**3. Anesthesia for bladder and prostate**

#### **3.1. Oncological surgery of bladder and prostate**

This part covers transurethral resection of bladder tumor (TUR BT), radical cystectomy and radical prostatectomy operations as urological surgery. Bladder cancer is the fourth most common cancer in the United States. Initial diagnosis and treatment of non‐muscle invasive bladder cancer is TUR BT. Radical cystectomy is the treatment of choice for invasive urinary bladders tumors. Prostate cancer is a major cause of morbidity and mortality and it is esti‐ mated that there will be 240,890 new diagnoses of prostate cancer in 2011 and that prostate cancer will be responsible for approximately 33,720 deaths in 2011 [28].

#### *3.1.1. Preoperative considerations*

Average blood loss associated with radical cystectomy has been reported from 560 to 3000 mL [29, 30] and blood loss associated with radical retropubic prostatectomy is commonly reported between 550 and 800 mL, although higher estimates are infrequently reported [31, 32]. Blood transfusion for patients with high risk of bleeding has been recommended before elective procedures.

In patients who underwent surgery, the major and most common causes of the nonsurgical death are deep vein thrombosis (DVT) and related pulmonary thromboembolism. Especially, patients who underwent radical surgery such as prostatectomy and cystectomy have major risk factors for development of DVT due to malignancy, surgery, immobility and advanced age. For good postoperative care of patients and to prevent the development of DVT, DVT profilaxy is needed before the surgery in patients with high risk for DVT. The risk of devel‐ opment DVT in patients undergoing open radical prostatectomy without DVT profilaxy is estimated to be 32% [33].

#### *3.1.2. Intraoperative considerations*

Because of the possible excessive blood loss, wide‐channel venous cannula is required. After positioning the patient, arterial cannula should be placed for monitoring the patient. If there is a risk for excessive blood loss, central venous catheter should be utilized for purpose of transfusion. However, central venous pressure monitoring could not demonstrate cardiac performance related to fluid infusion [34].

#### *3.1.3. Choice of anesthesia*

General endotracheal anesthesia is indicated; consideration should be given to a combined general/neuraxial technique for postoperative analgesia [35]. The sensorial block level must be Th10 for TUR BT and Th6 for radical cystectomy or prostatectomy. Especially, obturator nerve blockade should be added to neuraxial block to prevent the adductor jerk due to electri‐ cal stimulation of cautery applied in lateral wall localized tumors of the bladder. Obturator nerve block is performed following verification of the level of spinal anesthesia with the patient in lithotomy position. A 21 gauge 100 mm stimulable needle is inserted perpendicu‐ larly 2 cm inferior and 2 cm lateral point from the pubic tubercle. According to the "traditional approach", the needle was inserted from the skin through the inferior rami of the pubic bone, redirected anterolaterally and contacting with the obturator nerve after advancing to a depth of 2–4 cm. After the contraction of adductor muscle group was observed, 10 mL 0.25% levobu‐ pivacaine was administered with current at 0.3–0.5 mA [3, 4].

#### *3.1.4. Complications*

The anesthesiologist should always consider that patients underwent radical cystectomy and urinary diversion could produce bacteremia. If ileal conduit operation performed, ionic alterations may cause metabolic disturbances. This disorder usually emerges in the form of hyperchloremic metabolic acidosis. When urine contact with intestinal segment, ammonium, ammonia, hydrogen and chloride are reabsorbed from intestinal segment. Alkalizing agents or drugs such as chlorpromazine or nicotinic acid that blockade the chloride transport can be used successfully for the treatment of this disorder [35].

Hemorrhage is the most common observed complication of radical surgery in urological field. For radical prostatectomy operations during the pelvic lymph node dissection hypogastric veins can be injured and results in extensive blood loss. Similarly, the deep dorsal vein com‐ plex can be injured during the transection of this vein complex and extensive blood loss may also occur. Additionally, deep vein thrombosis and pulmonary thromboembolism are other radical prostatectomy‐related major complications [30].

#### **3.2. Nononcological surgery of bladder and prostate**

Nononcological urological surgery procedures of bladder and prostate include such as trans‐ urethral resection of prostate, suprapubic transvesical prostatectomy and cystoscopy. Most patients with bladder obstruction caused by benign prostatic hyperplasia are successfully treated by transurethral resection of the prostate (TURP) or, if prostate size is over than 70 cc, suprapubic transvesical prostatectomy could be performed [36]. Diagnostic examination of the lower urinary tract is often performed using a cystoscope and initial diagnosis and treat‐ ment of bladder cancer is conducted by transurethral resection of bladder.

#### *3.2.1. Preoperative considerations*

bladders tumors. Prostate cancer is a major cause of morbidity and mortality and it is esti‐ mated that there will be 240,890 new diagnoses of prostate cancer in 2011 and that prostate

Average blood loss associated with radical cystectomy has been reported from 560 to 3000 mL [29, 30] and blood loss associated with radical retropubic prostatectomy is commonly reported between 550 and 800 mL, although higher estimates are infrequently reported [31, 32]. Blood transfusion for patients with high risk of bleeding has been recommended before

In patients who underwent surgery, the major and most common causes of the nonsurgical death are deep vein thrombosis (DVT) and related pulmonary thromboembolism. Especially, patients who underwent radical surgery such as prostatectomy and cystectomy have major risk factors for development of DVT due to malignancy, surgery, immobility and advanced age. For good postoperative care of patients and to prevent the development of DVT, DVT profilaxy is needed before the surgery in patients with high risk for DVT. The risk of devel‐ opment DVT in patients undergoing open radical prostatectomy without DVT profilaxy is

Because of the possible excessive blood loss, wide‐channel venous cannula is required. After positioning the patient, arterial cannula should be placed for monitoring the patient. If there is a risk for excessive blood loss, central venous catheter should be utilized for purpose of transfusion. However, central venous pressure monitoring could not demonstrate cardiac

General endotracheal anesthesia is indicated; consideration should be given to a combined general/neuraxial technique for postoperative analgesia [35]. The sensorial block level must be Th10 for TUR BT and Th6 for radical cystectomy or prostatectomy. Especially, obturator nerve blockade should be added to neuraxial block to prevent the adductor jerk due to electri‐ cal stimulation of cautery applied in lateral wall localized tumors of the bladder. Obturator nerve block is performed following verification of the level of spinal anesthesia with the patient in lithotomy position. A 21 gauge 100 mm stimulable needle is inserted perpendicu‐ larly 2 cm inferior and 2 cm lateral point from the pubic tubercle. According to the "traditional approach", the needle was inserted from the skin through the inferior rami of the pubic bone, redirected anterolaterally and contacting with the obturator nerve after advancing to a depth of 2–4 cm. After the contraction of adductor muscle group was observed, 10 mL 0.25% levobu‐

The anesthesiologist should always consider that patients underwent radical cystectomy and urinary diversion could produce bacteremia. If ileal conduit operation performed, ionic

cancer will be responsible for approximately 33,720 deaths in 2011 [28].

*3.1.1. Preoperative considerations*

elective procedures.

58 Current Topics in Anesthesiology

estimated to be 32% [33].

*3.1.3. Choice of anesthesia*

*3.1.4. Complications*

*3.1.2. Intraoperative considerations*

performance related to fluid infusion [34].

pivacaine was administered with current at 0.3–0.5 mA [3, 4].

This procedure is often performed on older patients with impaired renal function, cardio‐ vascular and respiratory problems. Thus, it is important to limit the block level to minimize hemodynamic changes during the spinal anesthesia in such patients [37, 38].

#### *3.2.2. Intraoperative considerations*

During the resection of prostate, surgeon must take maximum care not to damage prostatic capsule. In 2% of the patients who underwent resection of the prostate, capsule perforation may occur. In these patients, symptoms such as restlessness, nausea, vomiting and abdominal pain can be observed. If perforation occurred, the operation must be terminated immediately [39]. Bleeding may occur during the TURP but can be controlled easily. Since the irrigation fluids and blood mix during the TURP, it is difficult to determine the amount of bleeding. According to the researches, estimated bleeding during the TURP operation is 2–4 mL/min of resection time or 20–50 mL/g of resected prostatic tissue [40]. The need for transfusion due to hemorrhage during TURP is in 2.5% of patients undergoing TURP [41].

The clinical presentation of TURP syndrome is multifactorial, initiated by excessive absorp‐ tion of irrigating solution that affects central nerve system (CNS), cardiovascular, respira‐ tory and metabolic homeostasis. Initial signs of TURP syndrome cover burning sensations in the face and neck along with lethargy and apprehension. Additionally, headache and irri‐ tability may be observed due to affected CNS. Finally, visual disturbances, confusion, sei‐ zures and eventually coma may be observed. These CNS disturbances have been attributed to hyponatremia, which occurs with the absorption of any type of irrigating solution and 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].

#### *3.2.3. Choice of anesthesia*

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

#### *3.2.4. Complications*

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 covers older patients with lots of comorbidities.
