Cystoscopy/Transurethral Procedures

Usual Preop diagnosis

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).

Evaluations

The renal pathways are evaluated using cystoscopes and resectoscopes

• The cystoscope is advanced via the urethra into the bladder, and it is possible to advance a small catheter into the ureteral orifice and advance it up to the kidney for evaluation (retrograde pyelography)
• It is possible to use a ureteroscope to inspect the ureter and intrarenal collecting system (nephroscopy)
• A resectoscope is used to trim tissue

Transurethral procedures

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. 

Preoperative Considerations

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

Anesthetic considerations

Pts of all ages

Bladder tumors in elderly patients - consider medical hx of CAD, CHF, PVD, cardiovascular disease, COPD, and renal function.

Neurological

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.

Symptoms

• Severe HTN, bradycardia, dysrhythmias, and cardiac arrest due to massive sympathetic discharge with stimulation below the level of spinal cord transection (Foley, defecation)
• Pts become flushed to the upper body, nasal stuffiness and headache (vasodilation), and pale to the lower body (vasoconstriction)
  • Treatment - deepening anesthesia, antihypertensive agents if needed

Musculoskeletal

Positioning of paraplegics or quadriplegics may be difficult due to pressure sores or contractures

Laboratory

As indicated from H&P - monitor H&H (hematuria, O₂ carrying capacity), K⁺ for arrhythmias

Preop area

Verify NPO, consent signed, questions answered, then Versed 1-2 mg IV as needed

Options for anesthesia

Topical

2% lidocaine jelly

Spinal

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

• TNS mechanism is unclear
• Symptoms include burning, aching, cramp-like sensation, and radiating pain in the anterior and posterior aspects of the thighs
• Symptoms present 1-24 hrs. post-procedure, resolves within 10 days
• Associated with lithotomy position
  • Treat with NSAIDs; opioids may be required

Lumbar epidural

1.5-2% lidocaine with epinephrine 5 mcg/mL, 15-25 mL. Supplement with 5-10 mg boluses as needed.

General anesthesia

Induction

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)

Maintenance

Sevo

Emergence

Extubate when awake, following commands

Complications

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