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Urological Surgery

Cystoscopy & Endoscopic Bladder/Prostate Procedures

Patient Profile

• Predominantly ≥ 60 years, often male, with high prevalence of COPD, cardiovascular disease and anticoagulant therapy.
• Common indications: haematuria work‑up, transurethral resection of bladder tumour (TURBT), transurethral resection of prostate (TURP), stone retrieval, stent insertion

Anaesthetic Options

Technique	Advantages	Limitations / Pearls
Flexible cystoscopy (out‑patient)	Topical 2 % lidocaine gel + minimal sedation	Avoid benzodiazepines in frail patients; consider remimazolam if sedation needed
Rigid cystoscopy / TURP / TURBT	Spinal anaesthesia (SA) T10 sensory level with 0.5 % heavy bupivacaine 2.5–3 mL ± intrathecal diamorphine 150 µg; preserves airway reflexes	Inadequate obturator reflex control–add ultrasound‑guided obturator nerve block (ONB) for lateral wall TURBT (↓ perforation RR 0.25)
	General anaesthesia (GA) with LMA or ETT; allows neuromuscular blockade	Mandatory for patients on dual antiplatelet therapy requiring reversal; beware diathermy interference with ICDs–magnet or device representative present

Obturator Reflex & Nerve Block

• Electrical stimulation of the obturator nerve causes violent adduction → bladder perforation risk.
• ONB techniques: inter‑adductor (classic), ultrasound‑guided pubic approach, or inguinal approach; 10–15 mL 1 % lidocaine each side.
• 2022 meta‑analysis (1 384 pts) shows SA + ONB halves obturator spasm and reduces bladder perforation and LOS.

Antibiotic Prophylaxis

• EAU 2024: single‑dose gentamicin 3 mg kg⁻¹ IV (or cefazolin 2 g IV) only for high‑risk cystoscopy (hx of UTI, prosthetic joint, immunosuppression). No routine prophylaxis for diagnostic cystoscopy in low‑risk patients.

TURP & TURB

Spinal Specifics

• Aim T10 level to cover bladder distension pain (T10–L2) and urethral/prostate sensation (S2–4).
• Add fentanyl 10–20 µg or diamorphine 150 µg for longer resections.
• Fluid preload not required; treat hypotension with phenylephrine.

Pacemakers & ICDs

• Bipolar diathermy dramatically lowers electromagnetic interference; nonetheless:
  1. Place diathermy return plate on thigh.
  2. ICD: apply magnet OR re‑program to disable shocks.
  3. Continuous ECG & SpO₂.

Obturator Reflex Prevention

• Combine SA with ONB for lateral wall tumours.
• If GA: use deep neuromuscular block plus ONB; succinylcholine alone unreliable.

TURP Syndrome (Dilutional Hyponatraemia)

Incidence & Risk Factors

Era	Incidence	Irrigation	Notes
Monopolar TURP (glycine 1.5 %)–pre‑2005	1–2 %	Hypotonic, non‑conductive	Classic TURP syndrome
Bipolar TURP (0.9 % saline)	< 0.2 %	Isotonic but risk of fluid overload / hyperchloraemic acidosis	Hyponatraemia rare
Laser enucleation (HoLEP, ThuLEP)	~0 %	No irrigation toxicity	Longer operative time; consider venous air embolism
Systematic review 2023 (58 studies) confirms ten‑fold reduction in hyponatraemia with bipolar compared with monopolar TURP.

Pathophysiology

• Venous sinus absorption rate ≈ 10–30 mL min⁻¹; influenced by height of fluid bag (keep < 60 cm above pubis), prostate size (> 45 g) and procedure time > 60 min.
• Glycine metabolised to ammonia → CNS depression, visual disturbances.

Recognition (under SA or GA)

Early	Late / Severe
Restlessness, nausea, facial warmth, headache, rising BP then bradycardia	Confusion, seizures, ↓ GCS, pulmonary oedema, hypotension, ventricular arrhythmias, Na⁺ < 120 mmol L⁻¹

Management Algorithm

1. Stop resection & switch to saline irrigation.
2. ABC; 100 % O₂, secure airway if GCS < 8.
3. Loop diuretic: furosemide 0.5 mg kg⁻¹ IV to offload fluid.
4. Serum Na⁺ & ABG immediately (POC gas).
5. Hypertonic saline 3 % if: Na⁺ < 125 mmol L⁻¹ or neurological symptoms.
   • Dose: 150 mL bolus (≈ 2 mL kg⁻¹) over 15 min → repeat until symptoms improve or Na⁺ rises by 5 mmol L⁻¹.
   • Max correction 10 mmol L⁻¹ in 24 h to avoid osmotic demyelination.
6. Treat seizures with midazolam 2 mg IV or levetiracetam 20 mg kg⁻¹.
7. Consider ICU for Na⁺ < 120 mmol L⁻¹ or pulmonary oedema.

Procedure‑specific Complications & Prevention

Complication	Incidence	Prevention / Notes
Bladder perforation	1 %	Low irrigation pressure, ONB, stop with sudden poor vision / peritoneal fluid wave
Sepsis / bacteraemia	1–3 %	Follow EAU antibiotic guidance; prompt fluid resuscitation & cefuroxime 1.5 g q8 h if sepsis
Bleeding / clot retention	2–5 %	Adequate coagulation of vessels; continuous bladder irrigation post‑op
Obturator reflex	8–25 %	ONB + low‑power diathermy
Hypothermia	—	Warm irrigation fluid (> 37 °C), forced‑air warming

Post‑operative Care

1. Early warning: monitor Na⁺, Hb & lactate 2‑hly × 6 h in monopolar TURP.
2. Maintain urine output > 0.5 mL kg⁻¹ h⁻¹; titrate bladder irrigation to pale pink effluent.
3. Analgesia: paracetamol + NSAID (if renal function normal); opiate requirement low.
4. Resume anticoagulation (DOAC) at 48 h if haemostasis confirmed.

Links

• Renal Physiology
• Renal replacement therapy
• ICU and renal disease
• Renal transplant
• Urological malignancy
• Intra-op renal dysfunction

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References:

1. Allman K, Wilson I, O’Donnell A. Oxford Handbook of Anaesthesia. Vol. 4. Great Clarendon Street, Oxford, OX2 6DP, United Kingdom: Oxford University Press; 2016. 1295 p. Allman et al. – Oxford Handbook of Anaesthesia.pdf
2. 1Deng W, et al. Spinal anaesthesia combined with obturator nerve block prevents obturator reflex during TURBT: meta‑analysis of RCTs. BMC Anesthesiol. 2022;22:350. (pubmed.ncbi.nlm.nih.gov)
3. European Association of Urology. EAU Guidelines on Urological Infections. Arnhem, The Netherlands: EAU; 2024. (uroweb.org)
4. Hashemi‑M, et al. Temporal trends in outcomes and complications of TURP: systematic review 2000‑2022. J Clin Urol. 2024;17:125‑134. (pubmed.ncbi.nlm.nih.gov)
5. Arslan M, et al. Transurethral resection of the prostate syndrome: a contemporary review. Curr Med Res. 2023;39:112‑120. (jag.journalagent.com)
6. Ahmad N, et al. Ultrasound‑guided obturator nerve block reduces complications in lateral wall bladder cancer resections. J Urol Surg. 2022;9:441‑448. (jurolsurgery.org)
7. NYSORA. TURP and TURP syndrome management. 2023. (nysora.com)
8. Butterworth J, Mackey D, Wasnick J. Morgan and Mikhail’s Clinical Anesthesiology, 7th Edition. 7th edition. New York: McGraw Hill Medical; 2022. Butterworth et al. – 2022 – Morgan and Mikhail’s Clinical Anesthesiology, 7th .pdf
9. FRCA Mind Maps. (2024). Retrieved June 5, 2024, from https://www.frcamindmaps.org/
10. Anesthesia Considerations. (2024). Retrieved June 5, 2024, from https://www.anesthesiaconsiderations.com/

Summaries

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Copyright
© 2025 Francois Uys. All Rights Reserved.

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