UROLOGY

Anaesthesia for urological Learning objectives

surgery After reading this article, you should be able to:
Hazem H Alaali
C formulate an anaesthetic plan and analgesic regime for the
management of common urological procedures
Michael G Irwin C identify the clinical manifestations of transurethral resection of
the prostate syndrome and know how to manage it
C name commonly used drugs in anaesthesia with a potential for
Abstract
Anaesthesia is commonly used to facilitate urological procedures and significant accumulation in patients with renal impairment or
many patients are elderly with multiple co-morbidities. Urological proce- that may induce nephrotoxicity
dures range from minor day case to major surgery in which extensive re-
sources are needed both intra- and postoperatively. For simple day case
procedures like cystoscopy or ureteroscopy, general anaesthesia is most morbidities and to assess the degree of major organ function.
commonly used because it allows for early ambulation. Transurethral Exercise tolerance is a good predictor of propensity to post-
resection of the prostate (TURP) needs special attention. TURP syndrome operative complications and can be assessed as metabolic
due to excessive absorption of the irrigation fluid can be catastrophic if equivalent tasks (METs) where 1 MET is the metabolic equiva-
not managed early. Avoiding contributing factors and choosing regional lent of a resting adult. Under 4 METs, or the inability to walk up
anaesthesia which allows for early detection are key. Careful perioperative two flights of stairs, is associated with increased risk.
planning and risk stratification is important in major urological cancer sur- Special attention should be paid to the drug history and their
gery. Most of these procedures will require general anaesthesia (due to effects on renal function.
longer operative time and more extensive surgical trauma). Postoperative Physical examination and laboratory investigations can be
pain management in the form of epidural or patient-controlled multi- performed based on history and physical examination. Most
modal analgesia are essential. Postoperative high-dependency care is perioperative medical complications involve the cardiac and/or
beneficial. respiratory systems so these deserve special attention. Renal
Keywords General anaesthesia; postoperative care; preoperative function may also be compromised and many patients will
assessment; regional anaesthesia; surgery; transurethral resection of require testing preoperatively.
prostate syndrome; urology The lithotomy position is most commonly used during uro-
logical surgeries and patient suitability for this may need to be
Royal College of Anaesthetists CPD matrix: 3A03 assessed and any limitation of movement in hip/knee joints
documented.

Intraoperative care

Introduction Standard American Society of Anesthesiologists (ASA) moni-

toring (non-invasive blood pressure (NIBP), electrocardiography
Anaesthesia is commonly used to facilitate urological procedures
(ECG), pulse oximetry, capnometry, temperature) should be used
and many patients are elderly with multiple co-morbidities.
in all patients. Further more invasive monitoring will depend on
Urological procedures range from minor day case procedures, the type of surgery and patient co-morbidity.
to major surgery in which extensive resources are needed both For obvious anatomical reasons, urological surgery is a field
intra- and postoperatively (high-dependency unit (HDU)/inten- where regional anaesthesia is widely practised. Benefits of
sive care unit (ICU)). Consequently anaesthesia may encompass
regional anaesthesia include lesser effects on the respiratory
local, monitored anaesthesia care (MAC), regional or general
function, faster postoperative oral intake, pain relief, a lower
techniques.1
incidence of postoperative deep vein thrombosis (DVT), and
easier detection of neurological symptoms during transurethral
Preoperative assessment resection of the prostate (TURP) surgery (see below).
A thorough assessment of the patient history, including any General anaesthesia (GA) is mostly chosen for very short
anaesthetic records, is important in detecting any underlying co- procedures (day case cystoscopy), for lengthy major surgery
(radical cystectomy, nephrectomy) or when particular posi-
tioning is required (e.g. lateral or head down). It is, of course,
possible to combine regional and general anaesthesia with the
Hazem H Alaali BSc MD CABA is a Fellow in Anaesthesiology, University of
use of epidural techniques. This can have the advantage of
Hong Kong, Hong Kong. He is also a Chief Resident in Anaesthesia at
reducing general anaesthetic drug requirements and can facilitate
Salmaniyah Medical Complex, Kingdom of Bahrain. Conflict of interest:
more prolonged postoperative analgesia. Epidural anaesthesia
none declared.
can also help reduce intraoperative blood loss and bowel
Michael G Irwin MB ChB MD FRCA FANZCA FHKAM is Professor and Head, distension during pelvic and intra-abdominal cancer surgery.
Department of Anaesthesiology, University of Hong Kong, Hong Kong, Renal function may be impaired and, therefore, it is prudent to
Chief of Service of the Department of Anaesthesiology, Queen Mary choose drugs which are not likely to further compromise renal
Hospital, Hong Kong. Conflicts of interest: none declared. function and which are not metabolized in the kidney (Table 1).

ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 1 Ó 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Alaali HH, Irwin MG, Anaesthesia for urological surgery, Anaesthesia and intensive care medicine (2015),
http://dx.doi.org/10.1016/j.mpaic.2015.03.004
 UROLOGY

fibrescope under local anaesthesia (lignocaine lubricant gel) with

Commonly used drugs in anaesthesia with a potential or without mild sedation. Rigid cystoscopy is indicated for the
for significant accumulation in patients with renal diagnosis of the lower GU pathology, and/or dilatation of ure-
impairment thral strictures.
General anaesthesia in the lithotomy position is most
Muscle relaxants Rocronium, vecronium commonly used as most of these procedures are short day cases
Analgesics Pethidine, morphine requiring early ambulation. Spinal anaesthesia may also be used
Induction agents Barbiturates and one must ensure a block to around the T10 dermatome to
Anticholinergics Atropine, glycopyrolate achieve satisfactory conditions for surgery.
Cholinesterase inhibitors Neostigmine, edrophonium
Antibiotics Penicillins, cephalosporins, Transurethral resection of the prostate (TURP)
aminoglycosides,
vancomycin Benign prostatic hyperplasia occurs in around 40% of men above
Antihypertensives Clonidine, methyldopa, hydralazine, 60 years old so, consequently, transurethral resection of the
diuretics prostate is the most common surgical intervention in the uro-
Miscellaneous Inotropes, digoxins surgical patients. During the procedure, a resectoscope is inser-
ted through a modified cystoscope and facilitates the prostatic
Table 1 tissue to be cut and coagulated. Significant bleeding may occur
due to opening of venous sinuses.
Where this is not possible, then the pharmacodynamic effects Various complications can develop during the procedure. The
must be closely monitored. For example muscle relaxants such as most important of these is bleeding and TURP syndrome. Other
atracurium or cistracurium would be preferable to rocuronium, complications may include hypothermia, bladder perforation,
but if there was a good reason to use rocuronium then neuro- coagulopathy and postoperative sepsis.
muscular function can be assessed and the effects reversed with Patients are usually elderly (>60 years) with multiple co-
sugammadex if necessary. Suxamethonium is best avoided in morbidities. Chronic renal impairment is not unusual in the
patients with renal impairment in which serum potassium may elderly and where there has been significant urinary tract outflow
be raised. obstruction. A detailed pre-anaesthesia check must be per-
Non-steroidal anti-inflammatory drugs (NSAIDs) and cyclo- formed. The mortality for TURP ranges between 0.5 and 0.7%
oxygenase 2 inhibitors (coxibs) can interfere with renal autor- mainly due to heart failure, pulmonary oedema and renal failure.
egulation. Total intravenous anaesthesia (TIVA) with propofol Cross-matched blood should be available.
and remifentanil is safe in renal dysfunction. Patients may be Care must be taken during patient positioning (lithotomy).
more sensitive to the pharmacodynamic effects in the presence of Two people are needed to move the legs simultaneously up or
uraemia and protein binding may be reduced leading to higher down to avoid stressing the spinal ligaments. Pressure points
free drug fractions. Consequently careful titration of drugs with must be padded, most importantly to avoid the straps of the legs
target-controlled infusion (TCI) is a suitable technique. from exerting excessive pressure on contact points. Iatrogenic
Postoperative nausea and vomiting (PONV) is not a particular nerve palsies recorded before include: injury to the common
problem for this type of surgery but can be reduced by good pain peroneal nerve (loss of dorsiflexion of the foot) due to strap
management (minimizing opioid use, where possible), adequate pressure against the head of the fibula; injury to the saphenous
hydration and prophylactic antiemetic use. nerve (numbness of the medial calf) due to tight straps over the
medial aspect of the legs; and injury to the obturator component
Postoperative care of the femoral nerve due to excessive flexion of the thigh against
the groin.
Postoperative pain management aims to provide good analgesia
Unless contraindicated, regional anaesthesia (single sub-
with little or minimal residual sedation to facilitate faster
arachnoid injection) is the recommended popular technique for
discharge. For day case procedures, short-acting opioids like
TURP, as it allows early identification of the neurological mani-
fentanyl along with paracetamol can be safely used.
festation of TURP syndrome. Also the vasodilatation produced
Postoperative pain management in inpatients usually includes
and the venous pooling helps reduce the circulatory overload,
patient-controlled analgesia (PCA) or epidurals. If PCA is to be
and decreases the incidence of postoperative DVT. If GA is
used, one should keep in mind the renal functions and the cu-
chosen, it is best achieved with controlled ventilation via a
mulative effects of opioid metabolites. Some anaesthetists
supraglottic airway device. High airway pressures must be
advocate using fentanyl rather than morphine as fentanyl has no
avoided as this increases bleeding from the prostatic bed. A large-
active metabolites, whereas morphine is metabolized by the liver
calibre intravenous cannula is sited in case of significant
to morphine-6-glucuronide (M6G) which is then excreted by the
bleeding. A forced air warmer, fluid warmer and body temper-
kidneys.2 Drugs like paracetamol can be used safely.
ature irrigation fluids should be used to maintain normothermia.
Endoscopic procedures of the lower genitourinary tract TURP syndrome
Examination of the bladder and lower genitourinary (GU) tract TURP syndrome refers to the symptoms and signs that occur as a
are very common procedures both for the diagnosis and treat- result of the absorption of large amounts of irrigation fluid. It can
ment of diseases. Cystoscopy can be performed with a flexible present either intra- or postoperatively. Prompt recognition and

ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 2 Ó 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Alaali HH, Irwin MG, Anaesthesia for urological surgery, Anaesthesia and intensive care medicine (2015),
http://dx.doi.org/10.1016/j.mpaic.2015.03.004
 UROLOGY

During regional anaesthesia, the patients may complain of

Ideal irrigation fluid nausea, chest tightness, shortness of breath, dizziness, restless-
ness, confusion and blurring of vision. These signs will, of course,
C Isotonic (prevent haemolysis) be masked by general anaesthesia and diagnosis delayed. Patients
C Electrically inert (prevent current dissipation from diathermy) may have an increase or decrease in blood pressure with refractory
C Transparent (no impairment of surgical field visualization) bradycardia. On the ECG nodal rhythm, ST segment changes, U
C Sterile (prevent infection) waves and widening of the QRS complexes may be observed.
C Inexpensive The best way to manage TURP syndrome is to prevent it.
Box 1 Avoiding contributing factors (see above) and choosing regional
anaesthesia which allows for early detection are important.
treatment are essential to limit morbidity and mortality associ-
ated with this condition (Box 1).3
Laser prostatectomy
Many factors contribute to the development of TURP syn-
drome. The ideal type of irrigation fluid is shown in Box 2; A laser can be used to destroy the enlarged prostate tissue as a
(surgery should ideally be less than 1 hour); the hydrostatic minimally invasive procedure and an alternative to TURP. A
pressure of the irrigation fluid should be less than 60 cm above Cochrane review5 of 20 studies involving 1898 subjects found laser
the heart level; and the prostatic venous pressure should not be techniques to be useful and relatively safe alternatives to TURP.
low (maintain normovolaemia). The small number of enrolled subjects and differences in study
The average amount of irrigation fluid absorbed is 20 ml/ design limit any definitive conclusions regarding which type of
minute (1e1.5 litres during the average procedure (1 hour)), but laser technique is the most effective. Improvements in symptoms
this may increase if the precautions listed above not taken into and urine flow slightly favoured TURP, though laser procedures
consideration. had fewer side effects and shorter hospitalization times. The
However, no ideal irrigation solution exists. Most commonly follow-up durations of these studies ranged from 6 to 36 months
used solutions are 1.5% glycine (288 mmol/litre), 2.7% sorbitol and men with extremely large prostates were generally excluded
(195 mmol/litre) or 3% mannitol. Among them, glycine is most from the trials. The risk of needing a reoperation for recurrent
commonly used. Glycine is a non-essential amino acid, metabo- symptoms was higher following laser procedures. Study results
lized in the liver to ammonia. It has some cardiac and central were insufficient to adequately compare laser techniques with
nervous system toxicity and is an inhibitory neurotransmitter in other minimally invasive procedures. More studies, using ran-
the retina. A large amount of glycine slows down the transmission domized treatment assignment, enrolling larger numbers of sub-
of impulses from the retina to the cerebral cortex causing transient jects, and comprehensive measures of treatment effectiveness and
blindness in some cases (resolves spontaneously within 24 hours). side events, are needed to better define the long-term safety and
The use of glycine solution with a tracer amount of ethanol for durability of laser techniques for treating lower urinary tract
detecting and quantifying irrigating fluid absorption has been symptoms associated with benign prostatic obstruction.
pioneered by Hahn and his colleagues in Sweden.4 Alcometers The anaesthetic management of laser prostatectomy is similar
can be used easily during both general anaesthesia and regional to TURP, with the benefit of less fluid absorption so that the risk
to help in early detection of glycine toxicity. of TURP syndrome is reduced. Also, the precise laser beam
causes less bleeding compared to the ordinary resectoscope.

Endoscopic procedures of the upper genitourinary tract

Management of TURP syndrome Ureteroscopy is used to outline the anatomy of the upper urinary
tract and kidneys, remove renal calculi, stent the ureters and for
C Notify the surgeon renal biopsies.
C Stop surgery after coagulating bleeding points Most of these patients have renal impairment secondary to GU
C Airway, Breathing, Circulation tract obstruction, so renal function should be checked.
C Supplementary oxygen and ventilate if needed Generally these are done as day case procedures in the li-
C Fluid restriction thotomy position under general anaesthesia without muscle
C Check urea, electrolytes, haemoglobin and arterial blood gases relaxation (often using a laryngeal mask airway). Postoperative
C Frusemide 20 mg IV pain is usually mild and can be easily managed with simple
C Mild hyponatraemia (Na >120), fluid restriction may suffice analgesics such as paracetamol. As usual, NSAIDs will be con-
C Severe hyponatraemia (Na <120), use hypertonic saline traindicated in the presence of renal insufficiency.
C Slow correction (<0.5 mmol/hour), to avoid central pontine
myelinosis
Percutaneous stone removal
C Seizures: anticonvulsant, e.g. midazolam, diazepam or
thiopentone This is indicated for the removal of large (staghorn) stones. Pa-
C Hypotension: inotropic support and invasive monitoring tients are usually healthy but may have had haematuria which
C Admit to intensive care unit postoperatively may require a full blood count check if severe. As before, renal
obstruction can result in impairment of function.
TURP, transurethral resection of the prostate.
The procedure first involves stenting of the ureter (in the li-
Box 2 thotomy position), then the patient is placed prone to insert a

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Please cite this article in press as: Alaali HH, Irwin MG, Anaesthesia for urological surgery, Anaesthesia and intensive care medicine (2015),
http://dx.doi.org/10.1016/j.mpaic.2015.03.004
 UROLOGY

guide wire percutaneously into the renal pelvis to conduct the rotation from side to side is needed to assist surgical exposure.
nephroscope. There is a risk of CO2 absorption from the peritoneum. The
Due to the prone position, general anaesthesia with the use of surgeon may ask for injection of a dye (indigo carmine to visu-
a reinforced endotracheal tube is a suitable technique. Special alize the ureters) and this can cause changes in the blood pres-
attention should be paid to appropriate protection and padding sure. As surgery is prolonged with high intra-abdominal
for pressure points such as the eyes, nose and nerves, and pressures and involves the pelvic region, DVT prophylaxis must
keeping the head in the neutral position. It is also important to be ensured.
document that such measures have been taken. The chest and There has been growing interest in the last few years in
pelvis must be supported while the abdomen is free. laparoscopic and robot-assisted prostatectomy. These procedures
Postoperative pain can be managed with opioids and/or are less invasive and produce a quicker recovery and return to
paracetamol. Again, NSAIDs are avoided if there is impaired daily activities. The blood loss is markedly reduced especially
renal function. A chest radiograph can be ordered if there is a with robotic surgery. The anaesthetic implications are similar to
suspicion of pneumothorax. other laparoscopic surgical procedures, although the operations
can be quite long and may necessitate a prolonged time in the
Major (radical) surgery head down, trendelenburg position. Patients can be managed
postoperatively in the general ward.
There is a wide variety of major urological procedures per-
formed, mainly for the treatment of tumours of the GU tract.
Nephrectomy
Such surgery requires careful perioperative planning and risk
stratification in order to formulate a management strategy. Nephrectomy is a major procedure performed to remove renal
The main concerns are long operative time, fluid and blood tumours or non-functioning kidneys. It may also be used to
loss with consequent possible blood transfusion, large surgical retrieve healthy kidneys for living related organ donation. Apart
incision and the need for more aggressive pain management. from the healthy kidney donors, most of patients presenting for
This is coupled with a generally elderly patient population and a nephrectomy have impaired renal function. Some may have a
more marked surgical stress response. Most of these procedures paramalignant syndrome such as polycythaemia, hypercalcaemia
will require general anaesthesia (due to longer operative time or hypertension. General anaesthesia is usually required because
and more extensive surgical trauma). Contemporaneous epidural of the long operative time as well as patient discomfort from the
analgesia is a useful addition as it reduces intraoperative position. Most nephrectomies are performed in the modified
anaesthetic drug requirements, reduces respiratory complica- lateral position with a kidney rest under the iliac crest (Figure 1).
tions, facilitates weaning and produces excellent postoperative The loin is hyperextended over the table break to open the flank
analgesia. Patient-controlled multimodal analgesia is an accept- space, and the upper arm is suspended above the patient. It is
able alternative. Cross-matching of enough blood units and important to ensure that arms are not overstretched. Potential
maintaining normothermia with fluid and forced air warming intraoperative complications include massive bleeding, hypo-
devices is mandatory. As most surgery is neoplastic, cell saver tension due to the position causing retraction of the inferior vena
devices are seldom used. A large-bore intravenous cannula is cava (IVC), and pneumothorax due to opening of the pleura
inserted and invasive monitoring such as arterial and/or central during surgery. Occasionally the tumour may involve the IVC
venous line insertion can be considered depending on the extent necessitating the clamping leading to hypotension. In rare cases
of surgery and co-morbidity. Point of care testing for arterial of extensive tumour extension, thoracotomy may be needed,
blood gases and blood parameters (Hb, electrolytes, and coagu- while very rare cases where IVC thrombosis has spread to the
lation) can be useful. Prearrangement of an HDU or ICU bed is
advisable.

Radical prostatectomy
Prostatic carcinoma is the most commonly diagnosed cancer in
men and is present in 75% over 75 years old and. Radical
prostatectomy is indicated under the age of 70 years with local-
ized disease and who have a life expectancy of at least 10 years.
As the name implies, it involves removing the whole prostate
gland, the seminal vesicles, the ejaculatory ducts and a portion of
the bladder neck. The patient is placed in the hyperextended
supine position with the iliac crest over the break in the operating
table. Care must be taken not to put excessive strain on the back.
The operating room table is also tilted head down to make the
operative field horizontal.
Precautions for rapid fluid and blood administration must be
in place. Epidural analgesia is useful as described above.
Many surgeons will combine radical prostatectomy with
laparoscopic pelvic lymph node dissection. Here there are added Figure 1 Modified lateral (hyperextended) position using a kidney rest
concerns. Often a steep head down Trendelenburg position and under the iliac crest to improve the exposure of the flanks.

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Please cite this article in press as: Alaali HH, Irwin MG, Anaesthesia for urological surgery, Anaesthesia and intensive care medicine (2015),
http://dx.doi.org/10.1016/j.mpaic.2015.03.004
 UROLOGY

heart, cardiopulmonary bypass may even be needed. Epidural hyperchloraemic metabolic acidosis and hypokalaemia second-
analgesia is recommended in radical nephrectomy. Other options ary to urinary absorption from the gastrointestinal tract. Ileus is
include a paravertebral block (single shot or continuous via a very common and nasogastric drainage may be helpful.
catheter), PCA and/or regular paracetamol. NSAIDs are generally
avoided due to the poor renal reserve in these patients and po- Minor urological procedures
tential for bleeding.
Circumcision: in babies younger than 3 months, it can be per-
Laparoscopic nephrectomy has become the standard of care
formed as day case surgery under local anaesthesia in the form of
now in many places for the removal of small kidney tumours.
a dorsal penile nerve block or caudal epidural block.7 Older
Also, laparoscopic donor nephrectomy is increasingly becoming
children usually require general anaesthesia with a block for
the preferred method in kidney retrieval.6 The procedure requires
postoperative pain management with paracetamol or NSAIDs as
the patient to be in the lateral decubitus position with intra-
required.
abdominal insufflation of CO2 and its attendant effects. Major
complications include sepsis, bowel injury, rhabdomyolysis and
Orchidectomy: is indicated in case of injury, torsion or to treat
acute renal failure. The procedure may be converted to open and
testicular carcinoma. General anaesthesia with supraglottic
the anaesthetist should explain this to the patient beforehand and
airway can be chosen. Supplemental ilioinguinal block may be
have a clear plan should this eventuate.
performed to help reduce the need for postoperative pain
medications. A
Radical cystectomy
This involves excising the urinary bladder and forming a urinary
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operatively, the most commonly encountered complication is

ANAESTHESIA AND INTENSIVE CARE MEDICINE --:- 5 Ó 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Alaali HH, Irwin MG, Anaesthesia for urological surgery, Anaesthesia and intensive care medicine (2015),
http://dx.doi.org/10.1016/j.mpaic.2015.03.004