Anticipate renal impairment 2° chronic obstruction. Pneumoperitoneum during robotic surgery may ↓ renal blood flow and oliguria postop. Tests: Cr
Musculoskeletal	Various arthritides may cause problems with positioning for regional anesthesia and surgery.
Endocrine	Increased incidence of diabetes mellitus.
Hematologic	Moderate blood loss expected with larger glands. For glands < 30 g, no T&C necessary; for glands 30-80 g, T&C 2 U PRBCs; for glands > 80 g, T&C 4 U PRBCs. Tests: Hct
Laboratory	Other tests as indicated from H&P
Premedication	Continue commonly used drugs (e.g., digitalis, β-blockers, diuretics, NTG) to prevent cardiovascular complications. Sedation prn anxiety (e.g., midazolam 1-2 mg iv on call to OR).

INTRAOPERATIVE

Anesthetic technique: Regional (spinal, continuous spinal, continuous lumbar epidural), GA, or combined techniques are acceptable for open procedures. Robotic procedure typically require GA. If regional anesthesia used, optimal block level is T8-T10 (depending on incision site). Advantages of regional anesthesia include potential for lower intraop blood loss, possible lower incidence of DVT postop, and faster return of bowel function. Disadvantages include positioning considerations (see below).

Regional anesthesia:

Spinal	Bupivacaine (0.75%) 12 mg in 7.5% dextrose solution (1.6 mL)
Epidural	1.5-2% lidocaine with epinephrine 5 mcg/mL, 15-25 mL, supplemental iv sedation as necessary. Additional epidural lidocaine (5-10 mL boluses) may be needed, depending on length of procedure. Alternatively, smaller volumes of bupivacaine (0.25-0.5%) or ropivacaine (0.5-1%) may be used. The addition of opiates has been associated with ↑ urinary retention in noncatheterized patients.

General anesthesia:

Induction	Standard induction (see p. B-2).
Maintenance	Standard maintenance (see p. B-3). In robotic cases, recheck ETT position after the patient has been positioned and the abdomen insufflated to avoid mainstem intubation. Patient movement is not well tolerated by the robot → visceral/vascular injury.
Emergence	No special considerations. Airway edema may occur after prolonged steep Trendelenburg position.
Blood and fluid requirements	Moderate-to-large blood loss IV: 14-16 ga × 1-2 NS/LR @ 4-6 mL/kg/h	Additional requirements dependent on type of anesthesia. Regional techniques are associated with higher fluid requirement because of sympathectomy and systemic vasodilation; they also may be associated with lower blood loss than GA.
Monitoring	Standard monitors (see p. B-1). Depending on underlying disease: ± CVP ± Arterial line	Some patients require CVP to aid in assessment of volume status. Arterial line is often useful for continuous BP monitoring and frequent blood draws. Patients at particularly high risk (e.g., Hx of preexisting cardiopulmonary disease) should probably have both.
Positioning	Anticipate ↓ BP on return from lithotomy position. [check mark] and pad pressure points [check mark] eyes	Rx: volume (200-500 mL NS/LR) or ephedrine (5 mg iv) may be necessary. Elderly patients with arthritis or respiratory impairment may not tolerate the extreme positioning associated with robotic prostatectomy. (A combined technique with GA maybe considered.) NB: In lithotomy position, peroneal nerve compression at lateral fibular head → foot drop.
Complications	Indigo carmine reaction Hemorrhage Hypothermia VAE Robot malfunction	Indigo carmine → false ↓ O₂ sat ± ↑ BP; rare allergic reaction → rash + bronchoconstriction + ↓ BP. Insufflation pressure may exceed venous pressure → VAE

POSTOPERATIVE

Complications

Peroneal nerve injury 2° lithotomy position

DVT

Airway edema → obstruction

Manifested by foot drop with loss of sensation on dorsum of foot. Seek neurology consultation. Incidence of DVT less with regional than GA. Sx: variable, with pain and tenderness over involved area.

Pain management

Significant postop pain. Rx: hydromorphone 0.01-0.02 mg/kg iv in incremental doses (e.g., 10-15 min prn).

Consider epidural infusion of dilute local anesthetics/opiates or PCA (see p. C-3). Robotic procedure patients have lower postop pain.

Tests

Hct