Major Urological Surgery Research Articles

Patient controlled epidural analgesia after major urologic surgery: A comparison of tramadol with morphine

AbstractThe purpose of the paper was to assess and to compare the effectiveness and safety of patient controlled epidural analgesia using tramadol or morphine for postoperative analgesia after major urological surgeries.For patient-controlled epidural analgesia; in group I (n = 30) a loading dose of 20 mg tramadol 0.1% with a continuous infusion of 1 mg/ml at a rate of 8 ml/h was administered preemptly and in group II (n = 30) a loading dose of 2 mg morphine in 20 ml normal saline was administered and a supplemental infusion of 0.2 mg/h morphine was begun at a rate of 2 ml/h. A demand epidural bolus dose of 5 ml with a lockout time of 30 minutes and a background infusion of 8 ml/h in tramadol 0.1% group and 2 ml/h in morphine 0.01% group were administered. VAS for pain intensity, vital signs, sedation scale and side effects were monitored at 0, 15, 30 minutes and 1, 2, 3, 4, 8, 12, 24 hours during the postoperative period.Adequate analgesia was provided in all patients. VAS values were significantly lower...

Patient controlled epidural analgesia reduces the amount of local anaesthetics and opioids administered in patients undergoing major urologic surgery

Patient controlled epidural analgesia reduces the amount of local anaesthetics and opioids administered in patients undergoing major urologic surgery

Patient-Controlled Epidural Analgesia after Major Urologic Surgeries

The efficiency and safety of patient-controlled epidural analgesia by using tramadol alone and combined with bupivacaine were investigated for postoperative pain treatment after major urological surgeries. For PCEA: in group I (n = 17) a loading dose of 20 mg tramadol with a continuous infusion of 1 mg/ml tramadol at a rate of 8 ml/h was given. In group II (n = 17), patients received an initial loading dose of 20 ml bupivacaine 0.125% and a supplemental continuous infusion of 8 ml/h. In group III (n = 17), a loading dose of 20 mg tramadol with 20 ml bupivacaine 0.125% were given and a supplemental infusion of 1 mg/ml tramadol in 20 ml bupivacaine 0.125% combination was begun with a rate of 8 ml/h. A demand epidural bolus dose of 5 ml with a lockout time of 30 min was also used in all patients. VAS for pain intensity, vital signs, sedation scale and side effects was monitored at 0, 15, 30 min and 1, 2, 3, 4, 8, 12, and 24 h of the postoperative period. Statistical significance was determined using Kruskal-Wallis, Fisher’s exact, analysis of variance for repeated measurements and Tukey tests. The hemodynamic values and sedation scales were insignificantly different (p > 0.05). The adequate analgesia was provided in all patients. However VAS values were significantly lower in group III than in groups I and II at every measurement (p < 0.05). The incidence of side effects in all three groups was low (p > 0.05). In conclusion, we suggested that a combination of tramadol with bupivacaine can provide the most effective and safe postoperative analgesia with minimal risk for side effects.

The Effects of Perioperatively Administered Colloids and Crystalloids on Primary Platelet-Mediated Hemostasis and Clot Formation

The Effects of Perioperatively Administered Colloids and Crystalloids on Primary Platelet-Mediated Hemostasis and Clot Formation

Improvement of practice performance in urological surgery via clinical pathway implementation

The purpose of this study was to compare performance measurements to evaluate the effects of clinical pathway implementation on improving practice performances in urology. Since April 1997, a total of 18 clinical pathways have been created in the urology department. Of these clinical pathways, six were implemented for endoscopic surgery, and four and eight were for minor and major surgery, respectively. Eight prominent performance measurements, which were identified as representative indicators of the practice performances, were selected in endoscopic surgery, five in minor surgery, and 11 in major surgery. Between April 1997 and March 1999, 2,883 consecutive patients, who underwent endoscopic surgery, minor surgery, and major surgery, were evaluated herein. The treatment results for patients in the first and second years of clinical pathway implementation were compared to those from the year preceding the implementation. In endoscopic surgery, five of the eight performance measurements improved significantly in the first year of implementation. Notably, three of the five improved performances continued to improve in the second year. Similarly, in minor surgery, four of the five performance measurements improved significantly following 2 years. Finally, in major urological surgery, six of the 11 performance measurements also improved significantly after 1 year; four of which continued to improve during the second year. Therefore, we conclude that patient care, which is based on the implementation of clinical pathways, can improve practice performances and facilitate medical care.

Differential modulation of interleukin‐6 and interleukin‐10 by diclofenac in patients undergoing major surgery

Prostaglandins modulate cytokine release though increases in cAMP, regulating interleukin (IL) 6 and IL-10. Diclofenac inhibits cyclo-oxygenase activity and hence prostaglandin production. We hypothesized that diclofenac would affect release of IL-6 and IL-10 and modulate the immune response. In a randomized, double-blind, placebo-controlled study, we investigated the effect of diclofenac in patients undergoing major urological surgery. Patients were randomized to receive either diclofenac (50 mg orally every 8 h the day before surgery and 75 mg i.m. every 12 h on the day of surgery, n = 23) or placebo (n = 23). Standardized combined general anaesthesia and epidural analgesia was administered. Serum IL-6, IL-10 and cortisol were measured before surgery and 30 min and 2, 6, 12 and 24 h after skin incision. Temperature, leucocyte count and C-reactive protein concentration were measured before surgery and after 24 h. IL-6 and IL-10 concentrations increased, reaching peak levels at 12 and 6 h respectively in both groups. At 12 h, the IL-6 concentration was significantly lower in patients receiving diclofenac than in those receiving placebo (P = 0.003). In contrast, IL-10 concentration at 6 h was higher in diclofenac-treated patients (P = 0.008), and this was associated with less pyrexia (P = 0.03), a lower leucocyte count (P = 0.0002) and a lower C-reactive protein concentration (P = 0.0039). Serum cortisol concentration was similar in the two groups of patients until 24 h, when the concentration was lower in patients who received diclofenac (P = 0.002). Cortisol concentration correlated with IL-6 concentration at 24 h. Administration of diclofenac was associated with lower IL-6 and higher IL-10 concentrations, and lower leucocyte count, C-reactive protein concentration and temperature. Diclofenac may have an anti-inflammatory role in major surgery.

A comparison of five solutions of local anaesthetics and/or sufentanil for continuous, postoperative epidural analgesia after major urological surgery

A comparison of five solutions of local anaesthetics and/or sufentanil for continuous, postoperative epidural analgesia after major urological surgery

The effective use of automated apheresis of autologous red cells in elective orthopaedic and major urological surgery – a rural hospital experience

The use of automated apheresis of autologous red cells was investigated to assess the effectiveness of one to two collections using this procedure compared to the standard technique of three to four whole blood collections via venesection. Patient comfort and satisfaction, complications, cost, staff workload and utilization of the product were analyzed. From August 1999 to February 2000, 38 patients underwent red cell collection prior to elective orthopaedic or urological surgery. The patients ranged in age from 38 to 77 yr (62±10 yr). All patients preoperatively met specific height, weight, and haemoglobin criteria. Patients living in isolated areas and those with underlying medical conditions were specifically recruited so that their treatment would be limited to one intervention. Blood parameters were measured pre- and post-donation, and pre- and post-transfusion. The units collected and used were recorded, and the product utilization calculated. Thirty-two patients underwent the apheresis procedure (dual bag collection), one unit was collected from one patient and four units were collected from the remaining five patients. Fourteen patients also donated whole blood. Autologous red cells were used intra-operatively in 33 cases. Both red cells and whole blood were transfused in 14 cases. On average, over 75% of the red cell product was utilized and the post-transfusion haemoglobin values were comparable to those observed after whole blood transfusion. No surgical complications were associated with the red blood collection procedure. Donor tolerance/reaction was evaluated by a registered nurse during each procedure. Of the 43 collections, 41 resulted in no side effects or mild side effects associated with feedback. One patient demonstrated a moderate vaso-vagal response at the end of the second cycle and another patient developed severe citrate effects, a mild vaso-vagal response as well as mild responses resulting from vascular fluid volume shift and/or red blood cell loss. Patient comfort and satisfaction were assessed using a questionnaire. Most patients felt no discomfort during or after the procedure. Among those who experienced some discomfort, some noted feelings of numbness and coldness during the procedure and the most common symptom after the procedure was fatigue. All patients said that they would use this procedure again if required. The cost of apheresis red cell collection was compared to that of whole blood venesection collection taking into consideration the consultant time, nursing time, equipment and number of serology assays required. The absolute cost of collecting two units of red cells via apheresis is less than that needed to collect three units of blood via venesection despite the cost of the collection set since fewer serology screens were required and the total nursing time was less.

Premedication with clonidine and immune response in patients undergoing major urological surgery

s and Programme: European Society of Anaesthesiologists; 9th Annual Meeting with the Swedish Society of Anaesthesiology; Gothenburg, Sweden, 7-10 April 2001: Pharmacology

Pharmacokinetic-pharmacodynamic modeling of the respiratory depressant effect of alfentanil.

Although respiratory depression is the most well-known and dangerous side effect of opioids, no pharmacokinetic-pharmacodynamic model exists for its quantitative analysis. The development of such a model was the aim of this study. After institutional approval approval and informed consent were obtained, 14 men (American Society of Anesthesiologists physical status I or II; median age, 42 yr [range, 20-71 yr]; median weight, 82.5 kg [range, 68-108 kg]) were studied before they underwent major urologic surgery. An intravenous infusion of alfentanil (2.3 microg x kg(-1) x min(-1)) was started while the patients were breathing oxygen-enriched air (fraction of inspired oxygen [FIO2 = 0.5) over a tightly fitting continuous positive airway pressure mask. The infusion was discontinued when a cumulative dose of 70 microg/kg had been administered, the end-expiratory partial pressure of carbon dioxide (PE(CO2) exceeded 65 mmHg, or apneic periods lasting more than 60 s occurred During and after the infusion, frequent arterial blood samples were drawn and analyzed for the concentration of alfentanil and the arterial carbon dioxide pressure (PaCO2). A mamillary two-compartment model was fitted to the pharmacokinetic data. The PaCO2 data were described by an indirect response model The model accounted for the respiratory stimulation resulting from increasing PaCO2. The model parameters were estimated using NONMEM. Simulations were performed to define the respiratory response at steady state to different alfentanil concentrations. The indirect response model adequately described the time course of the PaCO2. The following pharmacodynamic parameters were estimated (population means and interindividual variability): EC50, 60.3 microg/l (32%); the elimination rate constant of carbon dioxide (Kel), 0.088 min(-1) (44%); and the gain in the carbon dioxide response, 4(28%) (fixed according to literature values). Simulations revealed the pronounced role of PaCO2 in maintaining alveolar ventilation in the presence of opioid. The model described the data for the entire opioid-PaCo2 response surface examined. Indirect response models appear to be a promising tool for the quantitative evaluation of drug-induced respiratory depression.

L'anestesia combinata epidurale e generale versus l'anestesia generale nel paziente urologico anziano ad alto rischio. Uno studio clinico prospettico e randomizzato: Combined epidural and general anaesthesia versus general anaesthesia in high-risk urological elderly patients. A prospective randomised trial

Twenty-eight elderly high-risk (ASA 3) patients undergoing elective major urological surgery were prospectively randomised to receive either combined epidural and general anaesthesia (CEGA) or general anaesthesia (GA). The use of intraoperative vasopressors was significantly higher in the CEGA group (p&lt;0.001). There was no significant difference between groups with regard to blood loss, volume replacement, postoperative complications and mortality. The CEGA allowed saving of inhalatory anaesthetic agents (p&lt;0.001) and a shorter total hospital stay than GA (p&lt;0.0044). The authors conclude that the CEGA exerted a significant beneficial effect on the intraoperative outcome in a group of high-risk surgical patients.

Tramadol infusion for pain therapy following bladder exstrophy surgery on pediatric wards

We investigated in 17 children (mean 7.1 years) the continuous administration of tramadol following augmentation cystoplasty or exstrophy reconstruction. Mean duration of the tramadol administration on the pediatric ward was 3.8 +/- 1.1 days (initial dosage 0.25 mg/kg/per hour, dose adjustment by the nursing staff). Mean tramadol consumption was 0.21 mg/kg/h on day 1 and was reduced to 0.08 mg/kg/per hour on day 4. Median pain score (assessed with ten-step scales) was 5 before treatment and between 2.5 (day 1) and 0.5 (day 5) during therapy. Lowest oxygen saturations (mean) ranged from 93.8% to 95.2%. Three patients (17.6%) suffered from nausea/vomiting on 3 of 64 treatment days (4.7%). Pruritus and extreme sedation did not occur. The continuous administration of tramadol is a simple and safe procedure following major urological surgery in children.

A Comparison of Intermittent Pneumatic Compression of the Calf and Whole Leg in Preventing Deep Venous Thrombosis in Urological Surgery

Purpose Intermittent pneumatic compression of the calf and/or thigh effectively decreases the incidence of deep venous thrombosis and other thrombotic sequelae but clinical data comparing these modalities are currently lacking. Materials and Methods A total of 90 patients undergoing major urological surgery was randomly assigned to receive calf length or thigh length pneumatic compression for antithrombotic prophylaxis. Duplex ultrasound of the lower extremities was performed preoperatively and twice postoperatively to evaluate for deep venous thrombosis. Health care providers in the operating room, recovery room and ward were asked to compare the compression systems, and a cost analysis was performed. Results A total of 47 patients wore the thigh length sequential pneumatic sleeves and 43 wore calf length uniform compression systems. A pulmonary embolus without evidence of deep venous thrombosis was detected in 1 patient (2%) using the thigh length system. A thrombus was detected in the common femoral vein by duplex ultrasonography in 1 patient (2%) with the calf length system. Nursing personnel found the calf length sleeves easier to apply and more comfortable by patient account but they were satisfied with both systems. There was a significant cost savings with the calf length pneumatic compression system. Conclusions Calf and thigh length pneumatic compression systems similarly decrease the risk of deep venous thrombosis in patients undergoing urological surgery. The calf length system has the added advantage of being less expensive and easier to use.

Cutaneous continent urinary diversion: History, patient selection and preparation

– History. The first supravesical urinary diversion was carried out in 1908. The results of a large number of cutaneous tubularised continent pouches were published in the fifties. The poor results urged urologists to try to improve the continence mechanisms, but it was not until the eighties that these urinary diversions became a stable part of their armamentarium, thanks to the popularisation of the Koch pouch incorporating the principles of detubularisation, reconfiguration and disruption of the peristaltic integrity. After that there was an explosion of interest in continent pouches and new techniques. Nowadays the Indiana, Koch and Mainz pouches and those associated with the Benchekroun valve and the Mitrofanoff principle are the most popular. Patient selection. Nowadays heterotopic continent urinary diversions are performed after a total cystectomy when the urethra is impracticable. The primary goal of cutaneous pouches is to improve the quality of life; a reasonable life expectancy is therefore the first criterion. Patients must be capable of performing self catheterisation and their motivation and intellective compliance must be considered when suggesting these operations. Dementia, renal failure, bowel diseases, malabsorption and previous intestinal demolition are absolute contraindications. Relative contraindications are radiotherapy and cardio-respiratory diseases. Unlike other authors, we believe that a dry continent stoma is the best choice for obese patients. Patient preparation. The ideal patient preparation should be effective, fast, cheap and not create stress or weakness. Dehydration has to be avoided. The mechanical intestinal wash-out could be done either by total irrigation of the bowel with saline solution or by polyethylene glycol electrolyte lavage solution. Antibiotic prophylaxis against aerobic and anaerobic germs reduces the complication rate of intestinal surgery and has to be recommended. Major urological surgery has a high rate of thromboembolism. It is routine practice for us treat with sub-cutaneous calcium heparine in order to reduce post-operative deep venous thrombosis and fatal pulmonary embolisms.

Anesthesia with Increasing Doses of Sufentanil and Midlatency Auditory Evoked Potentials in Humans

Our interest focused on the question whether sufentanil differs from alfentanil, fentanyl, and morphine with regard on its effects on midlatency auditory evoked potentials (MLAEP). Therefore, we studied MLAEP during general anesthesia with increasing doses of sufentanil in 16 patients scheduled for elective major urologic surgery. Anesthesia was induced with sufentanil (1 microgram/kg every 7 min to a total dose of 3 micrograms/kg). In 8 of 16 patients, further incremental doses of sufentanil were given to a total dose of 5 micrograms/kg. Auditory evoked potentials were recorded before and 5 min after every sufentanil dose on vertex (positive) and mastoids on both sides (negative). Latencies of the peaks V, Na, Pa, Nb, and P1 (ms), and amplitudes Na/Pa, Pa/Nb, and Nb/P1 (microV) were measured. In the awake state, MLAEP had high peak-to-peak amplitudes and a periodic waveform. During general anesthesia the brainstem response V was stable to increasing doses of sufentanil. There was a marked statistically significant increase in latency and decrease in amplitude of Nb and P1 after 1-2 micrograms/kg sufentanil, which remained stable under further sufentanil application. In contrast, the early cortical potentials Na and Pa increased only slightly in latencies. This increase was statistically significant at 4 micrograms/kg for Na and at 3 and 4 micrograms/kg for Pa. For the amplitudes Na/Pa and Pa/Nb there was only a slight and statistically insignificant reduction. After the largest dose of sufentanil (3-5 micrograms/kg) Na and Pa showed a similar pattern as in awake patients. We conclude that sufentanil does not differ essentially from alfentanil, fentanyl, and morphine with regard on its effects on MLAEP.

Quantitative Changes in Platelet Counts following Major Urological Pelvic Surgery

Postperative quantitative changes in platelet counts have been reported following various extensive surgical procedures. It is generally accepted that reactive thrombocytosis at levels less than 1,000,000/mm3 is a benign condition and is not associated with increased risk of postoperative thrombohemorrhagic complications. The role of prophylactic treatment with platelet inhibitors in these situations is controversial. We assessed retrospectively the timing and the extent of postoperative thrombocytosis in 85 consecutive patients following major urological pelvic surgery and evaluated its possible clinical significance to hemorrhagic and thromboembolic complications, in view of the coincidence of multiple potential risk factors for thromboembolism in these patients. 73 (85.9%) patients demonstrated marked postoperative changes of platelet counts. In 12 patients (14.1%) we found only minor fluctuations in platelet counts throughout the postoperative period. Two distinct groups of 26 and 47 patients respectively could be identified among these 73 patients, who differed in the rate and extent of changes in platelet counts. Those fluctuations were characterized by an early decrease in platelet levels (mean percentage change of 40 and 60% in groups I and II respectively). This was followed by a gradual increase leading to delayed thrombocytosis (mean percentage change of 225 and 305% in groups I and II respectively). Thromboembolic complications were diagnosed in 5 patients. The occurrence of thromboembolism preceded any significant increase in platelet counts in all 5 patients. There was no correlation between the timing of thromboembolic complications and timing and extent of the change in platelet count. We conclude that reactive thrombocytosis following major urological pelvic surgery is a frequent innocuous finding and is not associated with hemorrhagic or thromboembolic complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of predeposit autologous blood and intraoperative autotransfusion in urologic cancer surgery

A total of 20 patients underwent major urologic cancer surgery with the combined use of predeposit autologous blood and intraoperative autotransfusion with the Haemonetics Cell Saver. The estimated blood loss ranged from 400 to 2,000 mL (mean 1,208 mL). Total transfusion requirements for the 20 patients were 85.5 units of which 82.5 (96 %) were autologous. Predeposit autologous blood accounted for 53 percent, intraoperative autotransfusion blood 43 percent, and homologous blood 4 percent of the total transfusion requirements Of the 20 patients in the study, only 1 received homologous blood. There were no complications related to either modality of autotransfusion. Our data suggest that using the combined modalities of predeposit autologous blood donation and intraoperative autotransfusion, major urologic cancer surgery can be performed without homologous blood in most cases.

A Simple Test For The Detection of Intraoperative Rectal Injury In Major Urological Pelvic Surgery

We describe our experience with a simple inexpensive test with 2 practical uses: 1) to detect unrecognized intraoperative rectal injury and 2) to assess the adequacy of repair of rectal injuries.

“Blended” anaesthesia in urological oncological surgery: Our experience

Some major urological surgery may cause post-operative pain, which is difficult to control, as well as systemic metabolic stress. “Blended” anaesthesia, which is an association of regional anaesthesia and a light general anaesthesia, minimizes the stress on the neuro-vegetative system and reduces drug administration. We treated 39 patients: our data suggest that “blended” anaesthesia is very good for the elderly as well as for younger patients, expecially in Hospitals without a post-operative Intensive Care Unit.

Transdermal Fentanyl for the Treatment of Pain After Major Urological Operations

Transdermal Fentanyl for the Treatment of Pain After Major Urological Operations