**7. Patient positioning for urological surgery**

Nerve injuries comprise 22% of all anesthesia‐related medico‐legal claims in the United States [59]. In an extensive study that reviewed 380,680 cases over 10 years in single center reported that perioperative nerve injuries were observed in 112 cases. Urological procedures were 15% of all cases and 13% of cases have peripheral nerve injuries [60].

Different ocular injuries can be observed. Although minor complications like corneal abra‐ sion that can occur in any position are common, major complications like ischemic optic neu‐ ropathy occur in prone or Trendelenburg positions [61]. Compartment syndrome has been reported to occur in several positions after prolonged urologic surgery [62].

#### **7.1. The supine position**

The upper extremities should be properly secured to avoid pressure on the ulnar groove or hyperextension. One or both arms may be adducted or abducted while supine. Padding should be placed over the elbow and any sharp objects and the arms secured using the draw sheet tucked underneath the patient rather than the mattress.

Ulnar neuropathy is the most frequent site (28%) of anesthesia‐related nerve injury according to the ASA Closed Claims Database [63]. The median nerve is susceptible to neuropathy due to excessive stretching as it courses through the antecubital fossa. Careful attention should be given to avoid hyperextension at the elbow [64].

#### **7.2. The prone position**

**6.1. Preoperative considerations**

64 Current Topics in Anesthesiology

**6.2. Intraoperative considerations**

hypotension.

**6.3. Choice of anesthesia**

enough for testicular torsion.

**7.1. The supine position**

**7. Patient positioning for urological surgery**

of all cases and 13% of cases have peripheral nerve injuries [60].

sheet tucked underneath the patient rather than the mattress.

given to avoid hyperextension at the elbow [64].

reported to occur in several positions after prolonged urologic surgery [62].

In patients with fournier gangrene, there is usually rapid development of severe toxemia leading to sepsis and progressive organ dysfunction. The appropriate administration of intra‐ venous fluid therapy to maintain an effective circulating volume and prevent and inadequate

Routine monitorization is advised for all patients with urological emergencies. The patient with the risk of hypovolemia and hypotension, central venous catheterization must be per‐ formed to monitor the central venous pressure and providing rapid fluid transfusion. Invasive arterial blood pressure must be done to follow blood pressure in patients with the risk of

Most common anesthetic plan is general anesthesia in trauma patients, but neuraxial block‐ ade can be chosen for testicular torsion. If effected area is localized in patients with fournier gangrene or the patient is not septic, neuraxial blockade can be chosen, too. The sensorial block level must be chosen according to the level of legion. Th10 sensorial block level can be

Nerve injuries comprise 22% of all anesthesia‐related medico‐legal claims in the United States [59]. In an extensive study that reviewed 380,680 cases over 10 years in single center reported that perioperative nerve injuries were observed in 112 cases. Urological procedures were 15%

Different ocular injuries can be observed. Although minor complications like corneal abra‐ sion that can occur in any position are common, major complications like ischemic optic neu‐ ropathy occur in prone or Trendelenburg positions [61]. Compartment syndrome has been

The upper extremities should be properly secured to avoid pressure on the ulnar groove or hyperextension. One or both arms may be adducted or abducted while supine. Padding should be placed over the elbow and any sharp objects and the arms secured using the draw

Ulnar neuropathy is the most frequent site (28%) of anesthesia‐related nerve injury according to the ASA Closed Claims Database [63]. The median nerve is susceptible to neuropathy due to excessive stretching as it courses through the antecubital fossa. Careful attention should be

tissue perfusion is a core element of the preoperative practice of the anesthesia [58].

It is most commonly used for percutaneous nephrolithotomy, adrenalectomy and pediatric pyeloplasty via the dorsal lumbotomy approach. During positioning, attention should be paid to avoid inadvertent extubation of the trachea and to maintain the neck in neutral posi‐ tion, fixed relative to the thorax. All pressure points, including forehead, chin, elbows, knees, shins and toes, must be properly padded.

A decrease in cardiac index (CI) can occur when turning patients from the supine to the prone position ranging from 12.9 to 24% [20].

In contrast to the supine position, the prone position results in a minimal reduction in func‐ tional residual capacity relative to the upright position [65].

Other rare complications related to the prone position are ophthalmic injury, upper airway edema and venous air embolism.

#### **7.3. The lithotomy position**

The lithotomy position is most frequently used for transurethral cystoscopy procedures or for open urologic procedures where access to the perineum and anus is necessary. Elevating the legs into the lithotomy position translocates the blood volume of the lower extremities into the central compartment, increasing venous return. Similar to the supine position, placing the legs into lithotomy position will shift the abdominal viscera cephalad into the diaphragm, decreasing lung capacities and compliance.

Neuropathy of the common peroneal nerve is the most common lower extremity neuropa‐ thy seen in the lithotomy position, accounting for 78% of lower extremity nerve injuries [66]. The obturator nerve, which supplies motor innervation to thigh adductors, may be stretched when the patient's hips are flexed beyond 80–100° [67]. Posterior tibial nerve, lateral femoral cutaneous nerve and saphaneus nerve can be injured during lithotomy position.

#### **7.4. The Trendelenburg position**

The Trendelenburg position is obtained by tilting the patient in the supine position to head down. According to the Trendelenburg position, abdominal organs move toward the dia‐ phragm and facilitate the exploration of lower abdomen and pelvis by surgeons. The arms should be abducted <90° in the neutral position preferably. Physicians should be careful about the sliding down of the arms from the board when patient is tilted [68].

The Trendelenburg position may cause visual loss by impairing the venous drainage of the head. If the patient's head below the level of the heart, increased intracranial and venous pres‐ sure can intensify the pressure on optic nerve [69].

Edema can be observed in head or neck, due to the increased intracranial and venous pres‐ sure caused by the prolonged Trendelenburg position. Swelling of the face, eyes, larynx and tongue may occur and is essential for indication of fluid resuscitation.

#### **7.5. The lateral decubitus position**

The lateral decubitus position generally is preferred to explore surreal gland, kidney or col‐ lecting system without entering the peritoneal space. This position is suitable for simple nephrectomy procedure, removing renal tones that required open surgery and ureter stones localized in the upper urinary system.

Cardiac output while in the lateral decubitus position should remain unchanged unless venous return is impeded. Ventilation is increased in the dependent lung and gas exchange remains unchanged [70].
