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Jennifer Linehan, MD 

(Urology, Robotic)

(520) 440-5142

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ROBOTIC CYSTECTOMY

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  • Expect 8-10 hours

  • EBL: typically ~500cc, Type + Cross recommended.

  • Lines: A-line preferred, 2 large IVs, or central access. 

  • ERAS Protocol - Modified- No Block

 

Meds:

Entereg (Alvimpoan) This is given PO in preop to speed the return of bowel function.  It’s in a class called:  Peripherally-Acting Mu-Opioid Receptor Antagonists (PAMORA). It should have minimal effect on intraop anesthesia/analgesia

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ERAS Protocol for Cystectomy Cases

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  1. Patient is already given instructions they can drink Apple Juice and Gatorade up to 4 hours before surgery

  2. Pre-med with acetaminophen +/-gabapentinoid +/-NSAID (note: gabapentin causes more post-op drowsiness than Lyrica/pregabalin)

  3. Do a spinal with DUROMORPH (unless contraindicated, see dosing suggestion) – put in order set “Anesthesia Neuraxial Single dose” when you do this procedure. This will include orders for continuous pulse oximetry as well as medications for respiratory depression and pruritus

Intrathecal Morphine Dose by Age

<50: 0.3 mg

50-59: 0.2 mg

60-69: 0.15 mg

70-79: 0.10 mg

>80: not Routinely recommended, use judgement

4.   Give less IV fluids if patient can tolerate it

5.   Consider TAP block after the procedure – if you don’t do TAP blocks, call AIC and they will assign someone to        

      perform TAP block, use Exparel in block

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NEPHRECTOMY

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  1. Monitors: Aline and 2nd large bore IV

  2. Positioning: lateral

  3. Abx: Ceftriaxone 

  4. Fluids: prefers plenty of IVF if tolerating (2-3L)

  5. Surgical Time: estimated 4+ hours

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Narcotic-Sparing Pain regimen

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  • Surgeons write their own preoperative medications

  • Acetaminophen:

    • Caution in patients with liver disease

    • do not exceed 4g in 24 hours

    • start at least 6 hours after last dose

  • NSAIDs

    • Caution in patients with prior GI bleed or renal dysfunction

    • All patients: celecoxib 400mg x1/ibuprofen 600mg x 1/naproxen 500mg x1

    • Patients >65 yrs, <50kg, or CrCl 30-50 ml/min: celecoxib 200mg x1/ibuprofen 400mg x1/naproxen 250mg x1

    • Creatinine >1.5, CrCl <30ml/min – no NSAID recommended

  • Gabapentinoids (Gabapentin & Lyrica)

    • Consider lower dose or patients with OSA, age >65, or neuroaxial opioids

    • All patients: Gabapentin 300-600mg x1, Lyrica 75-150mg  x 1

    • Patients >65,  CrCl 30-50 mL/min, h/o OSA or STOP BANG 5 or greater: Gaba 300mg, Lyrica 75mg

    • Patients Cr>1.5, CrCl <30mL/min: no gabapentinoid agent recommended 

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High Intensity Focused Ultrasound for Prostate Cancer

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Performed at ASC.  It's a new(er) non-invasive radiation-free technology that uses ultrasound to ablate prostate tissue.

Couple things to note when doing these cases:
 

  1. General anesthesia with an ETT.  Surgeon wants paralysis because it is absolutely important that the patient does not move during the procedure.  If the patient moves slightly, the rectum can be damaged with the ultrasound beams.

  2. Total anesthesia time was about 1 hour and 45 minutes because there is a lot of set up in the room after the patient goes to sleep

  3. No nitrous oxide.  Nitrous oxide interferes with the ultrasound beams.

  4. The patient will be positioned in right lateral decubitus all the way to the bottom edge of the bed.  The reps have a special attachment for the table for the feet, and a special axillary roll that we used.

  5. Pain after the procedure is mild.  More discomfort from the Foley catheter that is left in place than pain from the procedure.  Tylenol and Toradol are the preferred method of pain control in recovery. 

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