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Part 1 book “Handbook of clinical anaesthesia” has contents: Respiratory system, cardiovascular system, central nervous system, gastrointestinal tract, genitourinary tract, endocrine system, connective tissue, abdominal surgery, gynaecological surgery, obstetric surgery, thoracic surgery,… and other contents.
Handbook of Clinical Anaesthesia Fourth Edition Edited by Brian J Pollard Gareth Kitchen CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2018 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S Government works Printed on acid-free paper International Standard Book Number-13: 978-1-4987-6289-2 (Paperback); 978-1-138-05799-9 (Hardback) This book contains information obtained from authentic and highly regarded sources While all reasonable efforts have been made to publish reliable data and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made The publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and not necessarily reflect the views/opinions of the publishers The information or guidance contained in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines Because of the rapid advances in medical science, any information or advice on dosages, procedures or diagnoses should be independently verified The reader is strongly urged to consult the relevant national drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing any of the drugs, devices or materials mentioned in this book This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and treat patients appropriately The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and apologize to copyright holders if permission to publish in this form has not been obtained If any copyright material has not been acknowledged please write and let us know so we may rectify in any future reprint Except as permitted under U.S Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright com/) or contact the Copyright Clearance Center, Inc (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400 CCC is a not-for-profit organization that provides licenses and registration for a variety of users For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com For Claire, Mum and Dad, your unwavering support makes endeavours like this possible To my children, Joseph and Amelia – follow your dreams; anything is possible GK For all of our patients May this book improve both your safety and your experience of anaesthesia BJP http://taylorandfrancis.com Contents Preface vii Contributors ix List of abbreviations xiii PART 1 PATIENT CONDITIONS 1 Respiratory system Matthew Stagg Cardiovascular system Redmond P Tully and Robert Turner Central nervous system Eleanor Chapman Gastrointestinal tract Matthew James Jackson Genitourinary tract Brian J Pollard and Gareth Kitchen Endocrine system Brian J Pollard and Gareth Kitchen The blood Alastair Duncan and Santosh Patel Bones and joints Brian J Pollard and Gareth Kitchen Connective tissue John-Paul Lomas PART 2 SURGICAL PROCEDURES 37 91 129 145 163 197 225 243 277 10 Abdominal surgery 279 Brian J Pollard and Gareth Kitchen 11 Gynaecological surgery 305 Amy Hobbs, Sophie Kimber Craig and Patrick Ross 12 Obstetric surgery 317 Amy Hobbs and Sophie Kimber Craig 13 Urology339 Matthew James Jackson 14 Neurosurgery 353 Eleanor Chapman 15 Thoracic surgery 375 Matthew Stagg 16 Cardiac surgery 391 Akbar Vohra v Contents 17 Vascular surgery 423 Redmond P Tully 18 Ophthalmic surgery 439 Roger Martin Slater 19 ENT surgery 457 Ross Macnab, Katherine Bexon, Sofia Clegg and Adel Hutchinson 20 Head and neck surgery 475 Ross Macnab and Katherine Bexon 21 Plastic surgery 491 Brian J Pollard and Gareth Kitchen 22 Orthopaedics 503 Robert Peter Loveridge 23 Transplantation 513 Richard Wadsworth, Greg Cook, Andrew Roscoe, Zoka Milan, Ross Macnab and Kailash Bhatia 24 Paediatrics 533 Bernadette Lomas PART 3 ANAESTHETIC FACTORS 547 25 Preoperative assessment 549 Santosh Patel and Tom Wright 26 Airway591 Cyprian Mendonca, Narcis Ungureanu, Aleksandra Nowicka, William Tosh, Benjamin Robinson and Carol L Bradbury 27 Equipment and monitoring 623 Baha Al-Shaikh, Sarah Hodge, Sanjay Agrawal, Michele Pennimpede, Sindy Lee, Janine MA Thomas and John Coombes 28 Techniques: General 645 Baha Al-Shaikh, Sanjay Agrawal, Sindy Lee, Daniel Lake, Nessa Dooley, Simon Stacey, Maureen Bezzina and Gregory Waight 29 Techniques: Regional 663 Robert Peter Loveridge 30 Management problems 679 Clifford Shelton Index 749 vi Preface Welcome to the fourth edition of the Handbook of Clinical Anaesthesia We have retained the overall structure as in the first three editions The book continues to be a collection of individual entries each covering a particular topic, condition or problem which may be encountered in clinical anaesthesia The philosophy of the book has been retained in that all of the information is presented in a concise form without unnecessary information or ‘padding’ Over its lifespan between the first and the fourth editions, this book has undergone a significant evolution which we believe has served to improve it The original idea was conceived by John Goldstone and Brian J Pollard in 1994 John unfortunately had to withdraw from the project at the second edition For the fourth edition a second editor has been introduced again, Dr Gareth Kitchen The choice of Gareth is clear He is a young academic anaesthetist who has been able to instil new thoughts into the book and assist in driving it forwards and bringing on board a number of new names as experts in their fields In the first two editions, the authors of the various sections and monographs were drawn almost exclusively from the UK In the third edition, the authorship was widened into a much more international field In this fourth edition, we have returned to it being a UK-based field for the authors Not only that but as we, the editors, are based in the Northwest, we have selected our authors principally from this area as there is a huge amount of expertise here Remember that this book is not an exhaustive treatise It does not cover every eventuality; no book can that The Handbook of Clinical Anaesthesia is a distillation of facts and guidance and is intended to complement the major texts in the subject Individual entries are referenced where appropriate but the references are limited to a small number of key sources and include up-to-date reviews wherever possible Over the years this book has proved popular with trainees preparing for examinations in the speciality It has also proved very popular with established consultants and specialists who keep it beside the phone, on the office desk or in the operating theatre suite for straightforward advice on problems or situations encountered Finally, we would like to pay tribute to the many authors involved in the first three editions of this book A significant proportion of their text and information has been retained where the advice has not materially changed Many sections have nevertheless been rewritten as appropriate and updated as necessary The authors involved in the first three editions are too numerous to mention but to each and every one we thank you for your input to the previous editions and hope that you approve of this new version and its updated information BJP and GK vii http://taylorandfrancis.com Contributors Sanjay Agrawal FRCA Specialist Registrar William Harvey Hospital Ashford, Kent, UK Baha Al-Shaikh FRCA FCAI Consultant Anaesthetist and Visiting Professor William Harvey Hospital Ashford, Kent, UK Kailash Bhatia MBBS FRCA EDRA DA DNB Consultant Anaesthetist Central Manchester University Hospitals and St Mary’s Hospital Manchester, UK Greg Cook MBChB FRCA FFICM Consultant in Anaesthesia and Intensive Care Medicine Manchester Royal Infirmary Manchester, UK John Coombes MBBS FCAI Specialist Registrar William Harvey Hospital Ashford, Kent, UK Sophie Kimber Craig MBChB FRCA Consultant Anaesthetist Bolton NHS Foundation Trust Bolton, UK Maureen Bezzina MD Specialist Registrar William Harvey Hospital Ashford, Kent, UK Nessa Dooley FRCA Clinical Fellow Bart’s Heart Centre London, UK Katherine Bexon BMedSci BMBS FRCA Consultant in Anaesthesia Central Manchester University Hospitals NHS Foundation Trust Manchester, UK Alastair Duncan MBChB MSc FRCA Specialty Trainee in Anaesthesia North West Deanery, UK Carol L Bradbury FRCA Specialist Registrar in Anaesthesia University Hospitals Coventry and Warwickshire Coventry, UK Eleanor Chapman MBChB BSc FRCA Consultant Anaesthetist Salford Royal Foundation Trust Salford, UK Sofia Clegg MbChB FRCA Consultant in Anaesthesia Central Manchester University Hospitals NHS Foundation Trust Manchester, UK Amy Hobbs MBChB BSc FRCA Consultant Anaesthetist Bolton NHS Foundation Trust Bolton, UK Sarah Hodge FRCA Specialist Registrar William Harvey Hospital Ashford, Kent, UK Adel Hutchinson MBChB BSc (hons) FRCA Consultant in Anaesthesia Central Manchester University Hospitals NHS Foundation Trust Manchester, UK ix Obstetric surgery Royal College of Obstetricians and Gynaecologists (2015) Green Top Guideline 37b: Thromboembolic disease in pregnancy and the puerperium: Acute management Royal College of Anaesthetists (2011) Providing equity of critical and maternity care for the critically ill pregnant or recently pregnant woman 338 CROSS-REFERENCES Massive blood transfusion, Chapter 30 Amniotic fluid embolism, Chapter 30 Cardiomyopathy, Chapter Obstetric anaesthesia – general principles, Chapter 12 13 Urology MATTHEW JAMES JACKSON Anaesthesia for urological surgery – general principles 339 References 341 Cystectomy 342 References 343 Cystoscopy 343 Reference 344 Nephrectomy 344 References 346 Penile surgery 346 Reference 347 Percutaneous nephrolithotomy 347 References 348 Radical prostatectomy 348 References 350 Transurethral resection of prostate (TURP) 350 References 351 ANAESTHESIA FOR UROLOGICAL SURGERY – GENERAL PRINCIPLES high-risk patients undergoing low-risk surgical procedures; or medium-risk patients undergoing long and complex surgeries A wide spectrum of patients presents for urological surgery; procedures range from minor day-case operations to large open surgeries The majority of patients are elderly with multiple comorbidities Most surgeries are undertaken to treat or investigate cancer The incidence of urological cancer is increasing As techniques advance, an increasingly elderly population is presenting for operative management Reassuringly survival rates for most conditions are also improving Many patients presenting for urological surgery will require repeat procedures Urologists have historically used endoscopic techniques through natural orifices They are pioneering new minimally invasive techniques and are at the forefront of robot-assisted surgery With an increasing case load, the need for anaesthetists skilled in providing anaesthesia for urological surgery is increasing The challenges of urological anaesthesia are typically a high turnover list with PREOPERATIVE ASSESSMENT Patients are typically: • Male • Over 50 years of age • High incidence of chronic disease Preoperative assessment will be dictated by the nature of the surgery Patients undergoing transurethral procedures with a rigid scope are often repeat attenders with multiple comorbidities Assessment should include history and examination to identify comorbidities and consideration of further investigations to quantify the severity of disease Where patients have already had a similar procedure, assessment should focus upon any deterioration of health in the intervening time In high-risk cases, the merits of nonsurgical management or undertaking 339 Urology the procedure with a flexible scope and no anaesthesia should be discussed with the surgeon Patients undergoing radical surgeries require a through preoperative assessment CPET is increasingly used to risk stratify patients and plan an appropriate level of perioperative care Comorbidities should be optimised, but should not unduly delay tumour excision Genitourinary pathologies may bleed insidiously or obstruct the tract; therefore, preoperative U&E and FBC are mandated in most patients Both radical surgeries and transurethral resections can result in large blood loss; patients should have blood samples taken for group and save and/or cross-match depending on local guidelines Premedication is rarely required In the majority of cases, a clear explanation of the procedure will alleviate anxiety When this does not suffice, a shortacting benzodiazepine may be used PERIOPERATIVE MANAGEMENT 340 Antibiotics are often requested This should be according to local hospital protocols Often gentamicin is chosen, which should be used with caution in patients with pre-existing renal failure Many procedures are performed in the lithotomy or Lloyd–Davis position A head-down tilt may be requested In elderly patients care should be taken when moving the legs as limited movement due to joint disease or risk of dislocating a prosthetic joint are common Laparoscopic urological surgery often requires a steep head down positioning and insufflation with carbon dioxide, the physiological sequelae of which should not be ignored There is splinting of the diaphragm resulting in atelectasis, reduction in FRC and ventilation-perfusion mismatch Raised intracranial pressure, raised intraocular pressure, reduced venous return and increased systemic vascular resistance are also possible Oedema of the head and neck is common and can result in cerebral oedema, laryngeal oedema and optic disc oedema Passive regurgitation, air embolism and bradycardia are additional complications Major urological surgery can last for up to about 6 hours Due to delicate skin and reduced muscle mass in the elderly, these patients are at high risk of pressure sores Extreme care should be taken to protect and check pressure points Where irrigation is used in a transurethral procedure, the irrigation fluid should be warmed to body temperature before infusion For larger surgeries, warmed intravenous fluids and at least one body warming device should be used throughout the operation These patients are moderate to high risk of DVT Due to the risk of bleeding and common use of neuraxial techniques, low molecular weight heparin is usually postponed until after the surgery is complete Graduated compression stockings and intermittent calf compression should be used ANAESTHETIC TECHNIQUE Minor procedures are normally undertaken spontaneously breathing on a laryngeal mask or under spinal anaesthesia There is no general evidence for one technique over the other; however, relative merits should be considered for individual patients Major procedures require general anaesthesia, mechanical ventilation through an endotracheal tube and invasive monitoring Wide bore vascular access should be placed Tranexamic acid has been used in many procedures to reduce blood loss The NICE has approved the use of cell salvage for radical prostatectomies and cystectomies There are early signals in the research literature that certain anaesthetic techniques may reduce the risk of recurrence in cancer surgery including total intravenous anaesthesia, epidural anaesthesia and avoidance of homologous blood transfusion MONITORING Routine AAGBI minimum standards are essential Additionally, in the following circumstances additional monitoring is required: • Inspired and expired oxygen, carbon dioxide, nitrous oxide and volatile anaesthetic agent (if used) and airway pressure, when general anaesthesia is used • Temperature, when the time from induction to emergence is anticipated to be over 30 minutes duration References • Peripheral nerve stimulator, if neuromuscular blocking drugs are used • Depth of anaesthesia monitoring when using total intravenous anaesthesia (TIVA) in the presence of a muscle relaxant For patients with a precarious cardiovascular system, or those undergoing major surgery an arterial catheter is essential for frequent sampling and haemodynamic monitoring Indications for the placement of a central venous catheter are few Cardiac output monitoring may be used to guide fluid management in larger surgeries COMPLICATIONS Complications can be as a result of pre-existing comorbidities or intraoperative events Perioperative myocardial infarction is not uncommon in this patient cohort Postoperative confusion is frequently seen Care should be taken with drug administration in patients with compromised renal function Where a hypotonic, nonionic irrigation fluid is used there is a risk of developing TURP syndrome Most urological surgeries have the potential for massive blood loss This could either be insidious ooze from the operative site or perforation of a major blood vessel Management should follow the local major haemorrhage protocols POSTOPERATIVE MANAGEMENT Many patients undergoing simple procedures require a period of postoperative bladder irrigation, which prevents same day discharge Patients undergoing large procedures may benefit from a period on HDU Enhanced recovery packages are frequently used by centres with a high caseload ANALGESIA Transurethral procedures are relatively painless, the urinary catheter being responsible for the majority of the discomfort For most, simple analgesics suffice Use caution when prescribing NSAIDS in this patient group Major surgery requires a robust multimodal approach to postoperative pain relief For open surgery, an epidural delivering local anaesthetic and opioid is the standard technique Rectus sheath catheters, wound catheters, paravertebral catheters and local infiltration with an opiate PCA are alternative techniques Laparoscopic and robot-assisted approaches are less painful; many of these operations not need epidural analgesia REFERENCES Checketts M, Alladi R, Ferguson K, Gemmell L, Handy J, Klein A, Love N, Misra U, Morris C, Nathanson M, Rodney G, Verma R, Pandit J (2015) Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland Anaesthesia 71(1): 85–93 Crescenti A, Borghi G, Bignami E, Bertarelli G, Landoni G, Casiraghi G, Briganti A, Montorsi F, Rigatti P, Zangrillo A (2011) Intraoperative use of tranexamic acid to reduce transfusion rate in patients undergoing radical retropubic prostatectomy: Double blind, randomised, placebo controlled trial BMJ 343: d5701–d5701 Jikke Bootsma AM, Pilar Laguna Pes M, Geerlings SE, Goossens A (2008) Antibiotic prophylaxis in urologic procedures: A systematic review Eur Urol 54(6): 1270–1286 Linder B, Frank I, Cheville J, Tollefson M, Thompson R, Tarrell R, Thapa P, Boorjian S (2013) The impact of perioperative blood transfusion on cancer recurrence and survival following radical cystectomy Eur Urol 63(5): 839–845 NICE (2008) Intraoperative red blood cell salvage during radical prostatectomy or radical cystectomy NICE interventional procedure guidance [IPG258] https://www.nice.org.uk/guidance / ipg258 CROSS-REFERENCES Nephrectomy, Chapter 13 Cystectomy, Chapter 13 Transurethral resection of the prostate, Chapter 13 Percutaneous nephrolithotomy, Chapter 13 Radical prostatectomy, Chapter 13 341 Urology Penile surgery, Chapter 13 Anaesthesia for the elderly, Chapter 25 Massive haemorrhage, Chapter 30 CYSTECTOMY Bladder cancer is the most common malignancy of the urinary tract; the incidence is four times higher in men than in women Tumours are divided into those which invade the muscle (muscle-invasive bladder cancer) and those that not (non-muscle-invasive bladder cancer) Trans-urethral resection of bladder tumour (TURBT) is the first-line treatment for patients with non-muscle-invasive bladder cancer This procedure is similar to trans-urethral resection of the prostate (TURP), as is the anaesthetic management During endoscopic resection, if the tumour lies over the obturator nerve electrocautery can cause adduction of the lower limb–muscle relaxation may be required The high rate of recurrence and progression after TURBT necessitates the use of adjuvant treatments, and repeat cystoscopies Radical cystectomy is predominantly performed for muscle-invasive bladder cancer; it is occasionally performed if a tumour in a surrounding structure is invading the bladder Preoperative radiation may be used prior to the surgery to shrink the tumour and is associated with increased intraoperative bleeding risk Radical cystectomy includes bilateral pelvic lymphadenectomy in addition to removal of the prostate and seminal vesicles in men and the uterus, ovaries and part of the anterior vaginal vault in women The flow of urine needs to be diverted This can be achieved by creating either a conduit or pouch from an isolated portion of the gastrointestinal tract into which the ureters are implanted Cystectomy is traditionally performed via an extensive midline incision Laparoscopic and robot-assisted approaches are becoming increasingly common due to decreased blood loss, reduced postoperative pain, early return of bowel function, and shorter hospital stay PREOPERATIVE ASSESSMENT 342 Patients for cystectomy are generally over 50 years of age, smokers and have had previous anaesthetics for cystoscopy • Systematic review and optimization of chronic disease states is important • An association between long-term cigarette smoking and bladder cancer; screen for other smoking-related conditions • Check full blood count and ensure that blood is available for transfusion Bladder tumours bleed insidiously and a low starting haemoglobin is not uncommon Large intraoperative blood loss occurs occasionally and the risk is higher in patients who have received preoperative radiotherapy • Tumours may obstruct the ureters causing hydronephrosis Request urea and electrolytes to evaluate renal function • Bowel preparation with powerful laxatives may be required Ensure that the patient is well hydrated and has maintained adequate oral intake of clear liquids the day before surgery An enhanced recovery approach is used at many centres PERIOPERATIVE MANAGEMENT • These are long operations often in frail patients • Maintain body temperature using warm operating theatre, warming blanket, warm air duvet, fluid warmer and humidification of inspired gases • Positioning is important In open surgery, male patients are positioned supine with the legs apart with gentle hyperextension Female patients are placed in lithotomy position to allow for access to the perineum All pressure points should be padded • Minimally invasive approaches use steep Trendelenburg ANAESTHETIC TECHNIQUE • General anaesthesia alone or combined with epidural anaesthesia is usual • Controlled hypotension may reduce intraoperative blood loss and transfusion requirements • Spinal or epidural anaesthesia may facilitate induced hypotension but can produce hyperperistalsis due to unopposed Cystoscopy parasympathetic activity and hinder the construction of the urinary reservoir • Measure CVP due to the potential for excessive blood loss and inability to measure urine output during the first part of the operation • The patient should be well hydrated to maintain a vigorous urine output once the ureters are implanted • As with any long procedure, the use of thromboembolic prophylaxis should be used MONITORING • • • • Routine minimal monitoring Invasive arterial pressure Central venous pressure (CVP) Oesophageal Doppler POSTOPERATIVE MANAGEMENT Patients may be cared for on a general ward or on HDU depending upon individual circumstances The management of postoperative pain is best achieved via an epidural infusion of low-dose local anaesthetic and opioids The prolonged contact of urine with bowel mucosa may produce significant metabolic disorders including electrolyte abnormalities, altered sensorium, osteomalacia, recurrent urinary tract infections and formation of calculi The electrolyte abnormalities seen depend on the segment of bowel used Treatment consists of administering alkalinising agents or chloride transport blockers As hyperkalaemia usually is present, treatment must involve both correction of the acidosis with bicarbonate and replacement of potassium This is a major operation The operative mortality is 1%–3% Continuous epidural analgesia may contribute to a lower postoperative mortality The overall complications rate after radical cystectomy and urinary diversion may be as high as 25%–35% REFERENCES Cheung G, Sahai A, Billia M, Dasgupta P, Khan M (2013) Recent advances in the diagnosis and treatment of bladder cancer BMC Med 11(1): 13 Hsu RL, Kaye AD, Urman RD (2013) Anesthetic challenges in robotic-assisted urologic surgery Rev Urol 15.4: 178–184 Novotny V, Hakenberg OW, Wiessner D, Heberling U, Litz RJ, Oehlschlaeger S, Wirth MP (2007) Perioperative complications of radical cystectomy in a contemporary series Eur Urol 51: 397–401 Wu CL, Hurley RV, Underson GF, Herbert R, Rowlingson AJ, Fleisher LA (2004) Effect of postoperative epidural analgesia on morbidity and mortality following surgery in medicare patients Reg Anesth Pain Med 29: 525–533 CROSS-REFERENCES The elderly patient, Chapter 25 Complications of position, Chapter 30 Blood transfusion, Chapter 30 Postoperative pain management, Chapter 30 CYSTOSCOPY Cystoscopy allows the visualisation and biopsy of the urethra and bladder mucosa via either a flexible or a rigid fibre-optic scope Flexible cystoscopy is normally an outpatient procedure Lubricant gel containing local anaesthetic is applied to the urethral meatus and the scope passed into the bladder The bladder is not distended, and therapeutic interventions are limited Rigid cystoscopy requires distention of the bladder, achieved with a constant stream of irrigation fluid It is uncomfortable and is therefore undertaken in theatre under anaesthesia Rigid cystoscopy is used for bladder biopsies, resection of bladder tumours, extraction of stones and placement of ureteral catheters (stents) Transurethral laser lithotripsy under local anaesthesia appears to be safe and effective for large bladder calculi TURP and ureteroscopy are performed with modified cystoscopes Cystoscopy is a short procedure Patients often return regularly for several years to monitor the lesion under investigation The management of carcinoma of the bladder by radiotherapy and intravesical chemotherapy ensures a steady supply of 343 Urology patients for this procedure These patients are often very knowledgeable about the procedure, and their wishes, particularly regarding premedication and regional blocks, should be heeded A small number of patients have disease that cannot be controlled and proceed to cystectomy PREOPERATIVE ASSESSMENT • Assess cardiovascular and respiratory systems • Assess renal function: urea and electrolytes • The lesion under investigation may be an insidious source of blood loss; request an FBC • If repeat cystoscopy, ask if there has been any change in health status since the last visit and check previous anaesthetic records • Assess suitability for day-case anaesthesia In high-risk patients, a discussion with the surgeon regarding the relative risks and benefits of using a flexible cystoscope is advised PERIOPERATIVE MANAGEMENT Both general anaesthesia (using a supraglottic airway and spontaneously ventilation) and spinal anaesthesia are used There is little evidence that either approach is superior Spinal anaesthesia is preferred in severe respiratory disease The patient will be required to lie flat or head down during the operation A block to T10 should be achieved General anaesthesia routinely uses propofol and a short-acting opiate followed by inhalational agent or TIVA Prophylactic antibiotics are often required The procedure is performed in the lithotomy or Lloyd–Davis position When lifting the legs take care not to dislocate previous joint replacements POSTOPERATIVE MANAGEMENT 344 Diagnostic and check cystoscopies where no resection has taken place not result in significant postoperative pain Paracetamol may be adequate If a biopsy has been taken, intraoperative supplementation with an intravenous analgesic will usually be sufficient Simple analgesics with an antiemetic are normally adequate REFERENCE Kara C, Resorlu B, Cicekbilek I, Unsal A (2009) Transurethral cystolithotripsy with holmium laser under local anesthesia in selected patients Urology 74: 1000–1003 CROSS-REFERENCES Diabetes mellitus, Chapter The elderly patient, Chapter 25 Day-case surgery, Chapter 25 Preoperative assessment of pulmonary risk, Chapter 25 Complications of position, Chapter 30 NEPHRECTOMY Renal cell carcinoma (RCC) is responsible for over 90% of tumours These present between the fourth and seventh decade The tumour commonly spreads to bone, lung and brain and can extend along the inferior vena cava (IVC) in 10% of cases Paraneoplastic syndromes (hypertension, polycythaemia, hypercalcaemia, nonmetastatic hepatic dysfunction) are found in 20% of patients with renal cell carcinoma In addition to cancer, nephrectomy may also be performed for hydronephrosis, trauma, shrunken kidney, hypertension chronic infection and in living donors Nephrectomy involves the removal of a kidney with or without part of the ureter In cases of radical nephrectomy the renal fascia, adrenal gland and regional lymph nodes are removed Nephrectomies may be open, laparoscopic or robot-assisted Thermal ablative therapies or partial resection are used to treat smaller tumours and preserve renal function in high-risk patients The open operation is carried out via a dorsal, anterior subcostal, flank, midline or thoracoabdominal incision The laparoscopic approach is gaining popularity While operating time is longer than in open approaches, it is associated with less pain and quicker recovery times It may be performed transperitoneal or retro-peritoneal; the patient is positioned laterally In cases of caval extension, input from vascular and cardiac surgeons may be required Nephrectomy The majority of patients with renal cell carcinoma are anaemic and there is potential for considerable blood loss with all approaches PREOPERATIVE ASSESSMENT • Exclude associated conditions – Anaemia, paraneoplastic syndromes, respiratory disease (cigarette smoking is a major risk factor), hypertension, hypercalcaemia • Perform a systematic review – CPET may be helpful in high risk patients • Evaluate the degree of renal impairment • Establish the extent of the lesions and the type of ablative therapy • Patients with suspected or proven urinary tract infection should receive 48 h of antibiotic therapy • Ensure the availability of blood When a large tumour is to be resected, preoperative blood transfusion may be required in anaemic patients PERIOPERATIVE MANAGEMENT As there are several surgical approaches, it is important to discuss with the surgeon which position is to be used Generally, the patient is placed laterally on the operating table with the side of operation uppermost The table is flexed such that the head and feet are both lowered to facilitate surgical access Careful positioning of the patient is important as it can be lengthy and the lateral position has a high risk of nerve and soft tissue damage In case of radical nephrectomy for excision of tumour thrombus, a thoracoabdominal approach may be necessary Cardiopulmonary bypass to prevent embolization may be required ANAESTHETIC TECHNIQUE General anaesthesia is required with endotracheal tube and controlled ventilation The lateral position results in a ventilation – perfusion mismatch In addition, there is a risk of surgical disruption of the pleura during the dissection Arterial line and wide-bore venous cannulae should be placed on the side of the tumour and well secured Blood should be readily available Tranexamic acid can be used to reduce bleeding; cell salvage is recommended, with a leuco-depleting filter used to administer salvaged red cells Fluids should be warmed and the patient placed on or under a warming device Thromboprophylaxis is necessary – graduated compression stocking and intermittent calf compression In renal cell carcinoma with thrombus, anaesthetic management is complex and may require massive blood transfusion (up to 50 units of packed red blood cells, plasma and platelets) MONITORING The potential for massive blood loss is an indication for invasive monitoring Central venous line is necessary in selected patients In addition to routine monitoring, blood loss, temperature and urine output are useful COMPLICATIONS Pneumothorax may occur during thoracoabdominal or flank incisions At the end of the procedure, several large-volume breaths may be given to attempt to detect any pleural leak If there is a pneumothorax, the pleural injuries should be repaired and a chest tube or drain inserted The physiological effects of a pneumoperitoneum or pneumoretroperitoneum are seen in laparoscopic approaches In patients with partial nephrectomy, complications include haemorrhage, urinary fistula, uretheral obstruction and renal insufficiency POSTOPERATIVE MANAGEMENT There is a risk of atelectasis in the dependent lung and postoperative physiotherapy is essential Most patients benefit from a period of level one care for the first 12–24 hours postoperatively Enhanced recovery principles can be used in high volume centres Long-term outcome depends largely on the aetiology of the renal damage and the type of procedure After radical nephrectomy, postoperative 345 Urology complications occur in approximately 20% of patients and the operative mortality rate is approximately 2% ANALGESIA Open nephrectomy is a painful operation and requires optimal multimodal pain relief Paracetamol should be used in all patients with NSAIDs where renal function allows Epidural analgesia via a low thoracic or high lumbar catheter is used to deliver local anaesthetic and low-dose opiates If an epidural is not possible, intercostal nerve blocks from T9 to T12, paravertebral blocks or wound-bed catheters in addition to patient controlled analgesia (PCA) may be used REFERENCES Conacher ID, Soomro NA, Rix D (2004) Anaesthesia for laparoscopic urological surgery Br J Anaesth 93: 859–864 El Galley R, Hammontree L, Urban D, Pierce A, Sakw Y (2007) Anesthesia for laparoscopic donor nephrectomy; is nitrous oxide contraindicated? J Urol 178: 225–227 Sener M, Torgay A, Akpek E, Colak T, Karakayali H, Arslaw G, Haberal M (2004) Regional versus general anesthesia for donor nephrectomy: Effects on graft function Transplant Proc 36: 2954–2958 CROSS-REFERENCES Blood transfusion, Chapter 30 Complications of position, Chapter 30 Kidney transplant, Chapter 23 PENILE SURGERY Penile surgery includes a wide range of surgeries that are performed for medical, religious and cosmetic reasons Circumcision is the most common surgery; other surgeries are briefly considered Circumcision is the surgical removal of the foreskin; it is commonly performed in children and 346 young adults It is used when nonsurgical measures have failed to manage phimosis, recurrent balanitis, paraphimosis, balanitis xerotica obliterans and penile cancer It may also be performed for religious reasons and has been shown to reduce the risk of HIV transmission Penile cancer is rare, occurring in men over 60 years old; it is associated with chronic inflammatory conditions of the penis The most common procedure is local resection using a carbon dioxide laser Larger tumours require wide local incision, subtotal and total excision of the penis Various grafts may be used to cover the deficit or staged reconstruction of the penis may be considered Cosmetic surgery is performed to improve the appearance of the penis Penile lengthening is most commonly achieved by dividing the suspensory ligament and then grafting skin to cover its new length Penile girth can be enhanced by injecting liposuction fat or by forming a flap PREOPERATIVE ASSESSMENT With the exception of patients presenting for penile cancer surgery, this patient group tends to be young and fit The preoperative visit should be used to elicit evidence of multisystem disease PERIOPERATIVE MANAGEMENT For the majority of patients, penile surgery will be undertaken as a day case Patients are positioned supine The surgery is short A spontaneously breathing technique using a laryngeal mask is appropriate for most patients General anaesthesia may be supplemented by a penile block or local anaesthetic infiltration Adrenaline should be avoided due to the risk of causing ischaemia In children, a caudal injection is performed asleep to provide postoperative analgesia POSTOPERATIVE MANAGEMENT The majority of patients can return to the day-case unit and be discharged with simple analgesics several hours after surgery Percutaneous nephrolithotomy REFERENCE Pereira N, Cabral A, Vieira R, Figueiredo A (2013) Conservative treatment of penile carcinoma – A retrospective study of 10 years An Bras Dermatol 88(5): 844–846 CROSS-REFERENCES General principles of urological surgery, Chapter 13 Blocks: penile block, Chapter 29 Day case surgery, Chapter 25 PERCUTANEOUS NEPHROLITHOTOMY Percutaneous nephrolithotomy is a procedure whereby stones in the renal tract are removed with a rigid or flexible endoscope via ultrasound-guided puncture and fluoroscopy-controlled placement of the endoscope A guidewire is inserted through a hollow needle and advanced into the collecting system Then tract dilation is performed over the guidewire At the completion of access tract dilation, a working sheath is left in place to accommodate the endoscope and drain the irrigation fluid The procedure is particularly indicated in patients with staghorn calculi, and lower pole calculi larger than 10 mm Patients with stones resistant to extracorporeal shock wave lithotripsy should also be treated by this process Small calculi are removed through the endoscope under direct vision using a forceps or a stone basket Stones larger than 1 cm require fragmentation by a lithotripsy device The most efficient are the ultrasonic and the pneumatic rigid lithotripters Morbidly obese patients in whom shock wave lithotripsy is impractical or technically impossible may also need to be treated in this way Ureteroscopy via the transurethral route allows an alternative approach to investigate ureteric disease and undertake treatments The scope is passed transurethrally and navigated into the ureter It may be used to inspect and biopsy the ureter as well as remove smaller distal stones and place ureteric stents Patients should have renal function evaluated prior to the procedure PREOPERATIVE ASSESSMENT • Exclusion of commonly associated medical conditions (Crohn’s disease, processed diet, metabolic syndromes) • Patients may have compromised renal function due to obstructive nephropathy: review renal function • Bacteriologic evaluation of the urine Urinary calculi may harbour bacteria • Antibiotic prophylaxis according to local guidelines • Correction of an existing coagulopathy • Antiplatelet medication should be discontinued days before procedure PERIOPERATIVE MANAGEMENT The patient is usually placed in the prone position with the stone-containing side elevated: • Protect the eyes, shoulders, knees, elbows • Place arm with intravenous access above the head (beware of brachial plexus strain) • The other arm with the BP cuff may be placed by the side • Place a pillow under the chest and pelvis to free the abdomen for ventilation • Place a pad under the flank to prevent a mobile kidney from rotating anteriorly in the prone position • Turn the head to the side to be punctured in order to prevent neck strain In high-risk patients, in order to minimize the haemodynamic and respiratory changes, a full lateral or a supine anterolateral position may be used It prevents the discomfort and ventilation difficulties of the prone position, particularly in obese patients ANAESTHETIC TECHNIQUE General anaesthesia is necessary when a lengthy procedure is planned For shorter procedures, a spontaneously breathing technique with a laryngeal mask is suitable Muscular paralysis is usually required because the patient will be placed prone or lateral and coughing must be avoided during renal 347 Urology puncture An armoured (reinforced) tracheal tube should be used if placed prone Spinal anaesthesia has been used safely in selected patients Intrathecal low-dose bupivacaine and fentanyl offers reliable neuraxial block Combined spinalepidural anaesthesia with a sensory block above T6 is an attractive alternative to general anaesthesia It has the advantage of shorter hospital stay, better patient satisfaction and superior postoperative pain relief Local anaesthesia from delivering the local anaesthetic through the access track combined with sedation is safe and effective in selected patients COMPLICATIONS Bleeding is the most significant complication The kidney is a very vascular organ and tears in the parenchyma may occur if the rigid scope is not handled with care Bleeding requiring transfusion is rare Most reports quote 3% About 0.5% of cases may require balloon tamponade of the tract or arterial embolization Extravasation of irrigation fluid may result from a tear in the pelvicalyceal system It is important, therefore, that normal saline is used as the endoscopic irrigation fluid Water and glycine can cause fluid intoxication because they are absorbed from the peritoneum Pleural complications can result from an intercostal puncture to reach an upper calyceal calculus The pleura may be entered and either a minor pleural reaction is seen or following endoscopy there could be a massive collection of irrigation fluid and air within the thoracic cavity Infection is the most serious complication and may be seen in 0.3%–2.5% of cases Infected stones may be disintegrated at percutaneous nephrolithotomy, releasing bacteria into the urine and potentially into the bloodstream Bacteraemia is unavoidable, but the time of the endoscopy should be limited to h for a large infected stone and 1.5 h in case of noninfected stone If Gram-negative septicaemia is suspected, the patient should be treated aggressively immediately POSTOPERATIVE MANAGEMENT Intravenous fluids should be given to increase urine output and flush out any gravel via the nephrostomy 348 left in situ Analgesia with opioids and NSAIDs if renal function is normal Peritubal infiltration of 0.25% bupivacaine solution is efficient in alleviating postoperative pain REFERENCES Atallah MM, Shorrab AA, Abdel Magled YM, Demian AD (2006) Low-dose bupivacaine spinal anaesthesia for percutaneous nephrolithotripsy: The suitability and impact of adding intrathecal fentanyl Acta Anaesthesiol Scand 50: 798–803 Jonnavithula N, Pisopati MV, Druga P, Krishnamurthy V, Chiumu R, Reddy B (2009) Efficacy of peritubal local anesthetic infiltration in alleviating postoperative pain in percutaneous nephrolithotomy J Endoural 23: 857–860 Karacalar S, Bolen CY, Sarihasan B, Sarikaya S (2009) Spinal epidural anesthesia versus general anesthesia in the management of percutaneous nephrolithotripsy J Endourol 23: 1591–1597 Mehrabi S, Karimzadeh Shirazi K (2010) Results and complications of spinal anaesthesia in percutaneous nephrolithotomy Urol J 7: 22–25 Munohar T, Jain P, Desai M (2007) Supine percutaneous nephrolithotomy: Effective approach to high-risk and morbidly obese patients J Endourol 21: 44–49 CROSS-REFERENCES Blood transfusion, Chapter 30 Complications of position, Chapter 30 TUR syndrome, Chapter 30 RADICAL PROSTATECTOMY Prostate cancer affects older males The tumour can spread to surrounding structures and metastasize to bone and lung The cancer is often reliant upon an androgenic drive for growth and malignant transformation Treatment options include watchful waiting, radiotherapy, hormonal therapy and surgery There remain controversies in the optimal management of this disease; multidisciplinary teams must consider Radical prostatectomy the tumour characteristics on the background of the patient’s wishes and other comorbidities when considering the treatment pathway Radical prostatectomy is performed for malignant disease via an open, laparoscopic or robot-assisted technique Open surgery is usually via the retropubic approach; the perineal approach is rarely used Laparoscopy and robot-assisted are transperitoneal The prostate is removed together with pelvic lymph nodes, seminal vesicles, ejaculatory ducts and part of the bladder neck PREOPERATIVE ASSESSMENT During the preoperative visit: • Identify and assess chronic disease • Assess suitability for enhanced recovery • Assess suitability for spinal or epidural analgesia This is particularly useful in conjunction with general anaesthesia because it provides excellent postoperative analgesia, reduces perioperative blood loss and decreases the quantity of inhalational agent required • Check haemoglobin and ensure blood transfusion availability, as radical prostatectomy is often associated with significant operative blood loss Trendelenburg position, this can lead to reduced cardiac and respiratory performance in addition to head and neck swelling including cerebral and laryngeal oedema Retropubic prostatectomy can be performed under neuraxial analgesia alone if a T6 sensory level is achieved The intraoperative blood loss varies with the length of surgery and grade and stage of malignancy In some cases, transfusion up to units could be necessary It has been suggested that fibrinolysins, which exacerbate bleeding, are released by prostatic handling In case of laparoscopic approach, the amount of bleeding and need for transfusion are much reduced Less blood loss and a lower frequency of pulmonary emboli are associated with regional anaesthesia Because of the potential for massive blood loss, two large-bore intravenous cannulae, tranexamic acid and cell salvage are advisable Elasticated stockings and intermittent calf compression are used for deep vein thrombosis prophylaxis Body temperature should be maintained with a warming mattress, warm air overblanket, warmed intravenous fluids and a ventilator circuit humidifier Antibiotic prophylaxis according to local guidelines In addition to routine monitoring, invasive BP, core temperature, neuromuscular function and fluid balance should be monitored PERIOPERATIVE MANAGEMENT POSTOPERATIVE MANAGEMENT Patient positioning requires care since surgery is often lengthy The patient is usually placed supine in a hyperextented position which places the pubis above the head A steep Trendelenburg position is required for the laparoscopic approach When compared with the open surgical approach, laparoscopy is associated with shorter operating times, lower urinary leakage rates, lower stricture rates, lower blood loss and less pain If an epidural infusion is already in situ, then a multimodal approach using an infusion of local anaesthetic and an opioid will provide excellent analgesia for open surgery TAP block and penile block reduce opiate requirements when an epidural has not been placed Postoperative blood loss and urine output should be monitored Thrombophlebitis with pulmonary embolism is a major cause of postoperative mortality and low molecular weight Heparin should be used postoperatively CPET can be used to select the level of postoperative care; most patients will be able to return to ANAESTHETIC TECHNIQUE The combination of epidural and general anaesthesia with a muscle relaxant and volatile agent is a suitable technique for open surgery For minimally invasive surgery, an endotracheal tube is mandated; however, an epidural is not required The insufflated carbon dioxide spreads into the retroperitoneal space and increases the intra-abdominal and intrathoracic pressures In combination with the steep 349 Urology general ward care within 24 hours of the operation Principles of enhanced recovery have been successfully employed in this patient group With good case selection, the 5-year survival is 95% Operative mortality is low REFERENCES Biki B, Mascha E, Moriarty DC, Fitzpatrick JM, Sessler DI, Buggy DJ (2008) Anesthetic technique for radical prostatectomy effects cancer recurrence: A retrospective analysis Anesthesiology 109: 180–187 Joshi G, Jaschinski T, Bonnet F, Kehlet H (2015) Optimal pain management for radical prostatectomy surgery: What is the evidence? BMC Anesthesiol 15(1) Woldu S, Weinberg A, Bergman A, Shapiro E, Korets R, Motamedinia P, Badani K (2014) Pain and analgesic use after robotassisted radical prostatectomy J Endourol 28(5): 544–548 CROSS-REFERENCES The elderly patient, Chapter 25 Blood transfusion, Chapter 30 Thrombotic embolism, Chapter 30 Preoperative assessment of pulmonary risk, Chapter 25 Complications of position, Chapter 30 TRANSURETHRAL RESECTION OF PROSTATE (TURP) 350 Benign prostatic hyperplasia (BPH) occurs in over 40% of men aged over 60 years Resection of the prostate is reserved as second-line treatment for BPH for symptoms resistant to medical management The majority of prostatectomies are performed endoscopically using the transurethral route, with open procedures reserved for cancers and exceptionally large prostates To perform the operation, the patient is placed in the lithotomy position and a modified cystoscope (a resectoscope) is used to shave away the prostate at the bladder neck As the body of the prostate is removed, veins are exposed, but the capsule is maintained The exposed veins can bleed, causing significant blood loss; they can also absorb large amounts of irrigation fluid resulting in TURP syndrome Resectoscopes traditionally use mono-polar electrocautery This requires a nonionic solution to be used as irrigation to prevent current dissipation: 1.5% glycine solution is used This solution, in the presence of open veins, is responsible for TURP syndrome Bipolar electrocautery and lasers are replacing the mono-polar technique They result in better haemostasis and reduce the absorption of irrigation fluid PREOPERATIVE ASSESSMENT • Patients have a high incidence of cardiopulmonary problems The ability of the patient to manage an increased circulating volume as a result of absorbing irrigation fluid should be considered • In patients with cardiovascular comorbidities, anticoagulant therapy is common and the risk for bleeding is increased The anticoagulation medications may preclude neuraxial anaesthesia • The operation may be performed as a repeat procedure; changes in health during the intervening time should be assessed • Patients may present with haematuria or may have longstanding obstruction U&E and FBC should be check preoperatively • Prostatic bleeding can be difficult to control through the cystoscope Routine group and save is recommended Cross-matched blood should be available for the patients with large glands PERIOPERATIVE MANAGEMENT The procedure is performed in the lithotomy or Lloyd–Davis position Irrigating fluid is warmed to maintain patient core temperature All aspects of laser safety should be adhered to if a laser technique is used This includes protective eyewear for staff and patients, blinds for windows and signs on doors Antibiotic administration according to the hospital policy (usually gentamicin or a cephalosporin) References ANAESTHETIC TECHNIQUE OUTCOME Spinal anaesthesia is commonly used, although a number of patients prefer to be asleep There several considerations when performing a spinal technique: The reported hospital mortality is 0.2%–6% and may be as low as 0.5%–1% in specialist centres There is evidence of increased intermediate and long-term mortality and morbidity with TURP compared with open prostatectomy, and with other minimally invasive surgery in this age group Increased morbidity may be found after resections exceeding 90 min, gland size greater than 45 g and age older than 80 years • A block to T10 is required • Patients often have chest disease and may benefit from not having a general anaesthetic • In awake patients, the evaluation of mental status is the best monitor of the onset of the TURP syndrome and of bladder perforation • Spinal anaesthesia reduces central venous pressure, potentially resulting in greater absorption of irrigating fluid than with general anaesthesia • Degenerative changes in the spine of elderly patients may make neuraxial anaesthesia technically difficult Vertebral metastasis in patients with carcinoma represents a contraindication to regional anaesthesia If a general anaesthesia is used, a spontaneously breathing technique using a laryngeal mask is usually appropriate Vigilance for development of the TURP syndrome is required MONITORING • Routine monitoring in both general and spinal anaesthesia • Mental status if the patient is awake • Arterial line in these with precarious cardiovascular function POSTOPERATIVE MANAGEMENT TURP syndrome can develop intraoperatively or up to 24 hours postoperatively Postoperative full blood count and renal function test are useful to screen for anaemia (which may be due to haemodilution or excessive bleeding) and hyponatremia The initial postoperative period is not overly painful with the catheter being the major irritant; regular simple analgesia will suffice REFERENCES Burke N, Whelan J, Goeree L, Hopkins R, Campbell K, Goeree R, Tarride J (2010) Systematic review and meta-analysis of transurethral resection of the prostate versus minimally invasive procedures for the treatment of benign prostatic obstruction Urology 75(5): 1015–1022 Gehring H, Nahm W, Baerwald J, Fornara P, Schnieeweiss A, Roth-Isigkeit A, Schmucker P (1999) Irrigation fluid absorption during transurethral resection of the prostate Spinal vs general anaesthesia Acta Anaesthesiol Scand 43: 458–463 Hawary A, Mukhtar K, Sinclair A, Pearce I (2009) Transurethral resection of the prostate syndrome: Almost gone but not forgotten J Endourol 23: 2013–2020 Reich O, Gratzke C, Bachmann A, Seitz M, Schlenker B, Hermanek P, Lack N, Stief C (2008) Morbidity, mortality and early outcome of transurethral resection of the prostate: A prospective multicenter evaluation of 10,654 patients J Urology 180(1): 246–249 CROSS-REFERENCES The elderly patient, Chapter 25 Blood transfusion, Chapter 30 Fluid and electrolyte balance, Chapter 30 TURP syndrome, Chapter 30 Complications of position, Chapter 30 351 http://taylorandfrancis.com ... IIIB Stage IV T1a–T1b T2a T1a,T1b,T2a T2b T2b T3 T1a,T1b,T2a,T2b T3 T4 T4 Any T Any T N0 N0 N1 N0 N1 N0 N2 N1,N2 N0,N1 N2 N3 Any N M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1a or M1b 11 Respiratory system... Connective tissue John-Paul Lomas PART 2 SURGICAL PROCEDURES 37 91 129 14 5 16 3 19 7 225 243 277 10 Abdominal surgery 279 Brian J Pollard and Gareth Kitchen 11 Gynaecological surgery 305 Amy Hobbs,... Obstet Anesth 16 (3): 284–7 Howell PR, Kent N et al (19 93) Anaesthesia for the parturient with cystic fibrosis Int J Obstet Anesth 2(3): 15 2–8 Lamberty JM, Rubin BK (19 85) The management of anaesthesia