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Anesthesia for Urological Surgery

(Originally posted 3 January 2000 on About Anesthesiology)

INTRODUCTION
The methods and techniques of urological surgery have changed greatly in the last few years. New techniques include such things as the use of laparoscopy, shock wave lithotripsy, the use of the laser and endoscopic techniques. These methods are all designed to make surgery less invasive and to speed up recovery.

In addition, as in other areas of surgery, the push is toward same-day (ambulatory) surgery, or at least shorter stay surgery. The changes in surgical techniques combined with new and improved anesthesia techniques have made this possible and desirable.

CHOOSING THE KIND OF ANESTHESIA
There are many things that affect the choice of anesthesia for a given procedure. It is important to consider the surgical requirements, the patient's medical condition, etc. Equally important are the patient's preferences and the surgeon's preferences. Remember that while some types of anesthesia may be technically or theoretically possible, issues of patient comfort and safety as well as environmental factors may make these techniques less desirable. This is especially true of regional techniques where the patient is aware of semi-aware, required to lie in one position for a long period of time, etc.

Anesthesia can range from the minimalist approach of only local anesthesia given in the form of lidocaine jelly to mucosal surfaces (appropriate for only a handful of procedures), to local anesthesia with sedation, to nerve blocks with or without sedation, and on to regional anesthesia techniques (such as spinal or epidural), general anesthesia, or a combination of regional and general techniques. There are many different options - and I continue to stress that the technique should be tailored to the needs and desires of the patient and the surgery to be done.

There are some surgeries that pretty much require general anesthesia - and this should be considered for the following cases:

  • Almost all laparoscopic procedures
  • Open renal procedures
  • Very short procedures where prolonged regional blockade is undesirable
  • Very long surgeries
  • Other patient comfort concerns (severe anxiety, preference, embarrassment, etc.)

If regional anesthesia is chosen, it requires that the correct nerve distributions for the area of surgical interest are blocked by the technique chosen. For practitioners, this means that the following nerve innervations should be remembered:

  • Pelvis Parasympathetic from S2, S3, and S4 via the pelvic splanchic plexus
  • Pelvis Sympathetic from T11 and T12 from the hypogastric plexus
  • Kidney is supplied by T10 through L1
  • Prostate and bladder - S2, S3 and S4
  • Distention of the bladder requires blockade to the T10 or T11 level
  • Procedures on the ureters usually require blockade to the T10 level

(It should be noted that surgery on the kidneys is rarely done with just regional anesthesia even though the correct nerve distributions can be blocked. General anesthesia is usually done as it helps with many technical aspects of operating on the kidneys.)

OTHER BLOCKS OF INTEREST

Penile Nerve Block
The dorsal nerve of penis supplies the distal 2/3 of the penis. It is a terminal branch of the pudendal nerve. This block is often used for circumcision or as a supplemental form of post-operative pain relief for surgeries in this area.

Ilioinguinal/Iliohypogastric Block
Often utilized for post-operative pain relief for inguinal and genital surgeries.

THINGS TO WATCH FOR (or, what could go wrong):

  • Proper positioning and padding of pressure points is very important. Many of these surgeries are performed in the lithotomy position which can lead to nerve injuries if precautions are not taken.
  • Hypothermia is a concern with all anesthetics - but cold fluid used for irrigation can make this problem worse during urologic surgery.
  • Irrigation fluid and endoscopic techniques often make it hard to estimate blood loss.
  • TURP syndrome from irrigation fluids. Regional anesthesia is often preferred to aid in the early detection of this problem.
  • Bladder perforation is a risk when instrumenting the bladder. It is important to try to avoid the patient having to cough, move, or strain unnecessarily.
  • Bacteremia should be watched for in patients with obstructive problems and urinary infections.
  • Some of these patients may be latex allergic.
  • Carcinoma of the prostate is sometimes associated with the release of a fibrinolytic substance which can cause a coagulopathy. Also be on the lookout for renal problems associated with carcinoma.
  • It is often hard to predict how long some of these surgeries will take. General anesthesia may offer more control over this problem than other options.

 

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