Bb Urology

Front 1

How much fluid can be absorbed during TURP?

Back 1

20 cc/min

Front 2

What determines the amount of water that enters through the venous sinuses during a TURP?

Back 2

1. how many sinuses are open,
2. how long the resection takes,
3. how high the fluid is hung (pressure)

Front 3

How do the electrolyte fluids affect the current used during TURP?

Back 3

leads to dispersion of high frequency current

Front 4

What are the 2 MC electrolyte solutions used during TURP? Why?

Back 4

- glycine and cytal (sorbitol and mannitol)

1. isotonic (prevents hemolysis),
2. good refractive index (minimize dispersion of current)

Front 5

What are the complications of TURP?

Back 5

1. Hyponatremia
2. Hypervolemia
3. Bladder perforation
4. Bleeding
5. Septic Shock
6. Ammonia toxicity
7. Glycine toxicity

Front 6

What is the best treatment for hyponatremia during surgery?

Back 6

1. stop surgery,
2. administer NS / diuretics (lasix) / fluid restriction
3. If pt is seizing or Na <120 hypertonic saline / lasix / fluid restriction; d/c hypertonic saline when Na is in 120-130 range

Front 7

What is your goal correction of serum Na in hyponatremia?

Back 7

2 meq/hr

Front 8

What are signs of hyponatremia?

Back 8

-when serum sodium falls below 120meq/l - irritability, confusion, restlessness (due to cerebral edema);
-when serum Na is 105meq/l - EKG changes (widened QRS, ST elevation),
-when Na<100meq/L - vtach/fib occur

Front 9

What is the best monitor for hyponatremia during TURP?

Back 9

mental status

Front 10

What is the best sign of hyponatremia in a patient under GA?

Back 10

transient hypertension followed by hypotension

Front 11

What are the causes of fluid overload during TURP?

Back 11

1. fluid absorption in the prostatic venous sinuses,
2. autotransfusion from the lithotomy position

Front 12

what are signs of bladder perforation?

Back 12

1. pain in the periumbilical, inguinal, or suprapubic region radiating to the diaphragm,
2. tachycardia,
3. hypotension,
4. shoulder pain (diaphragm irritation),
5. bladder distention can result in bradycardia

Front 13

What is the mechanism of aminocaproic acid?

Back 13

prevents the formation of plasmin, and thus prevents the breakdown of clot
(plasminogen is converted to plasmin and plasmin digests the clot)

Front 14

When is aminocaproic acid indicated?

Back 14

excessive and severe bleeding (when other causes have been corrected and other remedies have failed) of the bladder, prostate, and urethra

Front 15

when is aminocaproic acid not recommended?

Back 15

1. renal or ureteral bleeding because clot formation and obstruction can occur,
2. if used in setting of DIC fatal thrombosis can occur

Front 16

What is the dose of aminocaproic acid?

Back 16

6g over 24 hours

Front 17

What can result from glycine toxicity?

Back 17

transient blindness

Front 18

During TURP what can be the symptoms of ammonia toxicity?

Back 18

CNS depression and delayed awakening

Front 19

Why can patients getting TURP get septic?

Back 19

urethral instrumentation

Front 20

What are complications of lithotripsy?

Back 20

1. arrhythmias (mechanical effects of shock waves),
2. tissue injury (skin bruising, flank ecchymoses),
3. alveolar rupture and hemoptysis
4. hematuria

Front 21

During resection of the lateral wall of the bladder the patients leg starts to move what nerve is being stimulated?

Back 21

- obturator is adjacent to the lateral wall of the bladder,
- sciatic is posterior to the lateral wall of the bladder

Front 22

What happens if you correct hyponatremia too fast?

Back 22

It can lead to brain shrinkage with demyelination in the CNS leading to quadriplegia

Front 23

When does brain edema with hyponatremia stop?

Back 23

when serum sodium reaches 130 meq/L - the minimum acceptable level for elective surgery

Front 24

How can you tell the difference from primary fibrinolysis and secondary fibrinolysis (DIC)?

Back 24

-primary - platelets are normal and fibrinogen is low
-secondary - both platelets and fibrinogen are low

Front 25

What are the absolute contraindications for laparoscopic procedures?

Back 25

1. severe cardiopulmonary disease
2. bowel obstruction
3. active infection
4. uncorrected coagulopathy

Front 26

What are the relative contraindications for laparoscopic procedures?

Back 26

1. previous abdominal surgery
2. minor coagulopathies
3. obesity
4. cirrhosis
5. inability to tolerate general anesthesia

Front 27

How is a pt positioned for a robotic prostatectomy?

Back 27

lithotomy with steep Trendelenburg

Front 28

What are the physiologic effects of steep trendelenburg position?

Back 28

1. diaphragm is forced cephalad, reducing lung volume by 15% and decreasing compliance
2. mediastinal structures become compressed - leads to pulmonary interstitial edema
3. increased CVP, PCWP, and myocardial work with decreasing CO
4. 45 degrees head down - venous pressure increased, HR slowed, SVC volume doubled, AV oxygen difference decreased
5. incr ICP and IOP - leads to facial cerebral, and buccal swelling

Front 29

At what pressure should pneumoperitoneum be set?

Back 29

usually 10-15 cmH20
-If above 20cm tends to trap blood in the lower extremities and can lead to postop DVT/PE

Front 30

What peak pressure should ventilators be set at during pneumoperitoneum?

Back 30

PAP 30-35 cmH20 - lessens airway injury and subsequent sub-Q emphysema

Front 31

How should legs be placed in lithotomy position?

Back 31

-Both legs should be elevated and flexed
-thigh should be flexed no more than 90 degrees before rotating stirrups laterally

Front 32

What is the result of common peroneal nerve injury?

Back 32

1. foot drop
2. loss of dorasal extension of toes
3. inability to evert the foot

Front 33

How do sciatic nerve injuries occur during lithotomy position? What is the result?

Back 33

-can be stretched if the legs are externally rotated

1. decreased strength in all muscles below the knee
2. decreased sensation to the lateral 1/2 leg and almost all of foot except the inner border of arch

Front 34

How do femoral nerve injuries occur during lithotomy position? What is the result?

Back 34

-excessive angulation of the thigh

1. unable to flex the hip or extend the knee
2. decreased sensation to the superior aspect of the thigh and antero-medial aspect of leg

Front 35

How does water immersion during ESWL effect CV and respiratory systems?

Back 35

-CV - elevated venous return occurs bc of increased hydrostatic pressures exerted upon the peripheral venous system
-Resp - decreased FRC and TV and increased V/Q mismatching secondary to position

Front 36

What is the purpose of the triggering mechanism of the lithotriptor?

Back 36

-designed to generate a shock wave 20 msec after the R-wve during the ventricular refractory period
-decreases occurrences of arrhythmias

Front 37

What are the 3 general reasons for hyponatremia and what can cause each situation?

Back 37

1. total body Na increased - edema
2. total body Na normal - SIADH or TURP
3. total body Na decreased - diuretics

Front 38

What are causes of SIADH?

Back 38

1. post-op
2. PPV
3. endocrine-pituitary damage
4. CNS dysfunction
5. drugs