Introduction:
The majority of urologic procedures are carried out using a cystoscope. In order to maximize surgical results, anesthesiologists should take into account a variety of criteria in addition to providing proper anesthetics, such as age, comorbidities, functional status, duration of operation, anticipated blood loss, and surgical scope.
Numerous urologic procedures are performed, and as the aged population has grown, so have the number of cases. Most urologic procedures are challenging to execute due to the small and constrained operating room. In order to give the best anesthesia during surgery, a thorough understanding and strategy are needed because the senior population are also at risk for perioperative problems.
What Are the Types of Urological Surgery?
The types of urological surgery are:
- Nephrectomy: The standard treatment for renal cell cancer is nephrectomy. (RCC). Depending on the features of the tumor, a partial or radical nephrectomy may be performed. Prior to surgery, it is necessary to assess for additional medical disorders such as cerebrovascular, pulmonary, and cardiovascular diseases. As the kidney will be removed entirely or partially, it may be significant in predicting residual renal function. Due to its nephrotoxic effects, nonsteroidal anti-inflammatory medication (NSAID) administration is frequently avoided in patients undergoing kidney surgery. However, NSAIDs have an opioid-sparing impact in addition to the postoperative analgesic effects, which may lessen the negative consequences of opioid use.
- Cystectomy: The preferred treatment for invasive bladder cancer is a cystectomy. The bladder may be removed entirely or in part, depending on the type of surgery with the risk of bleeding during the procedure. Therefore, a blood transfusion may be considered. However, a recent study evaluated the link between blood transfusion and increased recurrence. However, death is no longer significant. Unfortunately, acid-base abnormalities can occur in patients with ileal conduit urine diversion. Reabsorbing hydrogen ions, chloride ions, or ammonia from the ileal conduit could result in hyperchloremic metabolic acidosis.
- Transurethral Resection of Bladder Cancer: The cornerstone of diagnosing and treating bladder cancer is transurethral resection of bladder cancer (TURB), an endoscopic surgery. The shape, size, position, and quantity of tumors can be determined with TURB, which is carried out in an extremely constrained and congested bladder region. During TURB, the obturator nerve that runs near the lateral wall of the bladder may be activated, which could lead to an unanticipated movement of the ipsilateral thigh and an obturator nerve response. Therefore, during TURB, proper anesthesia should be given to ensure a sufficient operative environment and full resection.
- TURB procedures can be carried out under either general or local anesthesia. In elderly patients undergoing transurethral surgery, general anesthesia with propofol and desflurane is required which gives faster induction and recovery than spinal anesthesia. For a supraglottic airway device or endotracheal intubation, NMB is required. Under spinal anesthetic, numerous transurethral procedures were performed effectively, although spinal anesthesia fails to inhibit obturator nerve response. Hence, an obturator nerve block (ONB), was performed depending on the insertion position. The technique of ONB involves:
- Pubic Approach: The pubic ramus is reached by inserting the needle 3 cm laterally and 3 cm inferiorly from the pubic tubercle. At the obturator foramen, the obturator nerve was cut off. Effectively indicated in obese patients.
- Inguinal Approach: The adductor longus tendon's inner border and the middle of the ipsilateral femoral arterial pulse are reached by inserting the needle between the adductor brevis and adductor magnus, on which the obturator nerve is compressed.
- Other Techniques: These include the intravesical route and the inter-adductor approach, where a needle is placed at the adductor longus' upper end. (obturator nerve is blocked through the cystoscope).
What Is the Anesthetic Consideration in Urological Surgeries?
Urologic Emergency and Its Anesthetic Consideration:
Surgically necessary urologic emergencies are rather uncommon. The urologic emergencies include Fournier gangrene, testicular torsion, renal trauma, bladder trauma, urethral trauma, and scrotal trauma. The spermatic cord's rotation causes testicular torsion. This rotation prevents testis blood flow and hinders venous drainage. This pathology leads to the development of edema, ischemia, and necrosis.
- Preoperative Considerations: Fournier gangrene, a severe toxemia typically develops quickly, progressing to sepsis and organ failure. Hence prior to anesthesia administration of intravenous fluid therapy to maintain an efficient circulation volume and prevent insufficient tissue perfusion.
- Intraoperative Considerations: A central venous catheterization monitors the central venous pressure in the patient at risk for hypovolemia and hypotension and administers an immediate fluid infusion. To monitor blood pressure in patients at risk for hypotension, an invasive arterial blood pressure evaluation is performed.
- Anesthetic Consideration: In trauma patients, general anesthesia is the most often used anesthetic strategy; however, testicular torsion may require neuraxial blocking. Neuraxial blocking is another option if the affected area is localized in patients with Fournier gangrene or if the patient is not infected. The level of the sensory block must be selected in accordance with the legion level. Torsion of the testicles can be caused by a Th10 sensory block level.
Anesthesia for Urethra and Genital Surgery:
Radical orchiectomy combined with an inguinal incision is the initial treatment for testicular cancer. After chemotherapy, retroperitoneal lymph node dissection (RPLND) is a somewhat uncommon and challenging procedure used to treat testicular cancer.
- Preoperative Consideration: Patients who underwent retroperitoneal lymph node dissection and received adjuvant bleomycin preoperatively may develop pulmonary insufficiency. Additionally, fluid overload and oxygen toxicity could occur. In order to prevent acute respiratory distress syndrome from occurring in these patients postoperatively.
- Intraoperative Consideration: Patient monitoring on an ongoing basis is sufficient. In the event of bradycardia, the surgeon must be alerted to lessen the stretch on the spermatic cord, and if it does not get better, 1 mg of atropine should be administered.
- Anesthetic Consideration: For a radical orchiectomy, neuraxial anesthesia has been recommended as the anesthetic method of choice. Sedation must be applied to the neuraxial blockade, the sensory block level must be Th10, and the sensory block must be minimized to psychiatric trauma. It is necessary to select general anesthesia for the RPLND operation. High-level sensory block (Th4) along with sedation must be carried out if the neuraxial blockade is chosen if general anesthesia is not recommended.
Conclusion:
Elderly patients and patients with a range of diseases are both included in urologic procedures. Therefore, in terms of preoperative assessment, intraoperative treatment, and postoperative care, the general collaboration between the urologist and the anesthesiologist is necessary. Better outcomes, a higher standard of rehabilitation, and greater patient satisfaction result from a personalized, optimized strategy.
