What is the recommended anesthesia plan and patient positioning for a patient undergoing cystoscopy, cystolithotripsy, urethral stent removal, and possible open pelvolithotomy?

Anesthesia Plan and Patient Positioning

For this combined cystoscopy, cystolithotripsy, urethral stent removal, and possible open pelvolithotomy, recommend general anesthesia with short-acting agents (propofol/remifentanil) and consider thoracic epidural analgesia (T9-11) if open pelvolithotomy is anticipated, with lithotomy positioning for the endoscopic portion and supine positioning if conversion to open surgery is required. 1, 2

Anesthesia Selection

Primary Anesthesia Approach

• General anesthesia with short-acting agents is the optimal choice for this multi-component procedure given the anticipated duration and potential for open conversion 1, 2
• Use propofol for induction and maintenance (TIVA approach) or volatile-based anesthesia with desflurane, avoiding nitrous oxide to reduce postoperative nausea and vomiting 1, 2
• Remifentanil is preferred as the opioid due to its ultra-short acting properties, allowing rapid recovery 1, 2

Epidural Consideration

• Add thoracic epidural analgesia (T9-11) if open pelvolithotomy is likely, as epidurals are strongly recommended for major urological procedures to provide superior postoperative pain control and reduce opioid requirements 1
• If epidural is not feasible, intravenous lidocaine infusion can be administered for its anti-inflammatory and opioid-sparing properties 1
• Ensure 12-hour interval between LMWH injections and epidural manipulation for thromboprophylaxis safety 1

Alternative for Stent Removal Component

• While the stent removal portion could theoretically be performed under moderate sedation with midazolam or propofol without muscle relaxation (which shows significantly less pain and higher satisfaction than IV analgesics alone), general anesthesia is more practical given the combined procedures 3

Patient Positioning Strategy

Initial Positioning for Endoscopic Procedures

• Start in dorsal lithotomy position for cystoscopy, cystolithotripsy, and stent removal 1
• This positioning allows optimal access to the urethra and bladder, and facilitates visualization during endoscopic stone fragmentation 1, 4

Positioning if Open Pelvolithotomy Required

• Convert to supine position if open pelvolithotomy becomes necessary 1
• Supine positioning is equally safe as prone for percutaneous procedures and allows simultaneous retrograde access if needed 1
• Consider wide transverse incision (Maylard or Cherney) or vertical incision for adequate exposure if open conversion occurs 1

Critical Anesthetic Management Elements

Intraoperative Monitoring and Maintenance

• Maintain normothermia throughout using active warming devices, as hypothermia prevention is strongly recommended and particularly relevant given the potentially prolonged operative duration 1
• Prevent hypoxemia and hypovolemia through adequate oxygen delivery and goal-directed fluid management 1
• Monitor neuromuscular blockade depth and ensure complete reversal before extubation 1
• Maintain normoglycemia (blood glucose <10 mmol/L) and use low tidal volume ventilation to reduce barotrauma risk 1

Fluid Management

• Target euvolemia using goal-directed fluid therapy to avoid both fluid overload and hypovolemia, which can cause splanchnic hypoperfusion and ileus 1
• Consider esophageal Doppler or other cardiac output monitoring systems for optimization, particularly if the patient has significant comorbidities 1
• Use judicious vasopressors for arterial hypotension rather than excessive fluid administration 1

Perioperative Prophylaxis

Antimicrobial Coverage

• Administer single-dose IV antibiotics within 60 minutes before skin incision, using a 2nd or 3rd generation cephalosporin effective against both aerobes and anaerobes 1
• This is critical as urological procedures are classified as clean-contaminated 1

Thromboprophylaxis

• Provide pharmacological prophylaxis with LMWH plus well-fitting compression stockings 1
• Extended prophylaxis for 4 weeks should be administered as cystectomy and major urological stone procedures are considered high-risk 1

Multimodal Analgesia

• Implement preemptive multimodal analgesia including non-opioid agents (acetaminophen, NSAIDs if not contraindicated) to minimize opioid requirements 1
• Multimodal postoperative analgesic protocol should continue with opioid-sparing approach 1

Common Pitfalls to Avoid

• Do not use long-acting sedatives for premedication as they delay recovery 1
• Avoid excessive fluid administration which can lead to ileus and increased morbidity, but also avoid hypovolemia 1
• Do not allow hypothermia as it increases complications and recovery time 1
• Ensure adequate muscle relaxation reversal before extubation to prevent respiratory complications 1