Principles of anaesthesia in urological surgery

Anesthetic challenges of patients with cardiac comorbidities undergoing major urologic surgery

The cardiac patient undergoing major urologic surgery is a complex case requiring a great attention by the anesthesiologist. Number of this group of patients having to go through this procedure is constantly increasing, due to prolonged life, increased agressiveness of surgery and increased anesthesia's safety. The anesthesiologist usually has to deal with several problems of the patient, such as hypertension, chronic heart failure, coronary artery disease, rhythm disturbances, intraoperative hemodymanic changes, intraoperative bleeding, perioperative fluid imbalance, and metabolic disturbances. A cardiac patient undergoing major urologic surgery is a complex case requiring a great attention by the anesthesiologist. The scope of this review article is to present the most frequent issues encountered with this group of patients, and to synthetically discuss the respective strategies and maneuvers during perioperative period, which is the major challenge for the anesthesiologist.

Combined nephrectomy and major hepatectomy: indications, outcomes, and recommendations

BACKGROUND

Simultaneous nephrectomy with major hepatectomy (NMH) is uncommon. We reviewed our experience with NMH.

STUDY DESIGN

Records of patients who underwent NMH at Emory Hospital between January 1995 and May 2008 were examined. Patients undergoing resection of three or more liver segments at the same setting as a total nephrectomy were included. Indications and outcomes were assessed.

RESULTS

Twenty patients underwent NMH. Mean (+/- SD) age was 59.9+/-12.8 years, 6 (30%) were women, and 15 (75%) presented with comorbidities. Most kidney neoplasms were renal cell carcinomas of the right kidney (n=16, 80%) with a mean diameter of 10.0+/-6.1 cm. Eight patients (40%) also underwent thrombectomy for inferior vena cava tumor thrombus. The most common indications for hepatectomy were direct liver invasion in eight patients (40%) and distant hepatic metastases in nine (45%); liver tumors were 4.2+/-3.3 cm (mean +/- SD) in diameter. Mean (+/- SD) operative time was 8.3+/-2.6 hours. Liver resections included 15 (75%) right hepatectomies and 5 (25%) left hepatectomies. In all cases, tumor negative hepatic margins were achieved. Median operative blood loss was 1,700 mL (range 200 to 8,000 mL). Ten patients (50%) suffered complications in the postoperative period; three of these suffered major complications, resulting in one perioperative death (5%). Mean hospital stay was 12+/-8.8 days. Overall survival was 25 months (range 0 to 34 months).

CONCLUSIONS

In this large series of nephrectomy with simultaneous major hepatectomy, morbidity and mortality were acceptable. In specialized centers NMH may be considered in properly selected patients for combined resection for synchronous neoplasms of the kidney and liver.

Anesthesia for urological surgery in a European region with 6.7 million inhabitants (Catalonia, Spain)

STUDY OBJECTIVE

To describe the characteristics of anesthetic and postoperative care applied in urologic surgery.

DESIGN

Prospective, cross-sectional survey.

SETTING

131 authorized public and private hospitals in Catalonia, Spain.

MEASUREMENTS

Data were collected from a representative sample of 23,136 patients and all questionnaires related to urologic surgery were analyzed.

MAIN RESULTS

Data included patient characteristics, anesthetic techniques, and type of procedure. Eighty-five hospitals performed urologic surgery and 75.4% of activity took place in public hospitals. The median age of patients was 61 years and 87.3% were men. Preoperative physical status was poorer than in the rest of the surgical population. Surgery was elective in 93.2% of the cases, and the most frequent procedure was transurethral resection of bladder tissue (25.6%). The median duration of anesthesia was 60 minutes, and 9.7% of patients required postoperative admission to an intensive care unit. Regional anesthesia, especially subarachnoid block, was the most frequently used anesthetic technique.

CONCLUSIONS

The older age and poor physical status of urology patients make high demands on anesthetic resources and must be considered in the organization of services and training programs.