Urology

Last week I had a couple days of urology cases which taught me quite a bit about the kidney. One was a percutaneous nephrolithotomy, a procedure in which a needle is passed from the back into the kidney to remove a stone. This is done under fluoroscopic guidance with X-rays. Although the stone can be visualized and one can aim a needle at the stone, the surgeon can't tell what he's passing through to get to the stone. As a result, the patient had a significant bleed when a renal artery was punctured. The kidneys get a lot of blood, and when the vessel bled, we knew it; not only did a pool of blood collect on the floor, but the patient's heart rate doubled and his blood pressure tanked. It was a good example of how anesthesiologists must respond rapidly to surgical problems. While the surgeons put pressure on the bleed with a balloon, we quickly opened fluids wide open, transfused a unit of blood, sent blood gases, and obtained more IV access (not easy since the patient was lying on his belly). The patient did well with our interventions and we tided him over to the ICU.

On another day, we had a laparoscopic radical nephrectomy - removal of a kidney - for cancer. Laparoscopy involves the use of surgery through small incisions by introducing tools and a camera into the body; these minimally invasive techniques prevent the morbidity associated with a large incision. However, the surgeons were having a lot of difficulty removing the kidney and the three hour scheduled case ended up taking nine hours. It is a surgical decision whether to convert a laparoscopic surgery to an open one, and it can be difficult to weigh the risks and benefits. However, it was an important lesson in adapting anesthetic plans to difficult surgeries and preparing for changes in the surgical technique if necessary.