**2. Anesthesia for kidney and upper urinary tract surgery**

#### **2.1. Oncological surgery of kidney and upper urinary tract**

#### *2.1.1. Radical and partial nephrectomy*

Renal cell carcinoma (RCC) is the ninth common cancer in the USA. According to the SEER database analysis, it is estimated that there will be 62,700 new cases and 14,240 people will die because of this disease. The incidence of kidney and renal pelvis cancer was 15.6 per 100,000 in the USA between 2009 and 2013 [5]. All around the world, radical or partial nephrectomy is accepted curative treatment for kidney tumors. Partial nephrectomy can be performed depend‐ ing on the tumor size and localization of tumor. During the partial nephrectomy, localized solid mass must be removed entirely with clear surgical margins [6]. The European Association of Urology (EAU) Renal Cell Cancer Guidelines Panel recommends partial nephrectomy for the tumors less than 4 cm [7].

The flank incision provides advantages in terms of access to the kidney directly, but in case of vena cava involvement, it can be insufficient anatomically. If the tumor size is huge and abdo‐ men exploration or contralateral retroperitoneal exploration is needed, subcostal incision may supply advantages to the surgeon. Various factors including surgeon's experience, tumor size and localization, patient's body habits and localization of affected kidney can affect the inci‐ sion type [8].

#### *2.1.2. Radical nephroureterectomy*

Upper urothelial cell carcinoma is a rare tumor among genitourinary system tumors that con‐ stitute approximately 5% [9]. Radical nephroureterectomy with bladder cuff resections is a standard curative treatment for patients with non‐metastatic upper urothelial cell carcinoma, although advanced developments of minimal invasive surgery and surgical techniques for radical surgery are present [10].

#### *2.1.2.1. Preoperative considerations*

Known risk factors for RCC include tobacco smoking and be over the age of 60. The peak inci‐ dence of RCC is at the age of 60 years and male‐female ratio is 2:1. Hence, these patients with RCC generally have comorbidities such as coronary‐after‐disease and chronic obstructive pulmonary disease. Only small percent of patients (approximately 10%) have classic diag‐ nostic triad of symptoms including flank pain, hematuria and palpable abdominal mass. Paraneoplastic symptoms and impaired laboratory test including increased erythrocyte sedi‐ mentation rate, eosinophilia and increased hormone levels of prolactin, renin and glucocorti‐ coids [11]. The patient's health status is also optimized by management of anemia, glycemic control and treatment for hypertension, as well as dietary, weight and smoking‐cessation advice before surgery. A consultant‐led, multidisciplinary decision can be made as to which procedure and approach are required for each patient [12]. Because these patients usually have comorbid disease such as advanced age, hypertension, diabetes, chronic obstructive pul‐ monary disease and congestive heart failure and they have had a long and major surgery, it should be appropriate to prepare intensive care bed for these patients to stay in intensive care unit for the critical postoperative period. Intensive care unit can be appropriate to follow up and interfere with postoperative problems that must be treated quickly such as hypother‐ mia, electrolyte imbalance, hemorrhage, infections, pulmonary disorders and requirement of dialysis.

#### *2.1.2.2. Intraoperative considerations*

During the urological surgery, different complications can develop depending on surgical techniques used. For example, most of urological ventures require lots of irrigation fluids. In this venture, use of unheated irrigation fluid can lead to complications such as hypothermia,

In addition to neuraxial blockade, the use of peripheral blockade has gained importance in uro‐ logical surgery. For example, obturator blockade application for lateral wall localized bladder cancer could reduce intraoperative complications and increased cancer‐free survival [3, 4].

Renal cell carcinoma (RCC) is the ninth common cancer in the USA. According to the SEER database analysis, it is estimated that there will be 62,700 new cases and 14,240 people will die because of this disease. The incidence of kidney and renal pelvis cancer was 15.6 per 100,000 in the USA between 2009 and 2013 [5]. All around the world, radical or partial nephrectomy is accepted curative treatment for kidney tumors. Partial nephrectomy can be performed depend‐ ing on the tumor size and localization of tumor. During the partial nephrectomy, localized solid mass must be removed entirely with clear surgical margins [6]. The European Association of Urology (EAU) Renal Cell Cancer Guidelines Panel recommends partial nephrectomy for the

The flank incision provides advantages in terms of access to the kidney directly, but in case of vena cava involvement, it can be insufficient anatomically. If the tumor size is huge and abdo‐ men exploration or contralateral retroperitoneal exploration is needed, subcostal incision may supply advantages to the surgeon. Various factors including surgeon's experience, tumor size and localization, patient's body habits and localization of affected kidney can affect the inci‐

Upper urothelial cell carcinoma is a rare tumor among genitourinary system tumors that con‐ stitute approximately 5% [9]. Radical nephroureterectomy with bladder cuff resections is a standard curative treatment for patients with non‐metastatic upper urothelial cell carcinoma, although advanced developments of minimal invasive surgery and surgical techniques for

Known risk factors for RCC include tobacco smoking and be over the age of 60. The peak inci‐ dence of RCC is at the age of 60 years and male‐female ratio is 2:1. Hence, these patients with RCC generally have comorbidities such as coronary‐after‐disease and chronic obstructive

**2. Anesthesia for kidney and upper urinary tract surgery**

**2.1. Oncological surgery of kidney and upper urinary tract**

delayed recovery from anesthesia and tremor [2].

*2.1.1. Radical and partial nephrectomy*

54 Current Topics in Anesthesiology

tumors less than 4 cm [7].

*2.1.2. Radical nephroureterectomy*

radical surgery are present [10].

*2.1.2.1. Preoperative considerations*

sion type [8].

In thoraco‐abdominal approach, since the pleural space is entered, using the noble‐lumen endotracheal tube may facilitate the surgery by deflating the ipsilateral lung. Postoperative ventilation may be needed because of prolonged retraction of the lung that is causing con‐ tusion. During the diaphragm dissection, the phrenic nerve may also be injured by both thoraco‐abdominal incision and flank incision. During operation, excessive blood loss may occur at any stage of operation, which is the reason for the high vascularity of the tumor. Bleeding can be caused by the surrenal gland. At last, adjacent abdominal organs including colon, duodenum and liver may be injured. If the renal mass is on the left side, bleeding due to splenic injury may occur with an incidence as high as 10% [13]. When extensive bleed‐ ing is observed, wide‐channel venous cannulation and central venous cannulation should be obtained for monitoring both the central venous pressure and supply rapid blood transfusion. Prolonged retraction of vena cava may result of transient hypotension. Hence, direct arterial pressure monitoring may facilitate the control of blood pressure, especially in patients with cardiac comorbidity. Moreover, these applications may be helpful for the patients who need mechanic ventilation postoperatively. If the patient has caval obstruction due to naval throm‐ bus, additional management may be needed. Embolization of the tumor fragment may occur during the central venous catheter application, if the thrombus in vena cava extends into the right atrium. When atrial thrombus is observed, a pulmonary artery catheter is contraindi‐ cated. For this reason, many authors suggested that the use of intraoperative transesophageal echocardiography in order to detect tumor extension in the inferior vena cava [14–16].

#### *2.1.2.3. Choice of anesthesia*

The anesthetic management of patients undergoing radical nephrectomy should include gen‐ eral endotracheal anesthesia. Alternately, combined regional/general endotracheal anesthesia advised to be employed. If the general and epidural anesthesia are combined, epidural cathe‐ ter must be placed and test dose should be administered before the induction of general anes‐

thesia. To perform the induction of general anesthesia after evaluating the effect of the test dose will be reduced the risk of unintended intrathecal and intravascular injection. Although test dose is administered, it would be safer to administer the epidural dose partially and inter‐ mittently. When neuraxial blockade performed, sensorial block level must be Th4. It has been shown that intraoperative epidural infusion of local anesthetic suppresses the stress hormone response and reduces opioid requirement when compared to straight general anesthesia in open nephrectomy [13]. Also, it is advised to reduce pulmonary complications and be more effective to control postoperative pain.

#### *2.1.2.4. Complications*

Patients with renal failure may be sensitive to benzodiazepines. Cisatracurium may be consid‐ ered for muscle relaxation as it is metabolized via ester hydrolysis and Hofmann elimination. Other pharmacologic considerations for the patient with renal failure include adjusted dosing of antibiotics and avoidance of nonsteroidal anti‐inflammatory agents. Patients with chronic kidney failure have decreased platelet function and von Willebrand factor and reduced red blood cell volume. So the anesthesiologist must transfuse appropriate blood product [17].

#### **2.2. Nononcological surgery of kidney and upper urinary tract**

Nononcological urological surgery of kidney and upper urinary tract includes such proce‐ dures like simple nephrectomy, pyeloplasty, nephrolithotomy or pyelolithotomy, percuta‐ neous nephrolithotomy (PNL), extracorporeal shockwave lithotripsy (ESWL), retrograde intrarenal surgery (RIRS), percutaneous nephrostomy, ureterorenoscopy and ureteral stent replacement. Open stone surgery (nephrolithotomy or pyelolithotomy) is now dramatically reducing and the endoscopic and extracorporeal methods are increasing, overcoat ESWL in those hospitals which has an own lithotripter. Open surgery is actually indicated for the complex renal stone and the complicated ureteral stone [18]. Classically, PNL is done on the patient first in the supine position for replacement of the ureteral catheter and then in a prone position for accessing the caliceal system. Other procedures such as simple nephrectomy, pyeloplasty, nephrolithotomy and pyelolithotomy are performed on the patients in the lateral decubitus position.

#### *2.2.1. Preoperative considerations*

The anesthesiologist should evaluate not only patients' history and physical examination but also existing urinary tract infection. If it exists, antibiotherapy must be given perioperatively. All anticoagulation medications including aspirin and nonsteroidal anti‐inflammatory drugs (NSAIDs) are typically held for 5 days prior to surgery. Blood type and screening are recom‐ mended for the patients who are at high risk of intraoperative bleeding.

#### *2.2.2. Intraoperative considerations*

Antegrade or retrograde ureteropyelography (RPG) is often used to demonstrate the anatomical structure of urinary system or localized the level of urinary system obstruction. Due to the radiographic‐iodinated contrast media used in such PNL procedure, patients have predisposed factors for iodinated contrast media‐related adverse reactions such as a previous adverse reaction to iodinated contrast media, a history of asthma and atopy, dehydration, acute or chronic renal diseases and advanced age, where iodinated contrast media‐induced adverse reactions may observed [19]. The prone position alone for PNL is associated with a variety of position‐related complications. To avoid cervical spine injury during position‐ ing, the head should be held in a neutral position through the turn and positioning. Neck extension or head rotation could also impede carotid and/or vertebral artery blood flow and venous return. The etiology of peripheral nerve injury is usually multifactorial, requir‐ ing both a direct pressure and a stretch component. The large volume of irrigation fluid used during PCNL can decrease body temperature. Hence, monitoring core temperature is routine [2, 20, 21].

#### *2.2.3. Choice of anesthesia*

thesia. To perform the induction of general anesthesia after evaluating the effect of the test dose will be reduced the risk of unintended intrathecal and intravascular injection. Although test dose is administered, it would be safer to administer the epidural dose partially and inter‐ mittently. When neuraxial blockade performed, sensorial block level must be Th4. It has been shown that intraoperative epidural infusion of local anesthetic suppresses the stress hormone response and reduces opioid requirement when compared to straight general anesthesia in open nephrectomy [13]. Also, it is advised to reduce pulmonary complications and be more

Patients with renal failure may be sensitive to benzodiazepines. Cisatracurium may be consid‐ ered for muscle relaxation as it is metabolized via ester hydrolysis and Hofmann elimination. Other pharmacologic considerations for the patient with renal failure include adjusted dosing of antibiotics and avoidance of nonsteroidal anti‐inflammatory agents. Patients with chronic kidney failure have decreased platelet function and von Willebrand factor and reduced red blood cell volume. So the anesthesiologist must transfuse appropriate blood product [17].

Nononcological urological surgery of kidney and upper urinary tract includes such proce‐ dures like simple nephrectomy, pyeloplasty, nephrolithotomy or pyelolithotomy, percuta‐ neous nephrolithotomy (PNL), extracorporeal shockwave lithotripsy (ESWL), retrograde intrarenal surgery (RIRS), percutaneous nephrostomy, ureterorenoscopy and ureteral stent replacement. Open stone surgery (nephrolithotomy or pyelolithotomy) is now dramatically reducing and the endoscopic and extracorporeal methods are increasing, overcoat ESWL in those hospitals which has an own lithotripter. Open surgery is actually indicated for the complex renal stone and the complicated ureteral stone [18]. Classically, PNL is done on the patient first in the supine position for replacement of the ureteral catheter and then in a prone position for accessing the caliceal system. Other procedures such as simple nephrectomy, pyeloplasty, nephrolithotomy and pyelolithotomy are performed on the patients in the lateral

The anesthesiologist should evaluate not only patients' history and physical examination but also existing urinary tract infection. If it exists, antibiotherapy must be given perioperatively. All anticoagulation medications including aspirin and nonsteroidal anti‐inflammatory drugs (NSAIDs) are typically held for 5 days prior to surgery. Blood type and screening are recom‐

Antegrade or retrograde ureteropyelography (RPG) is often used to demonstrate the anatomical structure of urinary system or localized the level of urinary system obstruction. Due to the radiographic‐iodinated contrast media used in such PNL procedure, patients have

mended for the patients who are at high risk of intraoperative bleeding.

**2.2. Nononcological surgery of kidney and upper urinary tract**

effective to control postoperative pain.

*2.1.2.4. Complications*

56 Current Topics in Anesthesiology

decubitus position.

*2.2.1. Preoperative considerations*

*2.2.2. Intraoperative considerations*

Commonly, general anesthesia with an endotracheal intubation is preferred for simple nephrectomy, pyeloplasty, nephrolithotomy, pyelolithotomy and PNL, although sedation and neuraxial anesthesia for PNL have also been successful [22]. If neuraxial blockade is per‐ formed, the sensorial block level must be Th4.

Recently, anesthetic management of routine ESWL treatments on adults covers effective seda‐ tive and analgesic practice. Different applications could be used successfully such as meperi‐ dine and promethazine, midazolam with alfentanil, fentanyl and ketamine. Substantial research on the use of alfentanil by various routes reported that this drug is very effective [23–25].

#### *2.2.4. Complications*

The major complications during nononcological urological surgery of kidney and upper urinary system tract includes bleeding, bowel and collecting system injury, traumatic arte‐ riovenous fistula or false aneurysm, sepsis, atelectasis, pneumothorax, pleural effusion and hemothorax [26, 27]. As excessive amount of irrigation solution is used intraoperatively in surgical procedures like PCNL, hypothermia is frequently observed. Tekgül and colleagues reported that effects of irrigation solutions, administered at either 21 or 37°C in percutaneous nephrolithotomy (PCNL), on hypothermia and related postoperative complications such as late emergence and late recovery from anesthesia, shivering, lactic acidosis and excess bleed‐ ing [2].
