**4. Anesthesia for urethra and genital surgery**

#### **4.1. Oncological surgery of genital legion**

In this section, the title of oncologic surgery of the genital region covers the operations of radical orchiectomy and retroperitoneal lymph node dissection. Initial treatment of testicular cancer is radical orchiectomy with inguinal incision. Retroperitoneal lymph node dissection (RPLND) for the treatment of testicular cancer is a relatively rare and complex operation after chemotherapy.

#### *4.1.1. Preoperative consideration*

hyperglycinemiaand/or hyperammonemia if glycine is used [42, 43]. The amount and rate of fluid absorption depend on several factors such as hydrostatic pressure of the irrigation fluids, bladder distention, the size of opened venous sinuses and the length of resection time [44]. If there is a suspicion of TURP syndrome, operation must be terminated immediately and blood samples including electrolytes, creatinine, glucose and arterial blood gases must be sent for analyses and electrocardiogram should be obtained [45]. Treatment of hyponatremia and excessive fluid loading should be adjusted according to the severity of the patient's symp‐ toms. When patient's symptoms are mild (serum sodium level is greater than 120 mEq/L), only fluid restriction combined with loop diuretics can be enough to bring increased serum sodium levels to normal levels. If the serum sodium levels are less than 120 mEq/L, intrave‐ nous hypertonic saline administration is recommended for the patients with severe symp‐ toms. The 3% sodium chloride solution 100 mL/h should be infused and the patient's serum

sodium levels should be corrected at a rate not greater than 0.5 mEq/L/h [46, 47].

of the bladder, a neuraxial anesthesia should be used. The block level must be Th10.

Sedation and routine patient monitoring is enough for minor procedures. But other proce‐ dures such as suprapubic transvesical prostatectomy and TURP or necessitate full distension

Bleeding, transurethral resection syndrome (TUR), bladder perforation, hypothermia, intra‐ operative and early postoperative occurrence of disseminated intravascular coagulation are most common observed complications of TURP. Providing stable anesthesia is essential for these patients to minimize hemodynamic changes. Under the general anesthesia, it could be difficult to realize complications such as TUR syndrome and bladder perforation, so regional anesthesia is recommended for TURP operations [48, 49]. Side effects of TUR BT is bladder perforation that has a reported incidence of 0.9–5% and presents with the signs and symp‐ toms of inability to distend the bladder, low return of irrigation solution, abdominal dis‐ tension and tachycardia [50]. Rarely, intraperitoneal fluid extravasation related to bladder perforation during the TUR BT can be identified as 'TUR BT syndrome'. Similar clinic symp‐ toms can be observed like TUR P syndrome, but in TUR BT syndrome, intravascular fluid deficit that causes renal impairment is not observed. The mechanism of the possible causes of intravascular hypovolemia is that sodium equilibrates with the intraperitoneal fluid [51]. If the tumoral mass localized near the obturator nerve in bladder wall, bladder perforation may occur during the resection. The obturator nerve usually passes through the pelvis close to the lateral bladder wall, bladder neck and prostatic urethra. During the resection of bladder cancer, obturator nerve may stimulated by electrocautery that causes bladder perforation by the forceful thigh contraction of adductor muscles. Recently, combined neuraxial and obtura‐ tor nerve blockage is recommended to prevent this complication. This combined technique is recommended to reduce the complications of general anesthesia in these patients which often

*3.2.3. Choice of anesthesia*

60 Current Topics in Anesthesiology

*3.2.4. Complications*

covers older patients with lots of comorbidities.

The preoperative medical evaluation of cancer patients should include an assessment of nutri‐ tional status, functional status and symptom control (particularly regarding cancer‐related pain) in addition to an assessment of general medical issues. The natural history of the cancer and effects of any prior chemotherapy or radiation therapy should also be considered [52].

Pulmonary insufficiency may occur in patients who underwent retroperitoneal lymph node dissection and have adjuvant bleomycin preoperatively. Oxygen toxicity and fluid overload may also develop, too. Physicians must be careful in terms of developing acute respiratory distress syndrome postoperatively for these patients.

#### *4.1.2. Intraoperative consideration*

Routine monitorization of the patient is enough. If bradycardia occurs, surgeon must be warned to reduce the stretch of the spermatic cord and if it does not improve, 1 mg atropin should be given.

#### *4.1.3. Choice of anesthesia*

Neuraxial anesthesia has been considered as the anesthetic technique of choice for radical orchiectomy. Sensorial block level must be Th10, but minimized to psychiatric trauma, seda‐ tion must be added to neuraxial blockade. For the RPLND procedure general anesthesia must be chosen. If neuraxial blockade is chosen (if general anesthesia is contraindicated), high‐level sensorial block (Th4) with sedation must be performed.

#### *4.1.4. Complications*

Sometimes in this procedure, vagal reflex and bradycardia can occur during the operation due to stretch of the spermatic cord and patient can feel pain.

#### **4.2. Nononcological surgery of urethra and genital legion**

This section covers urological procedures such as cystoscopy, urethrotomy interna, scrotal orchiectomy, hydrocelectomy, varicocelectomy and penile prosthesis implantation.

#### *4.2.1. Preoperative consideration*

These procedures generally do not require any particular anesthetic technique, depending upon the procedure, the medical condition of the patient and patient's and/or surgeon's pref‐ erence, one technique may be more appropriate.

#### *4.2.2. Intraoperative consideration*

Routine monitorization is advised. During the varicocelectomy, bradycardia can occur due to stretch of the spermatic cord.

#### *4.2.3. Choice of anesthesia*

Many of these procedures are ambulatory, performed in cystoscopy suites with a rapid turn‐ over of patients and the anesthetic choice must also consider these concerns. Evaluation of the lower urinary system tract is often performed by the urologist with a flexible cystoscope. This procedure generally performed by the urologist with local topical anesthesia applied to the inside of the urethra as it does not require full bladder distention. If patient could not tolerate pain, the procedure must be performed under monitored anesthesia care with sedation [53]. Neuraxial anesthesia has been long considered the anesthetic technique of choice for these urological procedures. The sensorial block level must be Th10.

#### *4.2.4. Complications*

During the varicocelectomy, bradycardia can occur due to stretch of the spermatic cord.
