GU procedures

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What is the Sensory level to block (SAB or epidural ) for a TURP

T10 Sensory level

What is the advantages to a SAB or epidural for a TURP Procedure

Decreased Blood loss
Decreased Post-op VTE
Easier to ID early signs of TURP Syndrome

Complications of TURP

Bleeding
TURP Syndrome
Hypothermia
Coagulopathy
Septicemia (from colonized infected prostate)

What is TURP Syndrome

Occurs with absorption of 2L or more of irrigation fluid via venous sinuses in prostate.
Results in Circ. Overload:
--Inc BP
--Bradycardia
--Irrigation fluid solute toxicity
--Hyponatremia (dilutional)
--HypoOsmolality

Symptoms associated with Hyponatremia

Na: 125mEq/L No symptoms
--120 mEq/L Restlessness/ confusion/ wide QRS
--115 mEq/L Somnolence/ nausea//wide QRS/ ST elev
--110 mEq/L Seizures

What are the S/Sx to watch for with TURP Syndrome

-Cyanosis
-Dyspnea
-Arrythmias
-Dec BP
-CHF/ Pulm Edem
-Hemolysis

Treatment for TURP syndrome

*Early Recognition
*Terminate seizures
*Eliminate Absorbed Water: Loop diuretics
*Maintain oxygenation and perfusion
*Hypertonic Saline(3% or 5%) @ 100cc/hr max

What type of irrigationg solution is most commonly used in TURPS

Solution should be slightly hypotonic and non-electrolyte fluids....
--Glycine 1.5%
--Cytal: mix of sorbital 2.7% and mannitol 0.54%
(less common: Sorbital 3.3%, Mannitol 3%, Dextrose, urea)
Edit

What are the factors that affect solution absorption during a TURP

1. type of solution
2. duration of the resection
3. height of irrigation solution(60cm above is max)
4. pressure of solution administered
5. blood loss
Edit

What are the symptoms of glycine Toxicity from TURP

-circulatory depression and CNS toxicity
-Inhibitory neurotransmitter in CNS (rare transient blindness)
Edit

What are the causes of Bladder perforation of TURP

1. Cutting loop or knife electorde
2. tip of resectoscope
3. Overdistention of the bladder with irrigation fluid.
****Fluid goes in but does not come out!

Symptoms of bladder perforation during TURP

Awake pt: N/V, Diaphoresis, pallor, abd pain
Large perforations can cause sudden unexplained hemodynamic changes.

What are the advantages to using an Indigo Laser TURP

Laser "heats" tissue and it is reabsorbed
No irrigation
Less Painful
Quicker
Used with ambulatory surgery center.

Where can stones cause obstruction in the GU system

1. Nephrolithiasis (Kidney)
2. Ureterolithiasis (ureters)
3. Vesical Stone (Bladder)
4. Renal Pelvis Stones (painless)

What are the most common renal Calculi types

Calcium Stones (most common)
-also calcium oxalate(80%)
- calcium phosphate, uric acid

What disease states cause increased risks for renal calculi

Sarcoidosis
Malignancy
Idiopathic
Hypercalcemia
Hyperparathyroidism
Renal Tubular acidosis

What dietary items decrease risk of renal calculi

Dietary calcium (inhibits intestinal absorption of oxalate)
Coffee and Beer
2.5-3Liter of fluids a day
(Grapefruit juice increases risk)

What are the 4 types of Renal Calculi

1. Calcium Oxalate (80%)
2. Struvite (staghorn)(mag) (15%)
3. Uric Acid (6%)
4. Cystine (2%)

What are the s/sx of Renal calculi

1. Flank Pain
2. "Writhing pain" ("motionless"pain is symp of abd patho)
3. Infections and hematuria

Drug of choice for pain assoc with renal calculi

Toradol (decreases PG2 which is the mediating hormone of renal pain)

Surgical management of Renal calculi

Nephhrectomy
Open lithotomy(rare)
Lap nephrolithotomy
Cysto/ureteroscopy extraction
Laser (YAG)
Percutaneous nephrolithotomy
Extracorporal Shock Wave Lithotripsy (ESWL)

Advantages of Lithotripsy

Noninvasive
Pulverizes upper urinary tract stones by means of a shock wave

what is considered the gold standard of Lithotripsy

1st Generation:
- utilizes a bath of water as a medium to deliver the shock wave
-Must be able to visualize stone in upper urinary tract system

What is the gantry in lithotripsy

The hydraulic chair
--positions pt in semifowlers position, immerses pt in water, two fluoroscop units positioned above.

What are the 4 primary components of Lithotripsy

1. Energy source (spark plug)
2. focusing Device (ellipsoidal reflector)
3. Coupling medium (water)
4. Stone localization system (fluoroscopy)

Hydrostatic force of water displacing Blood during lithotripsy causes what physiological changes

Increased Venous Return, BP, PCWP, RAP
Water up to clavicles can Inc CVP by 10-14 cmH20
Increase in pulm cap blood flow, producing V/Q abnoormalities.

What offsets the hydrostatic pressures normalizing the physiological changes during lithotripsy

1. Vasodilation and hypotension due to anesthesia
2. Warm water
3. Semi-fowler position

Why do dysrhythmias occur in healthy normal patients during immersion and out of bath during lithotripsy

Rapid inc and dec in preload causing acute changes in RA and RV wall tensions.
-dec FRC
-Inc intrathoracic pressure
- inc intraabdominal pressure
- inc risk of aspiration

Why is timing of lithotripsy important

Shock waves should be synced with ekg. Must be given during absolute refractory period-- (20msec after R wave thereby reducing dysrhthmias)

what are some of the complications of lithotripsy

CHF
Dysrythmias (pacer? AICD?)
Drowning, electrocution, infection
Air bubbles
Renal parenchymal damage
Hematoma

Absolute contraindications to Lithotripsy

- Pregnancy
- Untreated coagulopathies
- abdominally placed pacemakers
- obstruction distal to renal calculi
- Morbid Obesity (>278#)
- AAA > 6cm

Relative contraindications to Lithotripsy

- AAA
- Metal Instrumentation in lumbar region
- Hemangioma in vertebral canal
- Untreated UTI

Advantages to a regional anesthesia for Lithotripsy

Awake patient, intact airway reflexes, can move arms making immersion and emmersion easier.
(disadvantage: puncture site is under water)

Advantages of General anesthesia with Lithotripsy

Controlled breathing- HFJV causes very little stone movement
Induction time is short

Disadvantages to GA with Lithotripsy

Distance from patient-
Tube kinking and Neck flexion
Drowning
Twitch monitor caution

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