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Anesthesia — An Overview for the Reconstructive Urologist

The surgeon and anesthesia team should agree on the expected duration, position, blood loss, airway access after docking, analgesia and postoperative destination. This overview covers those decisions and recognition of important complications. Drug dosing and block technique belong in the linked pharmacology and procedural articles.

See also: Analgesia, Nerve Blocks, Nausea & Vomiting, Positioning & Nerve Injury and ERAS.

Anesthetic Techniques and Services​

TermWhat it describesReconstructive application
General anesthesiaDrug-induced unconsciousness; airway, ventilation, analgesia and immobility require a coordinated planMost prolonged abdominal and robotic reconstruction
Regional anesthesiaNeuraxial or peripheral blockade, with or without sedation or general anesthesiaSelected endoscopic/perineal operations or postoperative analgesia
Local anesthesiaInfiltration of the operative fieldSelected minor procedures; total local-anesthetic exposure must include all injections and blocks
Monitored anesthesia care (MAC)An anesthesia service, not a particular depth of sedationSelected procedures requiring anesthesia assessment, monitoring, titration and capacity to rescue or convert to general anesthesia

ASA explicitly distinguishes MAC from moderate sedation. Purposeful response to verbal or light tactile stimulation describes moderate sedation; a patient receiving MAC may move through different depths. Neither the label “MAC” nor initially preserved spontaneous breathing removes the need for airway rescue capability.[1] Typical urologic uses are flexible cystoscopy, stent exchange and some prostate biopsies, usually with propofol, an opioid, dexmedetomidine or midazolam in varying combinations. Sedative and anesthetic drugs can alter diagnostic urethral pressure profiles and cystometrograms.[33]

General Anesthesia — Induction, Maintenance, Emergence​

Induction includes preoxygenation, a plan for loss of airway reflexes and appropriate monitoring. Hypnosis, analgesia and muscle relaxation are separate effects: a hypnotic or neuromuscular blocker does not substitute for analgesia. Maintenance must accommodate pneumoperitoneum, position, blood loss and changing surgical stimulation. Emergence includes recovery of ventilation and muscle strength, analgesic transition and an explicit extubation plan.

Volatile anesthesia and propofol-based total intravenous anesthesia are both reasonable for noncardiac surgery. The 2024 AHA/ACC guideline finds no apparent difference in cardiovascular events between these approaches. The same guideline regards neuraxial or general anesthesia as reasonable when neuraxial anesthesia is feasible.[2]

On environmental grounds, the 2026 AUGS sustainability white paper suggests that urogynecologists encourage anesthesia colleagues to use regional anesthesia and intravenous propofol when appropriate, because unmetabolized inhaled agents (desflurane above all) carry a large greenhouse-gas effect; it notes that the supporting evidence is inconsistent, and the anesthetic choice remains with the anesthesia team.[21]

Propofol-based anesthesia can reduce baseline PONV risk as part of a combined prevention plan; see PONV. A patient susceptible to malignant hyperthermia requires a nontriggering anesthetic and appropriate workstation preparation, not simply a change in the maintenance infusion.[7]

Regional Anesthesia​

TechniqueDeliveryBest suited to
SpinalSingle subarachnoid injection; dense block of finite durationShort endoscopic, perineal and lower pelvic operations (TURP, TURBT, some transvaginal repairs)
EpiduralCatheter; titratable, continuous infusionSelected major open abdominal operations; continued postoperative analgesia
Combined spinal-epiduralRapid spinal block plus a catheter for prolongationLonger operations that also need postoperative epidural analgesia

Either neuraxial route may be unsuitable because of the operation, patient physiology, infection, coagulation status or inability to manage complications. For major abdominal surgery, the 2024 AHA/ACC guideline considers epidural postoperative analgesia reasonable to decrease perioperative cardiac events (Class 2a, B-R); selection also accounts for the operation, physiology and coagulation status.[2]

What neuraxial blockade offers. In a Cochrane overview of nine reviews, neuraxial blockade compared with general anesthesia alone reduced 0–30-day mortality (RR 0.71, 95% CI 0.53–0.94; 20 studies, 3,006 participants) and pneumonia (RR 0.45, 95% CI 0.26–0.79; 5 studies, 400 participants), with no difference in myocardial infarction (RR 1.17, 95% CI 0.57–2.37; 6 studies, 849 participants). Adding a neuraxial block to general anesthesia did not change mortality (RR 1.07, 95% CI 0.76–1.51; 18 studies, 3,228 participants) but reduced pneumonia (RR 0.69, 95% CI 0.49–0.98; 9 studies, 2,433 participants).[11] The included trials are small and mostly older.[11]

Risks to plan for. Hypotension, motor weakness, urinary retention, postdural puncture headache (less frequent with atraumatic needles), and, rarely, spinal epidural hematoma. Treat hypotension according to its cause; a large fluid bolus is not an automatic response to every sympathectomy. New neurological deficits after neuraxial anesthesia require prompt assessment rather than attribution to positioning or a slowly resolving block.

Antithrombotic timing applies to both insertion and catheter removal, varies with drug, dose and renal function, and must be coordinated with postoperative prophylaxis. The fifth-edition ASRA guideline (2025) reorganizes recommendations by low-dose and high-dose regimens, keeps deliberately conservative interruption intervals because hemorrhagic complications are too rare to test in trials, and adds drug-specific assays where they can guide timing. For deep plexus or deep peripheral blocks, ASRA recommends applying neuraxial antithrombotic rules (grade IC); for other peripheral blocks, assess site compressibility, vascularity and consequences of bleeding (grade IIC). Use the current edition for drug-specific intervals, and see Antithrombotic Therapy.[12]

Peripheral Blocks and Local Anesthetic Safety​

Peripheral blocks complement the anesthetic but have procedure- and approach-dependent coverage; no fascial-plane block reliably replaces the full visceral, somatic and systemic analgesic plan. The 2026 ASA guideline strongly recommends fascial-plane blocks to reduce pain and/or opioid use in the first 24 hours after adult open abdominal, retroperitoneal and pelvic surgery; it also strongly recommends them for adult minimally invasive cholecystectomy, appendectomy, bariatric surgery, gastrectomy and liver resection to reduce pain and/or opioid use during the first 24 hours.[34] Options most used in GU work:

  • TAP or quadratus lumborum block: abdominal-wall analgesia for open pelvic surgery, cystectomy and nephrectomy; quadratus lumborum reaches further toward the flank and retroperitoneum.
  • Rectus sheath block: midline laparotomy or umbilical port sites.
  • Pudendal block: perineal urethroplasty and vaginal surgery, as an adjunct.
  • Ilioinguinal/iliohypogastric block: inguinal and scrotal surgery.

See Nerve Blocks for technique. Account for every local-anesthetic exposure in the cumulative toxicity assessment, including surgeon infiltration, blocks, tumescent or urethral preparations, catheter delivery and IV lidocaine; tell anesthesia each agent, dose and timing. If IV lidocaine is planned, coordinate its timing with blocks and infiltration using the Analgesia protocol; a consensus advises against overlapping exposure and specifies separation intervals.[30]

Local anesthetic systemic toxicity (LAST) presents as perioral numbness, tinnitus, seizure or sudden arrhythmia and hypotension, sometimes after the injection has finished. The ASRA checklist (2020 version) is: call for help and obtain the LAST rescue kit; secure the airway; treat seizures with a benzodiazepine (low-dose propofol only if none is available); and consider 20% lipid emulsion early, as a bolus of about 1.5 mL/kg over 2–3 minutes then about 0.25 mL/kg/min if under 70 kg, or about 100 mL bolus then about 250 mL over 15–20 minutes if over 70 kg. Repeat the bolus and double the infusion if the patient remains unstable; once hemodynamically stable, continue the infusion for more than 15 minutes, within the 12 mL/kg maximum. LAST resuscitation differs from standard ACLS: use smaller epinephrine doses (start below 1 mcg/kg) and avoid vasopressin, calcium-channel blockers, beta-blockers and further local anesthetic. Observe for at least 2 hours after a seizure and 4–6 hours after cardiovascular instability.[16]

Airway Management​

Anticipated Difficult Airway​

The ASA 2022 guideline supports an awake approach when difficult intubation is suspected and there is concern about difficult mask or supraglottic ventilation, aspiration, inability to tolerate brief apnea, or difficult emergency invasive airway access. Patient cooperation, physiology, expertise and available equipment affect the chosen pathway.[3]

Before robotic docking or restrictive positioning, confirm how the anesthesia team can reach the airway and how the robot and drapes will be released in an emergency.

Unanticipated Difficult Intubation — DAS​

The DAS 2025 update keeps the linear algorithm: Plan A tracheal intubation, Plan B supraglottic airway ventilation, Plan C facemask ventilation, Plan D emergency front-of-neck access. It prioritizes continuous oxygen delivery, first-attempt success (video laryngoscopy first where available), waveform capnography to confirm ventilation, and moving on when a plan fails.[4] The earlier 2015 guideline capped laryngoscopy at three attempts plus one by a more experienced operator and supraglottic insertion at three attempts. Treat this as a ceiling, not a requirement to persist through hypoxemia or trauma.[17]

After failed intubation, a second-generation supraglottic airway is the rescue route. If oxygenation is restored, pause and decide whether waking the patient is safest. Failed supraglottic rescue leads to a final optimized mask-ventilation attempt; cannot-intubate/cannot-oxygenate requires emergency front-of-neck access (scalpel-bougie-tube technique, practiced beforehand). Prepare for escalation early.[4][17]

Extubation Is Part of the Airway Plan​

Assess readiness, airway swelling, ventilation, neuromuscular recovery and likely difficulty of reintubation. Choose the location, timing and skilled assistance accordingly. Awake versus deep extubation is an individualized anesthesia decision; selected difficult airways may need a staged approach or continued ventilation. Document difficult airway events and inform the patient.[3]

Emergency Robotic Undocking​

A retrospective analysis of FDA MAUDE reports from 2000 to 2013 identified 10,624 robotic-surgery adverse events, including 144 deaths (1.4%) and 1,391 patient injuries (13.1%); device or instrument malfunction accounted for 75.9% of reports, and 7.3% of events required conversion to a non-robotic technique.[22] The 2025 RCSI national governance guide recommends regular emergency rehearsals that include undocking, patient repositioning and team communication.[31] Kalipershad and Peristerakis describe an institutional emergency safety protocol (ESP) with a trigger phrase, assigned roles, simulation and an uninterruptible power supply to preserve system power and console imaging during an outage.[23] The 2025 RCSI guide reproduces its example sequence: the bedside assistant controls the operative field, the scrub nurse removes instruments and releases ports, the circulating nurse moves the cart and returns the table to neutral, and the surgeon moves to the bedside.[31]

A simulation-based emergency undocking curriculum, tested across five robotic teams facing a simulated major vascular injury with robotic fault, produced significant gains in knowledge (+37.5 points, p = 0.004) and confidence (+15.3 points, p < 0.001) between baseline and course completion, with knowledge and confidence retained at 6-month reassessment. Between simulation attempts, checklist errors fell from 38 to 17 and undocking time and estimated blood loss both fell (about 40 seconds and 500 mL, respectively), though the trial was not powered to show these last two changes were statistically significant.[24] Confirm the emergency undocking and access plan with the anesthesia and nursing team before docking; see Positioning & Nerve Injury.

Neuromuscular Blockade and Reversal​

Paralysis provides neither unconsciousness nor analgesia. The ASA 2023 recommendations emphasize quantitative monitoring at the adductor pollicis and a train-of-four ratio of at least 0.9 before extubation. Clinical strength tests or visual or tactile twitch assessment alone cannot reliably establish recovery.[5]

For rocuronium or vecuronium, sugammadex is preferred over neostigmine at deep, moderate or shallow block. In the randomized 2026 SNaPP trial of adults aged at least 40 undergoing abdominal or thoracic surgery lasting at least two hours with an expected overnight stay, pulmonary complications or death by hospital discharge (or postoperative day 7 if still hospitalized) occurred in 331/1,743 (19.0%) assigned sugammadex versus 377/1,752 (21.5%) assigned neostigmine; atelectasis accounted for most events.[35] Neostigmine is a reasonable alternative at minimal block, quantitatively defined as a ratio of 0.4 to below 0.9. A patient who has spontaneously recovered to at least 0.9 does not need pharmacological antagonism.[5]

Persistent weakness, upper-airway obstruction or hypoventilation in recovery warrants immediate assessment and airway support; consider residual blockade alongside opioids, sedation and other causes.

AgentTypeDuration and notes
SuccinylcholineDepolarizingUltra-short; rapid-sequence induction. Contraindicated with known or suspected malignant hyperthermia susceptibility, skeletal muscle myopathies, and after the acute phase of major burns, multiple trauma, extensive denervation or upper motor neuron injury (severe hyperkalemia)[20]
Rocuronium, vecuroniumNon-depolarizing, intermediateTypically 30–60 minutes; sugammadex-reversible
CisatracuriumNon-depolarizing, benzylisoquinoliniumPredominantly Hofmann elimination; single-dose recovery is preserved in renal or hepatic impairment, but extended administration in patients with renal or hepatic impairment may increase laudanosine exposure and seizure risk; not reversed by sugammadex[5][32]

Deep blockade for laparoscopic and robotic surgery. Surgeons often ask for deep block to widen the working space. A 2024 Cochrane review of 42 trials (3,898 participants, mostly intraperitoneal oncologic resections) found deep versus moderate block likely made little or no difference to health-related quality of life or operating time, and the evidence for serious adverse events (38/1,155 versus 38/1,076 intraoperatively) and pain scores was very uncertain. Request deep block when exposure genuinely needs it, and plan reversal with sugammadex.[13]

Depth of Anesthesia and Awareness​

Processed EEG can supplement clinical assessment and anesthetic-delivery monitoring. BIS studies commonly targeted 40–60. The index is affected by drugs and artifacts. The 2019 Cochrane review (52 studies, 41,331 participants) found low-certainty evidence of less awareness compared with clinical-sign guidance (about 3 versus 9 per 1,000; only five of 27 studies reported events), but no evidence of a difference compared with end-tidal anesthetic-gas guidance (about 1 per 1,000 in both groups). It does not justify a routine instruction to lighten anesthesia to BIS 55–70 before surgery ends.[6]

In ENGAGES, 1,232 older adults were randomized; among 1,213 assessed, delirium occurred in 157/604 (26.0%) with EEG guidance versus 140/609 (23.0%) with usual care, without a significant reduction.[10]

Malignant Hyperthermia​

MH is a pharmacogenetic hypermetabolic crisis of skeletal muscle. Reactions occur in about 1 in 10,000 to 1 in 250,000 anesthetics, while the genetic abnormality may be present in as many as 1 in 400 people. A 2015 review reported that MH mortality fell from about 80% roughly 30 years earlier to under 5% in 2006, attributing the decline to improved understanding of MH; it identifies dantrolene as a treatment.[14] Suspect MH with an unexplained hypermetabolic picture during or after exposure to triggering volatile anesthetics or succinylcholine; do not wait for marked fever. A rising end-tidal CO2 despite increased minute ventilation is an early clue, followed by tachycardia, rigidity, hyperkalemia, acidosis and rhabdomyolysis; hyperthermia is often late. Succinylcholine-associated masseter rigidity warrants evaluation but is not by itself diagnostic of MH.[7][8]

Do not treat 10 mg/kg as a dantrolene ceiling

Stop triggering agents, call for help and the MH cart, and give high-flow 100% oxygen.[7] MHAUS recommends IV dantrolene 2.5 mg/kg rapidly, repeated according to the response.[7] More than 10 mg/kg may be necessary for persistent rigidity or hypermetabolism; lack of response despite large doses should also prompt reconsideration of the diagnosis.[7] The US Ryanodex label gives a minimum of 1 mg/kg by IV push with further boluses to a cumulative 10 mg/kg, repeating from 1 mg/kg if signs return, so follow the MH cart's product instructions.[19]

Cool when core temperature exceeds 39°C or is rising rapidly, stopping active cooling below 38°C. Treat hyperkalemia, acidosis and arrhythmias; avoid calcium-channel blockers with dantrolene. Monitor temperature, ventilation, potassium, CK, renal function, urine and coagulation. After stabilization, observation in an appropriate PACU or ICU setting should continue for at least 24 hours.[7]

Use the institution's MH cognitive aid for the full crisis and post-crisis protocol. The surgical team's immediate roles include stopping nonessential surgery, obtaining supplies and helping free airway access.

Perioperative Anaphylaxis​

Unexpected severe hypotension or bronchospasm may represent anaphylaxis without visible skin findings. Stop suspected triggers and nonessential surgery, call for help, support oxygenation and ventilation, and give epinephrine with rapid crystalloid resuscitation. In the monitored perioperative setting, trained anesthesia clinicians give an initial IV epinephrine bolus (50 micrograms in adults) with a 500–1,000 mL crystalloid bolus, then an infusion if the response is poor; this differs from the usual community IM pathway. Follow the dedicated perioperative algorithm.[9]

Antihistamines and corticosteroids must not delay epinephrine or resuscitation. Suspected triggers include antibiotics, neuromuscular blockers, dyes, colloids, latex, and hidden exposures such as chlorhexidine-coated lines or catheters and lubricants; sugammadex can also cause anaphylaxis.[9][18] After stabilization, obtain timed tryptase samples (once stable, 1–4 hours after onset, and at least 24 hours later), document all exposures and arrange specialist allergy investigation rather than permanently labeling every administered drug as the culprit.[9]

Regional Versus General — What the Evidence Shows​

QuestionFinding
Volatile versus propofol TIVA, cardiovascular eventsNo apparent difference; either is reasonable (2024 AHA/ACC, Class 2a)[2]
Neuraxial versus general, cardiovascular eventsNo apparent difference when neuraxial is feasible (2024 AHA/ACC, Class 2a)[2]
Postoperative delirium, regional versus general, hip fracture (RAGA, 950 patients)delirium 6.2% (29 patients) with regional versus 5.1% (24) with general anesthesia among 941 evaluable; no significant difference[15]
Mortality and pneumonia, neuraxial versus generalLower with neuraxial in small, mostly older trials; see above[11]

The Surgeon's Intraoperative Communication Checklist​

  • Before incision: expected duration, position, docking and emergency access, blood loss, bowel work, local anesthetic or block plan and postoperative destination.
  • During surgery: communicate changing stimulation, bleeding and operative difficulty; request changes in blockade or hemodynamic support with their clinical purpose.
  • Before closure: agree on extubation readiness, quantitative neuromuscular recovery, temperature, PONV prevention and analgesic transition.
  • At handover: report airway difficulty, reactions, blood loss, blocks and all local-anesthetic doses. Account for baseline opioid treatment and tolerance.

Pediatric Anesthesia Considerations​

Infants and young children undergoing pyeloplasty, ureteral reimplantation, bladder augmentation and other reconstructive procedures raise disposition, scheduling and pneumoperitoneum questions that the surgical team should discuss with pediatric anesthesia before the case.

  • Postoperative apnea in former preterm infants. A 1995 combined analysis of 255 infants after inguinal herniorrhaphy under general anesthesia estimated that apnea risk did not fall below 1% with 95% confidence until 54–56 weeks' postconceptual age in nonanemic infants without recovery-room apnea, varying by gestational age.[25] A 2026 individual-participant meta-analysis of 751 former preterm infants after open inguinal herniorrhaphy estimated risk below 1% at about 65 weeks' postmenstrual age after general anesthesia, versus about 45 weeks after neuraxial anesthesia.[29] A 2025 Campbell-Walsh-Wein Urology chapter recommends 23-hour postoperative observation with cardiorespiratory monitoring for former preterm infants below 50–60 weeks' postgestational age, and 23-hour observation for term infants below 44 weeks' postgestational age; discuss monitoring and disposition with pediatric anesthesia in light of the newer estimate, anemia, recovery-room events, anesthetic technique and the local pathway.[28][29]
  • Recent upper respiratory infection. In a prospective cohort of 216 children aged 1–5 years with mild-to-moderate upper respiratory infection undergoing ambulatory ilioinguinal surgery, respiratory adverse events occurred in 46/216 (21%).[26] Passive smoke exposure was associated with events (adjusted OR 5.31, 95% CI 2.07–13.6); the model's estimate for prior postponement within 15 days was imprecise (adjusted OR 4.3, 95% CI 0.83–22.4).[26] In children with active upper respiratory infection, reported risk factors include endotracheal intubation before age 5 years, prematurity, reactive airway disease and airway surgery.[28][36] Postponement practice for a severe or recent infection varies by institution.[28]
  • Pneumoperitoneum. In a prospective study of 29 children with normal renal function undergoing laparoscopy, renal regional oxygen saturation did not change significantly when investigators used insufflation pressures below 6 mmHg at 0–1 month, below 8 mmHg at 2–12 months, below 10 mmHg at 1–2 years and below 12 mmHg at 2–8 years.[27] Pneumoperitoneum in children further reduces functional residual capacity and lung compliance and can transiently reduce renal perfusion; urine output during pneumoperitoneum, particularly in an infant, is not a reliable guide to fluid resuscitation.[28]

Key Points​

TopicPoint
AirwayVideo laryngoscopy first where available; declare failure early; know the front-of-neck pathway
Neuromuscular blockQuantitative monitoring; train-of-four ratio at least 0.9 before extubation; sugammadex for rocuronium or vecuronium at deep to shallow block
Malignant hyperthermiaStop triggers; dantrolene 2.5 mg/kg (MHAUS), more than 10 mg/kg may be needed[7]
Local anestheticOne running total across all injections; LAST needs early lipid emulsion and reduced-dose epinephrine
NeuraxialInsertion and catheter-removal timing follow current ASRA guidance
AnaphylaxisEpinephrine and fluid first; timed tryptase

References​

1. American Society of Anesthesiologists. “Statement on Distinguishing Monitored Anesthesia Care from Moderate Sedation Analgesia.” Updated 2023. ASA statement.

2. Thompson A, Fleischmann KE, Smilowitz NR, et al. “2024 AHA/ACC Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery.” J Am Coll Cardiol. 2024;84:1869–1969. doi:10.1016/j.jacc.2024.06.013.

3. Apfelbaum JL, Hagberg CA, Connis RT, et al. “2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.” Anesthesiology. 2022;136:31–81. doi:10.1097/ALN.0000000000004002.

4. Ahmad I, El-Boghdadly K, Iliff H, et al. “Difficult Airway Society 2025 Guidelines for Management of Unanticipated Difficult Tracheal Intubation in Adults.” Br J Anaesth. 2026;136:283–307. doi:10.1016/j.bja.2025.10.006.

5. Thilen SR, Weigel WA, Todd MM, et al. “2023 American Society of Anesthesiologists Practice Guidelines for Monitoring and Antagonism of Neuromuscular Blockade.” Anesthesiology. 2023;138:13–41. doi:10.1097/ALN.0000000000004379.

6. Lewis SR, Pritchard MW, Fawcett LJ, Punjasawadwong Y. “Bispectral Index for Improving Intraoperative Awareness and Early Postoperative Recovery in Adults.” Cochrane Database Syst Rev. 2019;9:CD003843. doi:10.1002/14651858.CD003843.pub4.

7. Malignant Hyperthermia Association of the United States. “Managing a Crisis.” MHAUS acute-treatment guidance.

8. Malignant Hyperthermia Association of the United States. “Masseter Muscle Rigidity: Definition, Relationship to Malignant Hyperthermia, and Management.” 2018. MHAUS recommendation.

9. Resuscitation Council UK. “Emergency Treatment of Peri-operative Anaphylaxis.” 2024. Perioperative algorithm.

10. Wildes TS, Mickle AM, Ben Abdallah A, et al. “Effect of Electroencephalography-Guided Anesthetic Administration on Postoperative Delirium Among Older Adults Undergoing Major Surgery: The ENGAGES Randomized Clinical Trial.” JAMA. 2019;321:473–483. doi:10.1001/jama.2018.22005.

11. Guay J, Choi P, Suresh S, Albert N, Kopp S, Pace NL. “Neuraxial Blockade for the Prevention of Postoperative Mortality and Major Morbidity: An Overview of Cochrane Systematic Reviews.” Cochrane Database Syst Rev. 2014;2014(1):CD010108. doi:10.1002/14651858.CD010108.pub2.

12. Kopp SL, Vandermeulen E, McBane RD, Perlas A, Leffert L, Horlocker T. “Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fifth Edition).” Reg Anesth Pain Med. 2025. doi:10.1136/rapm-2024-105766.

13. Bijkerk V, Jacobs LM, Albers KI, et al. “Deep Neuromuscular Blockade in Adults Undergoing an Abdominal Laparoscopic Procedure.” Cochrane Database Syst Rev. 2024;1(1):CD013197. doi:10.1002/14651858.CD013197.pub2.

14. Rosenberg H, Pollock N, Schiemann A, Bulger T, Stowell K. “Malignant Hyperthermia: A Review.” Orphanet J Rare Dis. 2015;10:93. doi:10.1186/s13023-015-0310-1.

15. Li T, Li J, Yuan L, et al. “Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery: The RAGA Randomized Trial.” JAMA. 2022;327(1):50–58. doi:10.1001/jama.2021.22647.

16. Neal JM, Neal EJ, Weinberg GL. “American Society of Regional Anesthesia and Pain Medicine Local Anesthetic Systemic Toxicity Checklist: 2020 Version.” Reg Anesth Pain Med. 2021;46(1):81–82. doi:10.1136/rapm-2020-101986.

17. Frerk C, Mitchell VS, McNarry AF, et al. “Difficult Airway Society 2015 Guidelines for Management of Unanticipated Difficult Intubation in Adults.” Br J Anaesth. 2015;115(6):827–848. doi:10.1093/bja/aev371.

18. Savic L, Silversides JA, Leslie K. “Sugammadex Anaphylaxis: Mechanisms, Diagnosis, and Incidence.” Anesthesiology. 2025;143(1):199–204. doi:10.1097/ALN.0000000000005431.

19. Eagle Pharmaceuticals. “Ryanodex (dantrolene sodium) for injectable suspension: Prescribing Information.” DailyMed, revised 2024. DailyMed label.

20. Sandoz Inc. “Anectine (succinylcholine chloride) injection: Prescribing Information.” DailyMed, 2026. DailyMed label.

21. Chen CCG, Andiman S, Long J, et al. Health Care Sustainability: Strategies for Operating Rooms and Urogynecologic Procedures. Urogynecology (Phila). 2026;32(6):569-577. doi:10.1097/SPV.0000000000001835

22. Alemzadeh H, Raman J, Leveson N, Kalbarczyk Z, Iyer RK. “Adverse Events in Robotic Surgery: A Retrospective Study of 14 Years of FDA Data.” PLoS One. 2016;11(4):e0151470. doi:10.1371/journal.pone.0151470.

23. Kalipershad SNR, Peristerakis I. “The Introduction of an Emergency Safety Protocol Coupled with Simulation Training in Robotic Surgery, Has Enabled a More Cohesive and Efficient Response to Emergencies.” Surgeon. 2022;20(3):151-156. doi:10.1016/j.surge.2021.03.007.

24. Melnyk R, Saba P, Holler T, et al. “Design and Implementation of an Emergency Undocking Curriculum for Robotic Surgery.” Simul Healthc. 2022;17(2):78-87. doi:10.1097/SIH.0000000000000596.

25. Coté CJ, Zaslavsky A, Downes JJ, et al. “Postoperative Apnea in Former Preterm Infants After Inguinal Herniorrhaphy. A Combined Analysis.” Anesthesiology. 1995;82(4):809-822. doi:10.1097/00000542-199504000-00002.

26. Jarraya A, Kammoun M, Ammar S, Feki W, Kolsi K. “Predictors of Perioperative Respiratory Adverse Events Among Children With Upper Respiratory Tract Infection Undergoing Pediatric Ambulatory Ilioinguinal Surgery: A Prospective Observational Research.” World J Pediatr Surg. 2023;6(2):e000524. doi:10.1136/wjps-2022-000524.

27. Westgarth-Taylor C, de Lijster L, van Bogerijen G, Millar AJ, Karpelowsky J. “A Prospective Assessment of Renal Oxygenation in Children Undergoing Laparoscopy Using Near-Infrared Spectroscopy.” Surg Endosc. 2013;27(10):3696-3704. doi:10.1007/s00464-013-2950-3.

28. Ross SS, Phelps JR. Core Principles of Perioperative Management in Children. In: Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, eds. Campbell-Walsh-Wein Urology. 13th ed. Elsevier; 2025:718-730.

29. Dalal PG, Coté CJ, Malviya S, et al. "Postanesthesia Apnea in Former Preterm Infants for Inguinal Herniorrhaphy: An Update of Risk Factors from an Individual Participant Data Meta-analysis." Anesthesiology. 2026;144(6):1442–1453. doi:10.1097/ALN.0000000000005964

30. Foo I, Macfarlane AJR, Srivastava D, et al. "The use of intravenous lidocaine for postoperative pain and recovery: international consensus statement on efficacy and safety." Anaesthesia. 2021;76(2):238–250. doi:10.1111/anae.15270

31. Royal College of Surgeons in Ireland. Robotic Surgery Governance in Ireland: A Guide to Good Practice. January 2025. RCSI guide

32. Fresenius Kabi USA, LLC. "Cisatracurium Besylate Injection: Prescribing Information." DailyMed. 2025. Label.

33. Doyle PT, Briscoe CE. "The effects of drugs and anaesthetic agents on the urinary bladder and sphincters." Br J Urol. 1976;48(5):329–335. doi:10.1111/j.1464-410x.1976.tb06645.x

34. Joshi GP, Mariano ER, Elkassabany NM, et al. "2026 American Society of Anesthesiologists Practice Guideline on Perioperative Pain Management Using Local and Regional Analgesia for Cardiothoracic Surgeries, Mastectomy, and Abdominal Surgeries." Anesthesiology. 2026;144(1):19–43. doi:10.1097/ALN.0000000000005790

35. Leslie K, Darvall JN, Chan MTV, et al. "Sugammadex versus neostigmine for reversal of neuromuscular blockade and postoperative pulmonary complications (SNaPP): an international, randomised, controlled, phase 4 trial." Lancet Respir Med. 2026;14(9):761–774. doi:10.1016/S2213-2600(26)00158-X

36. Tait AR, Malviya S, Voepel-Lewis T, Munro HM, Seiwert M, Pandit UA. "Risk factors for perioperative adverse respiratory events in children with upper respiratory tract infections." Anesthesiology. 2001;95(2):299–306. doi:10.1097/00000542-200108000-00008