What the Anesthesiologist Should Know before the Operative Procedure
Many patients with bladder tumor choose radical cystectomy (RCX) as the treatment. RCX remains the most effective treatment for muscle invasive bladder cancer and for recurrent high-grade nonmuscle invasive bladder cancer (NMIBC) tumors. Different organs are moved for males and females. Because cystectomy interrupts the normal conduit for urinary flow, a urinary reservoir usually is created. A continent urinary diversion is frequently utilized. Many patients request continent diversion to maintain “normal” anatomy this entails making a section of bowel into a neobladder. The neobladder is then connected to the urethral with intact sphincter, such that normal urinary emptying is maintained. Alternatively a bowel segment, usually ileum, can be created to connect the ureters to the bowel segment that then is fashioned into a stoma at the skin. Urinary reconstruction in order to maintain a normal voiding pattern then can be performed either immediately after cystectomy or as an elective procedure afterwards.
Cystectomy is mainly categorized as partial and total cystectomy. Total cystectomy is also classified as radical or simple cystectomy.
Partial cystectomy is also called segmental cystectomy. While partial cystectomy is an option for bladder tumor resection, it is only used infrequently. The surgery involves resecting only the area of the bladder where the cancer is located or where an injury exists so that most of the bladder is preserved. Partial cystectomy is often performed if the cancer spread has not invaded the muscle layer of the bladder wall, or if it remains isolated to one area.
Simple cystectomy is defined as the removal of the entire bladder without removal of adjacent structures or organs and is infrequently performed today. Simple cystectomy also implies that there is no dissection of the pelvic lymph nodes. It may be indicated for neurogenic bladder complicated by frequent urinary tract infections. Initially, simple cystectomy was not routinely included during supravesical diversion which is indicated for pelvic malignancies, interstitial cystitis, cyclosphosphamide cystitis, severe incontinence, neurogenic bladder, severe urethral trauma, and obstruction of the upper tracts. But complications from the retained bladder occur in up to 80% of patients undergoing supravesical diversion without simple cystectomy and include pyocystis, hemorrhage, sepsis, pain, vesicocutaneous fistula, colovesical fistula, feelings of incomplete emptying, and development of cancer in the retained bladder. Because of the high complication and reoperation rate, simple cystectomy is recommend as a part of upper tract diversion in a patient whose urinary diversion is not expected to be reversed, and especially in patients who have some component of bladder outflow obstruction.
Radical cystectomy is to resect the entire bladder together with other pelvic organs and structures. The surgical procedure for radical cystectomy differs between male and female patients. In men, the prostate, seminal vesicles, and pelvic lymph nodes are removed with the bladder. In women, the uterus, fallopian tubes, ovaries, anterior wall of the vagina, and pelvic lymph nodes are removed with the bladder.
Once the entire bladder is removed, the urine must be diverted. A variety of urinary diversion options exist for patients undergoing a cystectomy. In some institutions, the number of cystectomy patients undergoing orthotopic neobladder diversion has greatly increased. Another exciting type of “diversion” that may have clinical applications in the near future is the tissue-engineered neobladder that uses autologous urothelial and smooth-muscle cells cultured on biocompatible synthetic or naturally derived substrates. Usually, patients who want to resume normal daily activities as soon as possible may be better served with an incontinent cutaneous diversion (conduit) rather than a neobladder. Currently, there is no evidence that one diversion is superior to others in term of life quality.
Surgical procedures for cystectomy include traditional open and minimally invasive cystectomy. Minimally invasive radical cystectomy, including laparoscopic radical cystectomy and robotic radical cystectomy, are a recent development and had gained popularity due to the potential benefits of lower surgical blood loss, early return of bowel function, and more rapid postoperative convalescence than conventional open procedures.
Open radical cystectomy
Radical cystectomy encompasses the removal of the bladder and the lower ureters, the prostate gland, and seminal vesicles in men, and the uterus, ovaries, and anterior vaginal wall in women. When accompanied by a pelvic lymphadenectomy, it is performed in the supine position, except when a concomitant urethrectomy is required, wherein a lithotomy position is used.
Following cystectomy, whether radical or simple, some form of urinary diversion is required. This can be accomplished with either a standard ileal conduit or a bladder substitution. An ileal conduit is constructed from 6 to 8 inches of terminal ileum isolated, with its blood supply, from the small intestine. The continuity of the small conduit and the distal end is brought through the abdominal wall as a stoma. The alternative, a bladder substitution, a more complex operation requires a longer segment of bowel to be isolated with its blood supply, and then to be fashioned into a pouch. For both diversion procedures the ureters are implanted into the bowel segment. For the continent diversion, the bowel is fashioned into the pouch and the most dependent part of the pouch is connected to the membranous urethra, whereas for the standard ileal conduit one end of the bowel loop is externalized to the skin into a stoma. Not all patients undergoing cystectomies are candidates for bladder substitution. For example, patients who require a urethrectomy are not candidates because of the need to remove the urethra.
Laparoscopic cystectomy is a form of minimally invasive surgery, performed through small incisions with the use of a laparoscope to view the bladder and the surrounding tissues. The bladder is approached transperitoneally. The lymphadenectomy can be done before or after the cystectomy procedure. Carbon dioxide is pumped into the surgical site to create space for access to the bladder and adjacent tissues. The cardiovascular and respiratory effects of pneumoperitoneum and the possibility of marked respiratory acidosis due to the absorption of carbon dioxide should be the concerns of anesthesia care providers. This is particularly important if the patient has respiratory insufficiency and/or pulmonary hypertension.
With the increasing adoption of robot-assisted laparoscopic techniques for prostate and kidney cancers, there has been growing interest in robot-assisted radical cystectomy. When performing robotic surgery, the surgeon sits at a console with a three-dimensional view of the operating field and controls the movements of miniature instruments at the end of robotic arms inserted through several small incisions. The movement of the surgeon’s hands is translated into precise movement of the instruments in the surgical field. Early outcomes obtained with this new technique are comparable with laparoscopic and open cystectomy as shown by retrospective studies. Long-term oncologic follow-up and, ideally, randomized prospective studies are needed to further compare these two approaches.
Following abdominal exploration and removal of the bladder and gender-specific associated pelvic organs, urinary diversion operations proceed by the isolation, transection, and transposition of the ureters to an appropriate place for subsequent diversion. Often ideal conduit creation is performed by hand through a small opening of abdominal wall.
1. What is the urgency of the surgery?
What is the risk of delay in order to obtain additional preoperative information?
Urgent radical cystectomy is rarely indicated. But delay of the procedure may confer an increased risk of disease-specific and tumor metastasis along with the anxiety of the patient and/or family members.
Emergent: Radical cystectomy is not emergent. Physicians should have time to optimize the patient’s conditions before operation.
Urgent: Urgent radical cystectomy is rarely indicated, unless there is active bleeding from the bladder which cannot be controlled non-surgically.
Elective: This surgery is never truly elective, since the majority of radical cystectomy operations are performed for the removal of invasive bladder tumors and should be performed as soon as the patient’s condition is optimized. Delay of the procedure may confer an increased risk of disease-specific and tumor metastasis along with the anxiety of the patient and/or family members.
2. Preoperative evaluation
Bladder tumor is predominantly a disease of the aging population, with a peaking incidence in the seventh decade when comorbid conditions are frequently present. The comorbidities include coronary artery disease, chronic obstructive pulmonary disease, atherosclerosis, and cerebrovascular accidents and further emphasize the importance of preoperative evaluation. A thorough pulmonary and cardiac evaluation must be conducted. The patient’s medications should be reviewed with extra attention to the agents such as aspirin, clopidogrel, and nonsteroidal anti-inflammatory drugs (NSAIDs) that can contribute to perioperative bleeding.
These medications should be discontinued and therapeutic anticoagulation reversed before surgery, when possible. Patients with coronary artery stents or other vascular stenoses should have the risks of distal infarction and surgical bleeding weighed carefully, ideally in consultation with physician who prescribed these drugs. In addition, a chest radiograph, electrocardiogram, routine electrolytes, coagulation studies, and a complete blood count are usually obtained for these patients before surgery.
Medically unstable conditions warranting further evaluation include: recent myocardial infarction (MI), unstable arrhythmias, stroke, transient ischemic attack (TIA), and chronic obstructive pulmonary disease (COPD) exacerbation. They warrant further assessment, consultation, work-up and optimization.
Delaying surgery may be indicated: Both patients and physicians should avoid any unnecessary delays if cystectomy is the treatment of bladder cancer. Although a consensus does not exist on how long is too long to wait for a cystectomy, there is general agreement that a cystectomy should be scheduled within 3 months of diagnosis of muscle invasive bladder cancer. Delaying surgery may be indicated if unstable medical conditions exist that justify further evaluation, such as a preoperative cardiac risk assessment with testing. Otherwise, additional testing may be unnecessary.
3. What are the implications of co-existing disease on perioperative care?
The objective of preoperative assessment is to identify and optimize any disease state. It is important to differentiate between chronic stable diseases and clinical states which need further specialist’s input. Concurrent medical therapy can be assessed and optimized for the perioperative period with appropriate preoperative testing.
Perioperative risk reduction strategies
Since bladder cancer is predominantly a disease of the aging population, the patient often has comorbid medical conditions like serious cardiac and pulmonary complications which are responsible for significant morbidity and mortality.
One overriding theme of the ACC/AHA Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery suggests that preoperative intervention is rarely necessary simply to lower the risk of surgery unless such intervention is indicated irrespective of the preoperative context. For example, patients who should undergo preoperative surgical revascularization are those whose long-term outcomes would be improved by CABG. CABG should not be done just to get the patient through the noncardiac surgery. Careful consideration also must be given before percutaneous coronary intervention.
Angioplasty is frequently accompanied by coronary stent placement, which may require a prolonged period of antiplatelet therapy. Surgery without a sufficient period after withdrawing antiplatelet therapy may increase bleeding risks, while risks from stent thrombosis increase if the antiplatelet therapy is terminated prematurely. For the patient who has a metal stent, particularly a drug-coated metal stent, and when antiplatelet therapy and/or anticoagulation regimens are altered preoperatively, the therapy should be resumed postoperatively as soon as clinically feasible. To balance the risk and benefit of these therapies, the decision to restart them should be made after a discussion between the cardiologist and the attending surgeon.
Pulmonary complications are common postoperatively for these patients. Several trials demonstrate that groups benefitting from perioperative contributions from respiratory therapies (intermittent positive-pressure breathing versus incentive spirometry and deep-breathing exercises) had a lower incidence of complications and shorter hospital stays than a control group. However, other studies have not shown a benefit for such interventions. Further trials are needed to determine if there is any role for incentive spirometry.
b. Cardiovascular system:
Patients may have hypotension or arrhythmias due to acute MI/unstable angina. If history, physical examination, or clinical suspicion suggest these conditions, further evaluation is needed which may include a 12-lead ECG, continuous ECG monitoring, cardiac biomarkers (e.g., troponin), resting echocardiogram (regional wall motion abnormality), with input from a cardiologist. Acute ischemia needs to be treated prior to surgery. Severe bradycardia or atrioventricular block may require a temporary pacemaker (transcutaneous, esophageal, transvenous). Ventricular tachycardia or ventricular fibrillation requires immediate cardioversion or defibrillation.
Baseline coronary artery disease or cardiac dysfunction
These patients should have a complete clinical history (functional status, changes in exercise tolerance, fatigue), prior ECG or noninvasive stress testing, and communication with a cardiologist or primary care physician. Outcome studies do not demonstrate a change when preoperative cardiac testing is performed in intermediate risk patients, or patients without signs or symptoms of acute ischemia, regardless of the physiologic stress of surgery.
Perioperative risk reduction strategies
Monitoring: Consider placing a pre-induction arterial line. Full perioperative hemodynamic monitoring (CVP, PA line, TEE) may also be warranted. Intraoperative assessment of intravascular volume status becomes more complex when the ureters are disconnected from the bladder or the diverting loop.
Goals: Optimize myocardial oxygen supply to demand ratio.
- Increase O2 supply
FiO2—Consider using higher FiO2 to achieve SpO2 near 100%.
Hemoglobin—A transfusion may increase oxygen carrying capacity.
Heart rate—Consider reducing heart rate with beta blockers or calcium channel blockers in order to increase perfusion time during diastole, as the left ventricle is perfused only in diastole. However total cardiac output may be reduced by slower heart rates if the ventricle cannot increase stroke volume to compensate.
Coronary perfusion pressure—Optimize coronary perfusion pressure, a determinant of the blood flow to cardiac muscle. This is diastolic pressure minus left ventricular diastolic pressure.
Minimize substantial hypercarbia—Hypercarbia may cause intense sympathetic discharge and significant increase in plasma catecholamine levels. But the response can be diminished by general anesthesia. When PaCO2 levels reach 56 to 65 mmHg, cardiac oxygen demand significantly increases, while coronary filling time shortens, as indicated by the increase in the tension time index and decrease in the diastolic time. This signifies a relative myocardial underperfusion.
- Reduce O2 demand
Heart rate—Beta blockers or calcium channel blockers reduce heart rate and oxygen consumption.
Contractility—Beta blockers and calcium channel blockers reduce contractility and O2 demand.
Afterload—This needs to be optimized. An increased afterload (systemic vascular resistance, SVR) raises the resistance and the pressure the heart needs to generate to create flow, hence myocardial oxygen consumption (pressure work) increases. However, if afterload is too low, it may reduce coronary perfusion pressure and reduce coronary artery blood flow.
Preload—Needs to be optimized to maintain adequate stroke volume, without over distending the ventricular cavity at the end of diastole, thereby pushing too far along Frank-Starling curve (avoid increasing pressure work). Such optimization may be especially difficult for patients with “diastolic dysfunction” which may occur with left ventricular hypertrophy.
Patients with pulmonary diseases are at high risk of postoperative lung dysfunction including pneumonia. Perioperative hypoxia may result from impaired cough force, pulmonary emboli, atelectasis, consolidation due to infection, or pulmonary congestion (and effusion) due to acute or chronic heart failure. Additionally increase in age leads to higher alveolar-arterial gradient of oxygen due to an increase in closing volumes and intra-pulmonary shunt.
Preoperative evaluation: Careful clinical history must be obtained including pack-year smoking history, status and frequency of exacerbations, oxygen requirements, current medication regimen (including steroid use), and available recent studies (spirometry). Unless an acute exacerbation is suspected, pulmonary testing may unnecessarily delay surgery.
Perioperative risk reduction strategies
1) Continue current pulmonary medications perioperatively; consider starting nebulizer and/or steroid therapy if appropriate (e.g., severe disease).
2) Pursue maneuvers intraoperatively to optimize gas exchange, including applying appropriate PEEP.
3) Epidural analgesia may be very beneficial for patients with severe cardiopulmonary comorbidities. For such a population, epidural analgesia both provides not only adequate pain control post-operatively but also significantly reduces systemic narcotic use with its related complications. While clinical experience indicates the benefit of epidural analgesia, there is no randomized trial proving the benefit of the epidural analgesia for cystectomy.
4) Due to the long duration of such procedures, general anesthesia should be provided and be maintained with inhalation agents for bronchodilation. However, any inhalation agent provoking bronchospasm, for instance desflurane, probably should be avoided. If a patient has pulmonary hypertension, nitrous oxide should be avoided due to its potential risk for worsening pulmonary hypertension. During maintenance, keep patients well anesthetized to avoid bronchospasm, adjust the ventilation I: E ratio to allow for adequate expiratory time to minimize auto-PEEP, and use PEEP to reduce atelectasis and shunting. However, caution should be made not to rupture an emphysematous bleb.
5) Postoperative—Apply appropriate pulmonary toilet, incentive spirometry, nebulizer and steroid therapy if necessary.
Reactive airway disease (asthma)
Preoperative evaluation: Assess severity of disease including frequency of exacerbations, triggers (cold weather, environmental, medications, and upper respiratory infections), routine and rescue medications, recent oral or IV steroid therapy, emergency room visits, hospitalizations, ICU admissions and intubations.
Perioperative risk reduction strategies: Continue control medications perioperatively and consider a course of nebulizer and/or steroid therapy if the patient has moderate to severe disease. Perioperative systemic corticosteroids are recommended for persistent symptoms if the peak flow rate and FEV1 are less than 80% predicted or below a previous best. As with COPD, post-operative epidural analgesia is recommended for severe asthma. The management of general anesthesia should be similar to that with COPD for induction, maintenance, and postoperative care in order to avoid bronchospasm.
Preoperative evaluation: Patients with bladder cancer generally are elderly. Radical cystectomy and urinary division are long in duration and create substantial surgical insult, so acute and chronic risk factors, and the likelihood of perioperative renal compromise may exist. This necessitates a thorough preoperative assessment of renal function.
- Urinalysis provides qualitative information that should be interpreted cautiously. While hematuria may suggest glomerular disease, injury to the kidneys or the lower urinary tract, it may be triggered by the bladder cancer. Pyuria may indicate urinary tract infection. Red blood cell casts may suggest interstitial nephritis, including pyelonephritis. Urinary pH, may assist in the diagnosis of some acid-base disturbances. The presence of proteinuria on a routine dipstick examination either may be normal, or suggest severe renal disease. Should any abnormal test exist or disease be suspected, further testing and therapy should occur prior to surgery. Because patient with bladder cancer often present with hematuria and RBC in urine may makes the interpretation of urine test different.
- Plasma creatinine and urea concentrations provide information about general renal function. A trend in serum creatinine values is always more useful than a single serum measurement. The simultaneous determination of BUN and serum creatinine levels offers a more complete evaluation of renal function than either determination alone. Elevated creatinine may underestimate the degree of renal impairment for females or for patients with reduced muscle mass. These measurements (BUN, and creatinine clearance) require careful interpretation, although delaying surgery to measure creatinine clearance is rarely indicted. If test results acutely deviate from baseline values levels obviously, surgery should be delayed until these parameters stabilize.
- Serum electrolyte concentrations and arterial blood gas may reveal a metabolic acidosis or electrolyte imbalance.
Perioperative risk reduction strategies: Minimize exposure to factors that can compromise renal function.
- Nephrotoxic drugs (aminoglycosides, NSAIDs).
- Hypotension. Major hemorrhage stemming from removal of the bladder and adjacent structures may occur and the use of invasive monitoring may be appropriate. Large bore intravenous access is recommended because of the risk of bleeding and potential massive transfusion.
- Volume status. Often, cystectomy is long operation, with a large incision, and substantial potential for fluid shifts and intraoperatively measuring urine output becomes difficult. Therefore, assessment of the patent’s volume status can be very challenging. This is particularly important for patients with heart failure. Furthermore, many of the patients may have concurrent chronic renal insufficiency. Therefore, patients may have limited ability to eliminate administered fluids.
We often measure CVP via external jugular vein, or estimate CVP by transducing pressure from a peripheral vein. Ideally, CVP is measured at beginning of the surgery after intraoperative patient positioning, and the trend is followed afterwards. However, such CVP measurements may not reflect PCWP, and they may not accurately predict the volume status trends, especially when vasopressors are being used. For the patients whose cardiopulmonary function is within normal range, CVP should closely approximate PCP.
A preoperative bowel preparation may render the patient dehydrated. Adequacy of rehydration may not be easy to determine as once the bladder is open, when urine output cannot measured. To the extent possible we would recommend performing rehydration prior to this point. Patients with end stage renal disease may need cystectomy due to recurrent urinary tract infections. Such patients may benefit from placing a central venous line preoperatively to guide fluid requirement and as well as for drug delivery.
- Sepsis. Infection should be treated promptly and preoperatively.
Select anesthetic drugs
The termination of action of most anesthetic drugs is due to redistribution, metabolism, and elimination. Biotransformation of these drugs usually results in pharmacologically inactive forms of the parent compound which are water soluble and excreted through kidney. Some non-depolarizing muscle relaxants (except atracurium and cisatracurium) are largely eliminated by the kidney, and dose reduction may be required for patients with impaired renal function. Dosing is best managed by assessing quantitative neuromuscular function. Succinylcholine (suxamethonium) administration causes a rise in serum potassium, which may be dangerous in patients who have hyperkalemia. Some drugs metabolites secreted to urine may be reabsorbed through epithelium of conduit and drug pharmacokinetics may be altered.
Preoperative evaluation: Assess the likelihood of perioperative aspiration. Particular attention is needed determine whether the patient has a full stomach and/or symptoms of gastroesophageal reflux disease.
Perioperative risk reduction strategies for pulmonary aspiration: Prior to general anesthesia or neuraxial blocks, consider awake nasogastric tube placement to empty stomach, and promotility agents, H2-blockers, and/or antacid medications. Nasogastric tube usually is left in place after completion of the surgery and is removed once bowel peristalsis returns, if an ileal loop conduit is created.
TIA and stroke are unstable medical issues that need to be resolved prior to surgery. Pre-operative evaluation: Detailed history should be taken and thorough neurologic exam should be performed (loss of consciousness, history of cerebrovascular disease, neurological deficits). If further evaluation is necessary (CT, MRI, carotid Doppler, echocardiogram, or neurology consult), it should take place prior to surgery.
A history of carotid disease may necessitate higher blood pressures in order to maintain adequate cerebral perfusion; arterial line is often needed. Regional anesthesia is not contraindicated. However, one should consider epidural analgesia induced by small, repeated boluses to avoid abrupt sympatholysis and to allow time for treatment of hypotension. Consider phenylephrine infusion. A bolus of local anesthetics via epidural catheter should be avoided during the operative bowel reanastomosis and intestinal peristalsis that could create unnecessary difficulty performing the anastomosis.
This is a common multisystem disease and often affects the renal system via microcirculatory changes or direct effects. An appropriate plan should be made for the management of glucose levels in such patients throughout the perioperative period.
Preoperative evaluation: This should be directed at establishing the impact on other organ damage and planning diabetic control through the perioperative period. The glycosylated hemoglobin level is not influenced by fasting and, if available, can identify those with poor control. The American Diabetes Association recommends target glycosylated hemoglobin of less than 7%.
Perioperative risk reduction strategies:
- For insulin-dependent patients undergoing major surgery, the insulin treatment program should be developed with intraoperative glucose levels determined every 2 hours. This should be instituted before surgery and maintained throughout the recovery period.
- Avoid hypoglycemia. The American College of Endocrinologists proposed statement recommends a target fasting glucose level of less than 110 mg/dL in noncritically ill hospitalized patients. However, data regarding the influence of intensive insulin therapy on outcome after major surgery are relatively scarce, although setting a target level too low risks creating hypoglycemia. Clinical presentation of hypoglycemia is masked by general anesthesia, so careful monitoring becomes essential when insulin is administered. Recommendations of the American Association of Clinical Endocrinologists and the American Diabetes Association include identifying elevated blood glucose in hospitalized patients, establishing a multidisciplinary approach to diabetes management in the ICU and other settings.
g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
The degree of systemic inflammation and hematological disorders in invasive bladder cancer are often associated with more aggressive disease. Preoperative of hemoglobin levels, serum C-reactive protein and platelet counts is important in the predictive accuracy of risk factors.
4. What are the patient’s medications and how should they be managed in the perioperative period?
Anesthesiologist should obtain a medication history from the patient prior to surgery, including vitamins, herbs and supplements, and understand the classification, indication and common side effects of such treatments. A general recommendation is for patients to take their routine medications during perioperative period with exceptions pertaining to: (1) monoamine oxidase inhibitors, (2) anticoagulants and fibrinolytic drugs (e.g., clopidogrel [Plavix]) if surgical hemostasis is needed, (3) nicotinic acid, (4) dosage adjustments for insulin and corticosteroids, (5) ACE inhibitors and receptor antagonists (angiotensin II receptor blocking drugs), and (6) drugs for erectile dysfunction (i.e., sildenafil [Viagra], vardenafil [Levitra], tadalafil [Cialis], or similar drugs).
Suggestions on commonly used medications:
- Antihypertensive medications—Continue on the day of the operation or procedure.
- Diuretics—Continue on the day of the operation or procedure.
- Cardiac medications (e.g., digoxin)—Continue on the day of the procedure.
- Antidepressant, antianxiety, and psychiatric medications—Continue on the day of the operation or procedure.
- Thyroid medications—Continue on the day of the operation or procedure.
- Birth control pills—Continue on the day of the operation or procedure.
- Eye drops—Continue on the day of the operation or procedure.
- Heartburn or reflux medications (e.g., Prilosec, Zantac)—Continue on the day of the operation or procedure.
- Narcotic pain medications—Continue on the day of the operation or procedure.
- Antiseizure medications—Continue on the day of the operation or procedure.
- COX-2 inhibitors—Continue on the day of the operation or procedure unless the surgeon specifies (usually concerned about bone healing).
- NSAIDs—Usually continue on the day of the operation or procedure.
- Anticoagulants (heparins, warfarin) —Continue for minor surgery, discontinue at an appropriate interval before major surgery, and consider bridging anticoagulation for patients at high risk for interim thrombosis.
- You need to discuss drugs such as clopidogrel (discussed drugs on next page)
- Vitamins, iron, Premarin—Discontinue on the day of the operation or procedure.
- Topical medications (e.g., creams and ointments)—Discontinue on the day of the operation or procedure.
- Oral hypoglycemic drugs—Discontinue on the day of the operation or procedure.
- Insulin— Patients on intermediate-acting insulin should take at least one half to two thirds of their evening dose the night before and on the morning of surgery, because approximately one half of insulin is used for non-nutrient metabolic needs. Insulin coverage should be anticipatory and dosed for basal coverage (with long-acting and intermediate-acting agents) and mealtime doses, with additional units for coverage as needed (with short-acting or ultrashort-acting insulin). Insulin administration should also mirror the route and frequency of nutrient intake; continuous feedings require more continuous insulin administration.
- Viagra, Levitra, Cialis, or similar drugs—Discontinue 36 hours before surgery.
- Herbals and nonvitamin supplements—Discontinue 7 days before surgery.
- MAOIs(monoamine oxidase inhibitors)—Patients taking these antidepressant medications need an anesthesia consultation before surgery (preferably 3 weeks before surgery).
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
Patients undergoing cystectomy and urinary division have an age-related increased incidence of cardiovascular diseases, pulmonary diseases and diabetes. Much attention should be directed to medications taken for these co-existing diseases.
i. What should be recommended with regard to continuation of medications taken chronically?
Beta blockers: Beta blockers should be continued for patients who already receiving beta blockers to treat angina, symptomatic arrhythmias, hypertension, or other ACC/AHA class I guideline indications, and for patients undergoing vascular surgery who are at high cardiac risk. Perioperative addition of beta blockers may be recommended for certain patients undergoing vascular surgery in who have identified CHD and are categorized as having a high cardiac risk. However, studies have not elucidated the ideal length of therapy, if a particular beta blocker is more effective or how long postoperatively a patient should continue therapy. Additionally, new institution of beta blockers perioperatively may be associated with an increased risk of stroke and death. The usefulness of beta blockers is uncertain for patients who are undergoing either intermediate-risk procedures or vascular surgery, in whom preoperative assessment identifies a single clinical risk factor, and those undergoing vascular surgery with no clinical risk factors.
Statins: Statins should be continued for patients scheduled for noncardiac surgery. For patients undergoing vascular surgery with or without clinical risk factors, statin use is reasonable. And statins may be considered for patients undergoing intermediate-risk procedures with at least 1 clinical risk factor.
Aspirin: Restart as soon as possible postoperatively. When aspirin is indicated for a coronary, increased vigilance for acute myocardial ischemia and infarction is warranted.
Clopidogrel: Patients may present with platelet glycoprotein IIB/IIIA receptor inhibitors for coronary stents. If so, they should be evaluated for the implantation date and whether they should have drug-eluting versus bare metal stent. Discussion with the surgeon and cardiologist may be necessary to optimize management and balance the risk of thrombosis/restenosis versus increased risk of bleeding. It is also important to determine when to restart antiplatelet aggregation agents. Antiplatelet aggregation drugs may be contraindicated for neuraxial blocks, unless they are discontinued well before the planned procedure.
Hypertension: Continue on the day of the operation.
Pulmonary: Continue the medications (inhaled beta agonists, leukotriene inhibitors, inhaled steroid, and oral therapy) perioperatively. The patient may need additional therapy (e.g. inhaled beta agonists as a nebulizer, steroid course) if they have moderate or severe COPD or asthma.
Neurologic: Patients may be on antiplatelet therapy for cerebrovascular disease and discussion with primary/surgical team should take place to assess risk of thrombosis/restenosis versus increased risk of bleeding. Antiepileptic and anti-Parkinson medications should continue perioperatively.
Antiplatelets: Please see above for aspirin and clopidogrel. Once again, risk of restenosis/thrombosis needs to be balanced with increased risk of bleeding from surgical site.
Anticoagulants: Many patients take warfarin for chronic atrial fibrillation and/or peripheral vascular diseases. Discontinuation of warfarin is often necessary. When warfarin is discontinued, anesthesia care providers need to discuss with surgical team and ensure: 1) INR is followed; 2) whether temporary heparin infusion is needed; 3) when warfarin will be restarted. If INR is greater than 1.3, epidural catheter placement is not advised.
Psychiatric: Continue antidepressant and antianxiety medications perioperatively. However, lithium is usually discontinued 2-3 days prior to the surgery.
j. How to modify care for patients with known allergies
Any known or potential trigger agents should be identified and avoided.
k. Latex allergy – If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
Whether the patient has sensitivity to latex (e.g., rash from gloves, underwear, etc.) or an anaphylactic reaction, prepare the operating room with latex-free products.
A list of drugs containing latex bottle tops should be available in every pharmacy and these drugs, if used, should have their tops pried open using a bottle opener. All personnel should use non latex gloves, tourniquets, catheters, and all anesthesia equipment must be latex free. All drugs needed for the treatment of an anaphylactic reaction should be at hand before the start of the case. No special pretreatment is required if the above steps are followed.
l. Does the patient have any antibiotic allergies – Common antibiotic allergies and alternative antibiotics
If there is a beta-lactam allergy, the drug of choice is vancomycin or clindamycin.
m. Does the patient have a history of allergy to anesthesia?
Documented: Avoid all trigger agents such as succinylcholine and inhalational agents.
- Proposed general anesthetic plan: Prepare the anesthetic machine to rid it of trace anesthetic gases, change the soda lime canister and circuitry, and remove all vaporizers for added safety.
- Ensure that the MH cart is available: Check that sufficient amount of dantrolene is available and that its “use by” date is not before the date of surgery.
Family history or risk factors for MH: If a close relative had a positive contracture test, then it is reasonable to treat the patient as an MH-susceptible patient. Whether the patient may have had previous uneventful anesthetics is no guarantee that MH is will not occur.
Local anesthetics/ muscle relaxants
Any known agent the patient is allergic to should be avoided.
5. What laboratory tests should be obtained and has everything been reviewed?
Hemoglobin levels: Patients are frequently dehydrated and thus hemoglobin must be evaluated in light of volume status (hypovolemic, euvolemic, or hypervolemic).
Platelet count: Because epidural analgesia may be indicated, a platelet count should be known prior to epidural catheter placement. A platelet count less than 100,000 is often considered as a cut off for epidural catheter placement.
Electrolytes and arterial blood gas analysis: any possible electrolytic imbalance and acid-base disorder should be identified before surgery.
BUN/creatinine ratio greater than 20:1 often suggests hypovolemia.
Blood glucose and glycosylated hemoglobin level for patients with diabetes mellitus.
Coagulation panel—If INR is greater than 1.3, epidural catheter placement is not advised.
Imaging: Include stress tests, pelvic imaging, etc. A CT scan is often available. Reviewing such imaging tests can strengthen the understanding of anatomical abnormality and size of the prostate. Such information is quite useful in planning intra-operative monitoring, intravenous access and potential massive transfusion.
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
a. General anesthesia
The procedure is usually performed under general anesthesia due to the length to complete the procedure, although epidural anesthesia with sedation is another option for open cystectomy and urinary diversion. Laparoscopic and robotic assisted cystectomy are performed under general anesthesia only, since the surgery often long, and requires steep Trendelenburg positioning with abdominal insufflation of carbon dioxide.
- Adequate sedation, analgesia, amnesia and muscle relaxation.
- Secured airway, ensuring positive pressure ventilation, reduction of intraoperative aspiration, and application of PEEP, which may be required for laparoscopic or robotic prostatectomy.
- Better management of patients who may become combative or delirious during long periods in awkward positions who cannot move and may be unable to breathe satisfactorily.
- Tolerance of positioning which is particularly important for laparoscopic or robotic prostatectomy due to requirement of steep head down position. For an open procedure, the surgeon often requests extension of the lower lumbar spine in order to improve the view of the surgical field. Some patients may not tolerate this positioning due to a spinal abnormality and/or back pain. Therefore, testing the patient’s tolerance of required positioning should be performed prior to induction of anesthesia in order to minimize the complications of the flexion position.
- Inability to communicate with the patient.
- Frequent postoperative nausea and vomiting as side effects of general anesthesia.
- Swings in hemodynamic
- May increase postoperative cognitive disorder (POCD) in the elderly.
- Positive-pressure ventilation used during general anesthesia can reduce cardiac output, and more likely cause pulmonary complications, and increase pelvic bleeding.
- Prolonged wake-up phase from anesthesia itself – sometimes long hang-over effect.
A need to plan postoperative analgesia especially in open prostatectomy.
These must be addressed preoperatively particularly for patients with a history of previous difficult mask ventilation and/or intubation, and for patients whose airway assessment is not favorable for intubation.
b. Epidural anesthesia
Epidural anesthesia can be performed with sedation for open cystectomy and urinary division. The insertion of the epidural catheter should be at low- mid-thoracic level. A T4 sensory level is recommended, because peritoneal stimulation is likely during this procedure. This approach is not frequently used in the United States. However, it is commonly used in other countries.
- Patients with pulmonary disease may benefit from maintaining spontaneous breathing, providing the surgeon does not actively retract abdominal contents into the upper abdomen.
- May reduce incidence and severity of POCD in the elderly.
- Pain control: excellent pain control may preclude need for intravenous narcotics and minimize their side effects.
- Potentially reduces incidence of MI and postoperative hypoxia.
- Contraindicated in patients taking clopidegrel, warfarin, or in patients with coagulopathy. Follow American Society of Regional Anesthesia guidelines.
- Patient or family refusal may preclude the catheter placement.
- Sympatholysis with spinal or epidural anesthesia may not be tolerated (eg. in coronary artery disease, aortic stenosis, cerebrovascular disease).
- Does not necessarily preclude need for invasive monitors such as arterial line, CVP, which now need to be placed in awake/sedated patient.
- It is not suitable for laparoscopic and robotic prostatectomy.
Plan postoperative anticoagulation therapy with the surgical team. Patients may be started on low molecular weight heparin. However, removal of catheter needs to be timed appropriately. If used BID 0.5 mg/kg, insertion or removal of catheter needs to wait until 12 hours from prior dose, and the next dose should be held for 2 hours after the catheter is removed.
c. Local anesthetic infiltration at incision site
May be considered in patients who have potential difficulty in postoperative pain management but not suite for epidural analgesia. Bupivacaine (0.5%, 20-30 mL) is usually injected at the incision sites either for open or laparoscopic procedure.
This can be performed in patients using antiplatelet therapy, with spinal anatomy disease, or with other contraindications to neuraxial block. There is no need to hold anticoagulants.
There can be patchy block and the quality of postoperative pain control may be less satisfactory compared to epidural analgesia.
6. What is the author’s preferred method of anesthesia technique and why?
Given the current literature, our preferred choice for open surgery of cystectomy and urinary division is general anesthesia. In this patient population general anesthesia is much beneficial considering the length of surgery and the positioning with flexion. Because the incision is low, postoperative pain control is not often a major issue without epidural analgesia. The local anesthetic infiltration at the incision site is beneficial to manage postoperation pain. Patient-controlled intravenous analgesia is not often needed.
However, for the patient with cardiopulmonary comorbidities, epidural analgesia for postoperation pain management seems advantageous. This is because systemic narcotic cause undesirable side effects, including respiratory drive suppression, limited coughing ability, and smaller tidal volumes. It may also be associated with high incidence of post-operative pneumonia. For robotic or laparoscopic radical prostatectomy, general anesthesia with endotracheal tube is the choice and epidural analgesia is not indicated.
We often start remifentanyl infusion at approximately 30 to 45 minutes of estimated time prior to extubation in order to wean off propofol or wash out inhalation agents. Remifentanyl not only significantly reduces the emergence time but also minimizes the likelihood of coughing and bucking during extubation. This technique is very useful if the measure is taken to prevent intraoperative awareness. If epidural is not used, the anesthesia provider need carefully assess the pain level and appropriate and prompt treatment should be given without delay. This is due to wean off of remifentanyl is quick and the patient may have require more narcotic postoperatively.
What are the most common intraoperative complications and how can they be avoided/treated?
Hemodynamic changes: Due to elevation of intrathoracic pressure, both venous return and cardiac output may decrease and anatropic medication may be needed. Hypotension is also often seen at the end of the procedure the patient is leveled and insufflation CO2 is discontinued, probably due to redistribution of the blood flow to the underperfused area during steep Trendelenberg position. Steep head down position and insufflation, usually at 15 mm Hg pressure intra-abdominally, may comprise the perfusion of internal organ and lower extremities. Increase in hydropressure in the upper body lead to facial, neck, periorbital and possible brain edema. Sever pharyngeal edema may occur and the patient requires reintubation after extubation. Therefore, carefully assessment of airway edema prior to extubation is necessary. Sometimes, the patient may be kept intubated, sit up, allow edema to subside, and then extubated either in ICU or post anesthesia care unit.
Other complications of pneumoperitoneum: In conjunction with head down position, pneumoperitoneum may cause endobronchial intubation. Once the steep head down position is finalized, ensure correct placement of the endotracheal tube. Subcutaneous emphysema is frequently encountered. Other rare complication can also occur including capnothorax, pneumothorax, pneumomediastinum, pneumopericardium, increased intracranial pressure, increased intraocular pressure, venous air embolism, brachial plexopathy and regurgitation.
b. If the patient is intubated, are there any special criteria for extubation?
Prior to extubation, the patient should be awake, alert, and able to respond to command and generate adequate tidal volume. The majority of patients are extubated at the completion of surgery and postoperative mechanical ventilation is not indicated. Occasionally, patients with severe respiratory insufficiency may need short term of ventilatory support postoperatively.
For those who receive laparoscopic or robotic cystectomy and urinary division, there is a risk that subcutaneous emphysema may extend along the tissue planes around the neck. Prolong steep head down position may also create severe pharyngeal edema which can cause airway obstruction after extubation. This complication should be kept in mind before extubation of these patients.
c. Postoperative management
What analgesic modalities can I implement?
Intravenous, epidural or intra-thecal morphine. Narcotic dosage may need to be adjusted appropriately for elderly. If intra-thecal or epidural morphine or patient controlled analgesia is given, postoperative monitoring with pulse oximeter should be kept for 24 hours.
What level bed acuity is appropriate?
The choice of floor, telemetry, and step down, or ICU admission depends on patients’ pre-operative comorbidities, intraoperative course, and hospital resources.
What are common postoperative complications, and ways to prevent and treat them?
The rate of minor complications for patients undergoing radical cystectomy is approximately 30%. The risk for a major complication with this procedure is about 5%, and the mortality rate is approximately 1% to 3%.
It is important to know not only the complications, but also the factors that can increase or decrease the risk for complications following cystectomy and urinary division. Important preoperative variables include age, sex, American Society of Anesthesiologists score, preoperative hemoglobin, smoking history, prior abdominal surgeries or external-beam radiation therapy, and type of diversion. The patient who has a standard radical cystectomy with ileal conduit or cutaneous ureterostomy usually requires 5 to 7 days of hospitalization, while the patient undergoing continent urinary diversion may require 7 to 10 days of hospitalization. Important intraoperative and postoperative variables include estimated blood loss, operative time, transfusion requirement, pathologic tumor stage, the need for surgical intensive care unit admission, and postoperative hemoglobin level.
What’s the Evidence?
Hautmann, RE. “The oncologic results of laparoscopic radical cystectomy are not (yet) equivalent to open cystectomy”. Curr Opin Urol. vol. 19. 2009. pp. 522-6. (An overview of oncologic outcomes of the laparoscopic radical cystectomy and open approach.)
Gwynn, ES, Clark, PE. “Bladder cancer”. Curr Opin Oncol. vol. 18. 2006. pp. 277-83. (An overview of the current treatment of bladder cancer.)
Gore, JL. “Mortality increases when radical cystectomy is delayed more than 12 weeks: results from a Surveillance, Epidemiology, and End Results-Medicare analysis”. Cancer. vol. 115. 2009. pp. 988-96. (Suggestion of prompt treatment for stage II bladder cancer.)
Hollenbeck, BK. “Identifying risk factors for potentially avoidable complications following radical cystectomy”. J Urol. vol. 174. 2005. pp. 1231-7. (Perioperative management that reduces morbidity and improves the quality following radical cystectomy.)
Freitas, ER. “Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft”. Cochrane Database Syst Rev. 2007. (Respiratory therapies contribute to a lower incidence of complications and shorter hospital stays in patients with serious cardiac and pulmonary complications.)
Stafford-Smith, M, Shaw, A, Aronson, S, Miller, RD. “Renal function monitoring”. pp. 1443-75. (Perioperative renal function monitoring regarding preoperative evaluation and perioperative risk reduction strategies.)
Fischer, SP, Bader, AM, Sweitzer, BJ, Miller, RD. “Preoperative evaluation”. pp. 1001-66. (Preoperative evaluation to quantify the risks associated with anesthesia and surgery.)
Sschoenberg, MP, Gonzalgo, ML, Wein, AJ. “Management of invasive and metastatic bladder cancer”. 2007. pp. 2468-78. (Clinical evaluation and surgical treatment of muscle-invasion bladder cancer.)
Cousins, J, Howard, J, Borra, P. “Principles of anaesthesia in urological surgery”. BJU Int. vol. 96. 2005. pp. 223-9. (An overview of principles of anesthesia in urological surgery including details regarding preoperative medication management, patient positioning during surgery and choice of anesthetic methods.)
Jaffe, RA, Sanuels, SI. “Urology. Anesthesiologist’s Manual of Surgical Procedures”. 2009. pp. 858-902. (Perioperative surgery consideration and anesthesia management of urology surgery.)
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- What the Anesthesiologist Should Know before the Operative Procedure
- 1. What is the urgency of the surgery?
- What is the risk of delay in order to obtain additional preoperative information?
- 2. Preoperative evaluation
- 3. What are the implications of co-existing disease on perioperative care?
- b. Cardiovascular system:
- c. Pulmonary:
- d. Renal-GI:
- e. Neurologic:
- f. Endocrine:
- g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
- 4. What are the patient's medications and how should they be managed in the perioperative period?
- h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
- i. What should be recommended with regard to continuation of medications taken chronically?
- j. How to modify care for patients with known allergies
- k. Latex allergy - If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
- l. Does the patient have any antibiotic allergies - Common antibiotic allergies and alternative antibiotics
- m. Does the patient have a history of allergy to anesthesia?
- 5. What laboratory tests should be obtained and has everything been reviewed?
- Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
- 6. What is the author's preferred method of anesthesia technique and why?
- a. Neurologic:
- b. If the patient is intubated, are there any special criteria for extubation?
- c. Postoperative management