Cystoscopy / TURBT
Patient phenotype
Cystoscopy: any age, often elderly with hematuria workup or surveillance. TURBT (resection of bladder tumor): typically older, smokers, often comorbid. Some recurrent + frequent visits.
Procedure
Lithotomy position. Rigid or flexible cystoscope through urethra. Diagnostic cysto: 15-30 min. TURBT: 30-90 min, irrigation fluid (sterile water historically, now glycine or saline with bipolar resectoscope). Single-shot intravesical chemotherapy at end (mitomycin C, gemcitabine).
Anesthetic plan
Diagnostic cysto: MAC + topical or spinal. TURBT: spinal preferred (anesthetic level T9-10, allows obturator reflex assessment + earlier discharge), GA acceptable. Short cases — choose based on comorbidities + tumor location.
Setup
- ·Standard monitors
- ·1 PIV
- ·Type & screen for large TURBT
- ·Spinal kit if neuraxial chosen
- ·Forced air warmer
- ·Foley after surgical placement
Biggest concerns by phase
Anticoagulation status
Hematuria patients often on AC (AF, valve, etc.). Hold per ASRA + urology + cardiology consensus. Bridge if high thrombotic risk.
Obturator nerve reflex (lateral wall TURBT)
Obturator nerve runs along bladder lateral wall. Resection electrocautery → adductor contraction → bladder perforation risk. Solution: spinal alone insufficient (somatic reflex preserved); add obturator nerve block, OR use GA + neuromuscular blockade.
TUR syndrome (with hypotonic irrigation)
Glycine or sterile water absorbed via open venous sinuses → dilutional hyponatremia, hypoosmolality, fluid overload. Modern bipolar systems use saline → drastically lower risk. Symptoms: confusion, seizure, pulmonary edema, BP swings. Treatment: hypertonic saline + diuretic.
Bladder perforation
Extraperitoneal (most): conservative (Foley drainage); intraperitoneal: surgical repair often needed. Watch for sudden abdominal distension, drop in irrigation return, BP/HR changes.
Continuous bladder irrigation + clot retention
TURBT often has CBI postop. Watch for clotting → bladder distension → pain + bradycardia. Pain control without excessive opioid (elderly).
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
75-yo M, AF on apixaban (held 48h), CAD on aspirin (continued), BPH, bladder tumor on lateral wall. TURBT planned. Spinal vs GA?
What an examiner probes for
- ▹Considers obturator reflex risk on lateral wall — favors GA + paralysis OR spinal + obturator block
- ▹Verifies AC washout adequate
- ▹Plans irrigation — bipolar/saline reduces TUR syndrome risk
- ▹Discusses postop CBI + hematuria
Sources
- Miller's Ch 73
- AUA Bladder Cancer Guidelines
Anatomy reference
Sourced reference images. 4 matches for "bladder urinary".
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