Anesthesia and the Renal and Genitourinary Systems

Patients requiring anesthesia for renal and genitourinary surgery are frequently at extremes of age. In older patients the physiologic changes of aging and concomitant cardiovascular and respiratory disease pose challenges. As a result, a thorough medical history, physical examination, and appropriate laboratory tests are necessary for evaluation. In pediatric patients, one should exclude concomitant congenital disease. Innervation of the kidneys, adrenals, ureters, urinary bladder, prostate, urethra, penis, scrotum, testis, and spermatic cord is primarily from the thoracolumbar and sacral outflow lending urologic surgery to regional anesthesia. Patients exhibit a variety of findings associated with renal dysfunction, such as hypertension, edema, nausea, and hematuria. Renal function tests help determine the cause, severity, and categorization of renal disease based on anatomic distribution: prerenal, postrenal, and intrinsic renal disease. Intrinsic renal disease can be further divided into glomerular, tubular, interstitial, and vascular abnormalities facilitating focused and targeted therapy. Drug pharmacokinetics and pharmacodynamics in kidney disease are of clinical significance in all urologic surgery. New technology has changed anesthetic outcomes in urologic surgery. Laser, endoscopic, laparoscopic, minimally invasive, and robot-assisted surgery have nearly eliminated some of the complications. Transurethral resection of the prostate (TURP) syndrome is exceptionally rare, the need for blood transfusion greatly reduced, and with the use of newer lithotripters the immersion effects of lithotripsy are eliminated. Newer challenges relate to the prolonged steep head-down tilt and pneumoperitoneum associated with these procedures. Preemptive analgesia, ERAS protocols, and multimodal pain therapy have benefitted patients in the perioperative period.