Hematuria, hydronephrosis, benign prostatic hypertrophy, cancer of the urethra, prostate, bladder, ureter, and renal pelvis, urinary tract stones, obstructions, or cystitis.
A kidney stone is a hard mass formed by calcium in combination with oxalate or chemicals (most common). These components come from diet, but kidney stones can also result from uric acid or an infection.
Patients with a family history of kidney stones, previous stones, hyperparathyroidism, hereditary renal tubular acidosis, gout, and excess Vitamin D intake (= decreased calcium absorption) are more prone to develop kidney stones. Patients with chronic bowel inflammation, intestinal bypass operations, or ostomy surgeries may also develop calcium oxalate stones.
Paraplegics and quadriplegics may present for repeated cystoscopies and stone extractions due to abnormal bowel and bladder function, which increases the risk of kidney stones. Note the risk of autonomic hyperreflexia (see later).
The renal pathways are evaluated using cystoscopes and resectoscopes
Transurethral resection (TUR) of any urethral, prostatic, or bladder pathology
Coagulation of bleeding vessels
Oxycholorosene instillation to treat localized infections (cystitis)
Stone extraction using special forceps or stone baskets. Larger stones must be broken up using extracorporeal shock wave lithotripsy (ESWL)
Incision and dilation of strictures utilizing a balloon catheter
Note: a temporary ureteral stent may be placed at the end of most endoscopic procedures to facilitate the passing of stone fragments - it extends from the kidney to the bladder
An alternative option is a percutaneous nephrostomy with the patient in a prone or flank position; then, a tube is introduced into the kidney under fluoroscopy.
Some patients move to the ESWL room for breakage of the stone in a water bath.
Position - lithotomy
Antibiotics - Gentamicin 80 mg IV is given slowly
Surgical time - 15-45 min; percutaneous 2-3 hrs. X-ray and fluoroscopy help locate stones and guide appropriate equipment; staff need to wear lead aprons
Morbidity - bleeding, infection, perforation, retained stones
Pts of all ages
Bladder tumors in elderly patients - consider medical hx of CAD, CHF, PVD, cardiovascular disease, COPD, and renal function.
Paraplegics and quadriplegics with lesions above T5 are at increased risk of developing autonomic hyperreflexia with stimulation below the level of spinal cord transection. The lower the transection, the less risk of autonomic hyperreflexia.
Positioning of paraplegics or quadriplegics may be difficult due to pressure sores or contractures
As indicated from H&P - monitor H&H (hematuria, O2 carrying capacity), K+ for arrhythmias
Verify NPO, consent signed, questions answered, then Versed 1-2 mg IV as needed
2% lidocaine jelly
75% bupivacaine 10-12 mg; for shorter procedures (<1 hr), consider low-dose 7.5 mg bupivacaine, mepivacaine (1.5% ~ 45 mg) or procaine (10% ~ 100-150 mg).
Lidocaine may be used, but the incidence of transient neurologic symptoms (TNS) may be as high as 30% for procedures done in the lithotomy position
1.5-2% lidocaine with epinephrine 5 mcg/mL, 15-25 mL. Supplement with 5-10 mg boluses as needed.
Preoxygenation
Lidocaine 1 mg/kg/IV
Propofol 1-2 mg/kg/IV
Fentanyl 1-3 mcg/kg/IV
Succinylcholine 0.5-1.5 mg/kg - avoid in paraplegics due to increased risk of dysrhythmias
ETT (may consider LMA for shorter procedures)
Sevo
Extubate when awake, following commands
Peroneal nerve injury - foot drop with loss of sensation over the dorsum of the foot
Fever/bacteremia
Bladder perforation - shoulder pain in awake pt. Under GA, may have unexplained HTN, tachycardia, or low BP (rare)
Pain - usually mild