Anesthetic considerations for urologic surgeries

Chang-Hoon Koo, Jung-Hee Ryu, Chang-Hoon Koo, Jung-Hee Ryu

Abstract

Urologic surgeries are widely performed, and the cases have increased owing to the fact that the elderly population is growing. The narrow and limited surgical space is a challenge in performing most urologic surgeries. Additionally, the elderly population is exposed to the risk of perioperative complications; therefore, a comprehensive understanding and approach are required to provide optimized anesthesia during surgery. We have searched the literature on anesthesia for urologic surgeries and summarized the anesthetic considerations for urologic surgeries.

Keywords: General anesthesia; Geriatrics; Perioperative care; Postoperative complication; Spinal anesthesia; Urologic surgery.

Conflict of interest statement

No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1.
Fig. 1.
Comparison of the classic and inguinal approach of obturator nerve block. T: pubic tubercle, C: needle insertion point of the classic approach; I: needle insertion point of the inguinal approach.
Fig. 2.
Fig. 2.
Enhanced recovery after surgery protocol in urologic surgery. LMWH: low molecular weight heparin.

References

    1. Joung JY, Lim J, Oh CM, Jung KW, Cho H, Kim SH, et al. Current trends in the incidence and survival rate of urological cancers in Korea. Cancer Res Treat. 2017;49:607–15.
    1. Brodak M, Tomasek J, Pacovsky J, Holub L, Husek P. Urological surgery in elderly patients: results and complications. Clin Interv Aging. 2015;10:379–84.
    1. Cui HW, Turney BW, Griffiths J. The preoperative assessment and optimization of patients undergoing major urological surgery. Curr Urol Rep. 2017;18:54.
    1. Findley GP. Knowing the risk: a review of the peri-operative care of surgical patients. London: National Confidential Enquiry into Patient Outcome and Death; 2011. p. 9.
    1. Lim BG, Lee IO. Anesthetic management of geriatric patients. Korean J Anesthesiol. 2020;73:8–29.
    1. Leavitt DA, Motamedinia P, Moran S, Siev M, Zhao PT, Theckumparampil N, et al. Can activities of daily living predict complications following percutaneous nephrolithotomy? J Urol. 2016;195:1805–9.
    1. Brouquet A, Cudennec T, Benoist S, Moulias S, Beauchet A, Penna C, et al. Impaired mobility, ASA status and administration of tramadol are risk factors for postoperative delirium in patients aged 75 years or more after major abdominal surgery. Ann Surg. 2010;251:759–65.
    1. Chen TY, Anderson DJ, Chopra T, Choi Y, Schmader KE, Kaye KS. Poor functional status is an independent predictor of surgical site infections due to methicillin-resistant Staphylococcus aureus in older adults. J Am Geriatr Soc. 2010;58:527–32.
    1. Li C, Carli F, Lee L, Charlebois P, Stein B, Liberman AS, et al. Impact of a trimodal prehabilitation program on functional recovery after colorectal cancer surgery: a pilot study. Surg Endosc. 2013;27:1072–82.
    1. Chow B, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215:453–66.
    1. Suskind AM, Walter LC, Jin C, Boscardin J, Sen S, Cooperberg MR, et al. Impact of frailty on complications in patients undergoing common urological procedures: a study from the American College of Surgeons National Surgical Quality Improvement database. BJU Int. 2016;117:836–42.
    1. Isharwal S, Johanning JM, Dwyer JG, Schimid KK, LaGrange CA. Preoperative frailty predicts postoperative complications and mortality in urology patients. World J Urol. 2017;35:21–6.
    1. Sathianathen NJ, Jarosek S, Lawrentschuk N, Bolton D, Konety BR. A simplified frailty index to predict outcomes after radical cystectomy. Eur Urol Focus. 2019;5:658–63.
    1. Mills E, Eyawo O, Lockhart I, Kelly S, Wu P, Ebbert JO. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med. 2011;124:144–54.
    1. Thomsen T, Villebro N, Møller AM. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev. 2014;27:CD002294.
    1. Ferraris VA, Davenport DL, Saha SP, Austin PC, Zwischenberger JB. Surgical outcomes and transfusion of minimal amounts of blood in the operating room. Arch Surg. 2012;147:49–55.
    1. Muñoz M, Acheson AG, Auerbach M, Besser M, Habler O, Kehlet H, et al. International consensus statement on the perioperative management of anaemia and iron deficiency. Anaesthesia. 2017;72:233–47.
    1. Ljungberg B, Bensalah K, Canfield S, Dabestani S, Hofmann F, Hora M, et al. EAU guidelines on renal cell carcinoma: 2014 update. Eur Urol. 2015;67:913–24.
    1. Chapman E, Pichel AC. Anesthesia for nephrectomy. BJA Education. 2016;16:98–101.
    1. Cassorla L, Lee JW. In: Patients positioning and associated risks. In: Miller’s Anesthesia. 8th ed. Miller RD, Eriksson LI, Fleisher LA, editors. Philadelphia: Elsevier; 2015. p. 1249.
    1. Novara G, La Falce S, Kungulli A, Gandaglia G, Ficarra V, Mottrie A. Robot-assisted partial nephrectomy. Int J Surg. 2016;36:554–9.
    1. Cockcroft JO, Berry CB, McGrath JS, Daugherty MO. Anesthesia for major urologic surgery. Anesthesiol Clin. 2015;33:165–72.
    1. Mathuram Thiyagarajan U, Bagul A, Nicholson ML. Pain management in laparoscopic donor nephrectomy: a review. Pain Res Treat. 2012;2012:201852.
    1. Freedland SJ, Blanco-Yarosh M, Sun JC, Hale SJ, Elashoff DA, Litwin MS, et al. Ketorolac-based analgesia improves outcomes for living kidney donors. Transplantation. 2002;73:741–5.
    1. Soulié M, Straub M, Gamé X, Seguin P, De Petriconi R, Plante P, et al. A multicenter study of the morbidity of radical cystectomy in select elderly patients with bladder cancer. J Urol. 2002;167:1325–8.
    1. Knap MM, Lundbeck F, Overgaard J. Early and late treatment-related morbidity following radical cystectomy. Scand J Urol Nephrol. 2004;38:153–60.
    1. Linder BJ, Frank I, Cheville JC, Tollefson MK, Thompson RH, Tarrell RF, et al. The impact of perioperative blood transfusion on cancer recurrence and survival following radical cystectomy. Eur Urol. 2013;63:839–45.
    1. Sui W, Onyeji IC, Matulay JT, James MB, Theofanides MC, Wenske S, et al. Perioperative blood transfusion in radical cystectomy: analysis of the National Surgical Quality Improvement Program database. Int J Urol. 2016;23:745–50.
    1. Abel EJ, Linder BJ, Bauman TM, Bauer RM, Thompson RH, Thapa P, et al. Perioperative blood transfusion and radical cystectomy: does timing of transfusion affect bladder cancer mortality? Eur Urol. 2014;66:1139–47.
    1. Kluth LA, Xylinas E, Rieken M, El Ghouayel M, Sun M, Karakiewicz PI, et al. Impact of peri-operative blood transfusion on the outcomes of patients undergoing radical cystectomy for urothelial carcinoma of the bladder. BJU Int. 2014;113:393–8.
    1. Vetterlein MW, Gild P, Kluth LA, Seisen T, Gierth M, Fritsche HM, et al. Perioperative allogeneic blood transfusion does not adversely affect oncological outcomes after radical cystectomy for urinary bladder cancer: a propensity score-weighted European multicentre study. BJU Int. 2018;121:101–10.
    1. Van der Aa F, Joniau S, Van Den Branden M, Van Poppel H. Metabolic changes after urinary diversion. Adv Urol. 2011;2011:764325.
    1. Amling CL. Diagnosis and management of superficial bladder cancer. Curr Probl Cancer. 2001;25:219–78.
    1. Fredman B, Zohar E, Philipov A, Olsfanger D, Shalev M, Jedeikin R. The induction, maintenance, and recovery characteristics of spinal versus general anesthesia in elderly patients. J Clin Anesth. 1998;10:623–30.
    1. Cesur M, Erdem AF, Alici HA, Yapanoglu T, Yuksek MS, Aksoy Y. The role of succinylcholine in the prevention of the obturator nerve reflex during transurethral resection of bladder tumors. Saudi Med J. 2008;29:668–71.
    1. Koo CH, Chung SH, Kim BG, Min BH, Lee SC, Oh AY, et al. Comparison between the effects of deep and moderate neuromuscular blockade during transurethral resection of bladder tumor on endoscopic surgical condition and recovery profile: a prospective, randomized, and controlled trial. World J Urol. 2019;37:359–65.
    1. Kanazi GE, Aouad MT, Jabbour-Khoury SI, Al Jazzar MD, Alameddine MM, Al-Yaman R, et al. Effect of low-dose dexmedetomidine or clonidine on the characteristics of bupivacaine spinal block. Acta Anaesthesiol Scand. 2006;50:222–7.
    1. Cuvas O, Er AE, Ongen E, Basar H. Spinal anesthesia for transurethral resection operations: bupivacaine versus levobupivacaine. Minerva Anestesiol. 2008;74:697–701.
    1. Lee YY, Muchhal K, Chan CK, Cheung AS. Levobupivacaine and fentanyl for spinal anaesthesia: a randomized trial. Eur J Anaesthesiol. 2005;22:899–903.
    1. Bolat D, Aydogdu O, Tekgul ZT, Polat S, Yonguc T, Bozkurt IH, et al. Impact of nerve stimulator-guided obturator nerve block on the short-term outcomes and complications of transurethral resection of bladder tumour: a prospective randomized controlled study. Can Urol Assoc J. 2015;9:E780–4.
    1. Labat G. Regional anesthesia: its technic and clinical application. Philadelphia: WB Saunders Company; 1922. pp. 249–50.
    1. Kakinohana M, Taira Y, Saitoh T, Hasegawa A, Gakiya M, Sugahara K. Interadductor approach to obturator nerve block for transurethral resection procedure: comparison with traditional approach. J Anesth. 2002;16:123–6.
    1. Dagli R, Dadali M, Emir L, Bagbanci S, Ates H. Comparison of classic and inguinal obturator nerve blocks applied for preventing adductor muscle contractions in bladder tumor surgeries: a prospective randomized trial. Urol J. 2019;16:62–6.
    1. Jo YY, Choi E, Kil HK. Comparison of the success rate of inguinal approach with classical pubic approach for obturator nerve block in patients undergoing TURB. Korean J Anesthesiol. 2011;61:143–7.
    1. Choquet O, Capdevila X, Bennourine K, Feugeas JL, Bringuier-Branchereau S, Manelli JC. A new inguinal approach for the obturator nerve block: anatomical and randomized clinical studies. Anesthesiology. 2005;103:1238–45.
    1. Aghamohammadi D, Gargari RM, Fakhari S, Bilehjani E, Poorsadegh S. Classic versus inguinal approach for obturator nerve block in transurethral resection of bladder cancer under spinal anesthesia: a randomized controlled trial. Iran J Med Sci. 2018;43:75–80.
    1. Wassef MR. Interadductor approach to obturator nerve blockade for spastic conditions of adductor thigh muscles. Reg Anesth. 1993;18:13–7.
    1. Hızlı F, Argun G, Güney I, Güven O, Arık AI, Başay S, et al. Obturator nerve block transurethral surgery for bladder cancer: comparison of inguinal and intravesical approaches: prospective randomized trial. Ir J Med Sci. 2016;185:555–60.
    1. Park HP. Irrigation fluids used for transurethral resection of the prostate: a double-edged sword. Korean J Anesthesiol. 2019;72:87–8.
    1. Hahn RG. Fluid absorption in endoscopic surgery. Br J Anaesth. 2006;96:8–20.
    1. Demirel I, Ozer AB, Bayar M, Erhan OL. TURP syndrome and severe hyponatremia under general anesthesia. BMJ Case Rep. 2012;2012:bcr-2012-006899.
    1. Shin HJ, Lee H, Na HS. The effect of a mixture of 2.7% sorbitol-0.54% mannitol solution on blood coagulation: an in vitro, observational healthy volunteer study using rotational thromboelastometry (ROTEM) Korean J Anesthesiol. 2019;72:143–9.
    1. Shah J, Vyas A, Vyas D. The history of robotics in surgical specialties. Am J Robot Surg. 2014;1:12–20.
    1. Seo IY. Urologic robotic surgery in Korea: past and present. Korean J Urol. 2015;56:546–52.
    1. Giri S, Sarkar DK. Current status of robotic surgery. Indian J Surg. 2012;74:242–7.
    1. Baltayian S. A brief review: anesthesia for robotic prostatectomy. J Robot Surg. 2008;2:59.
    1. Lee JR. Anesthetic considerations for robotic surgery. Korean J Anesthesiol. 2014;66:3–11.
    1. Jo YY, Kwak HJ. What is the proper ventilation strategy during laparoscopic surgery? Korean J Anesthesiol. 2017;70:596–600.
    1. Ahn S, Byun SH, Chang H, Koo YB, Kim JC. Effect of recruitment maneuver on arterial oxygenation in patients undergoing robot-assisted laparoscopic prostatectomy with intraoperative 15 cmH2O positive end expiratory pressure. Korean J Anesthesiol. 2016;69:592–8.
    1. Kim WH, Hahm TS, Kim JA, Sim WS, Choi DH, Lee EK, et al. Prolonged inspiratory time produces better gas exchange in patients undergoing laparoscopic surgery: a randomised trial. Acta Anaesthesiol Scand. 2013;57:613–22.
    1. Lee HJ, Kim KS, Jeong JS, Shim JC, Cho ES. Optimal positive end-expiratory pressure during robot-assisted laparoscopic radical prostatectomy. Korean J Anesthesiol. 2013;65:244–50.
    1. Gupta K, Mehta Y, Sarin Jolly A, Khanna S. Anaesthesia for robotic gynaecological surgery. Anaesth Intensive Care. 2012;40:614–21.
    1. Falabella A, Moore-Jeffries E, Sullivan MJ, Nelson R, Lew M. Cardiac function during steep Trendelenburg position and CO2 pneumoperitoneum for robotic-assisted prostatectomy: a trans-oesophageal Doppler probe study. Int J Med Robot. 2007;3:312–5.
    1. Mavrocordatos P, Bissonnette B, Ravussin P. Effects of neck position and head elevation on intracranial pressure in anaesthetized neurosurgical patients: preliminary results. J Neurosurg Anesthesiol. 2000;12:10–4.
    1. Weber ED, Colyer MH, Lesser RL, Subramanian PS. Posterior ischemic optic neuropathy after minimally invasive prostatectomy. J Neuroophthalmol. 2007;27:285–7.
    1. Awad H, Santilli S, Ohr M, Roth A, Yan W, Fernandez S, et al. The effects of steep trendelenburg positioning on intraocular pressure during robotic radical prostatectomy. Anesth Analg. 2009;109:473–8.
    1. Kalmar AF, Foubert L, Hendrickx JF, Mottrie A, Absalom A, Mortier EP, et al. Influence of steep Trendelenburg position and CO(2) pneumoperitoneum on cardiovascular, cerebrovascular, and respiratory homeostasis during robotic prostatectomy. Br J Anaesth. 2010;104:433–9.
    1. Gainsburg DM. Anesthetic concerns for robotic-assisted laparoscopic radical prostatectomy. Minerva Anestesiol. 2012;78:596–604.
    1. Taylor E, Miller J, Chi T, Stoller ML. Complications associated with percutaneous nephrolithotomy. Transl Androl Urol. 2012;1:223–8.
    1. Malik I, Wadhwa R. Percutaneous nephrolithotomy: current clinical opinions and anesthesiologists perspective. Anesthesiol Res Pract. 2016;2016:9036872.
    1. Hu H, Qin B, He D, Lu Y, Zhao Z, Zhang J, et al. Regional versus general anesthesia for percutaneous nephrolithotomy: a meta-analysis. PLoS One. 2015;10:e0126587.
    1. Srivastava A, Singh KJ, Suri A, Dubey D, Kumar A, Kapoor R, et al. Vascular complications after percutaneous nephrolithotomy: are there any predictive factors? Urology. 2005;66:38–40.
    1. Hosking DH, Bard RJ. Ureteroscopy with intravenous sedation for treatment of distal ureteral calculi: a safe and effective alternative to shock wave lithotripsy. J Urol. 1996;156:899–901.
    1. Chan PS, Fenn J, Li AK. Transurethral ureterorenoscopic lithotripsy and retrieval of ureteric calculi under local anaesthesia and sedation. Br J Urol. 1990;65:141–3.
    1. Vögeli TA, Mellin HE, Hopf B, Ackermann R. Ureteroscopy under local anaesthesia with and without intravenous analgesia. Br J Urol. 1993;72:161–4.
    1. Cybulski PA, Joo H, Honey RJ. Ureteroscopy: anesthetic considerations. Urol Clin North Am. 2004;31:43–7.
    1. Zimmer A, Greul F, Meibner W. Pain management in urology. Urologe A. 2013;52:585–95.
    1. De Oliveira GS, Castro-Alves LJ, Nader A, Kendall MC, McCarthy RJ. Transversus abdominis plane block to ameliorate postoperative pain outcomes after laparoscopic surgery: a meta-analysis of randomized controlled trials. Anesth Analg. 2014;118:454–63.
    1. Aniskevich S, Taner CB, Perry DK, Robards CB, Porter SB, Thomas CS, et al. Ultrasound-guided transversus abdominis plane blocks for patients undergoing laparoscopic hand-assisted nephrectomy: a randomized, placebo-controlled trial. Local Reg Anesth. 2014;7:11–6.
    1. Baeriswyl M, Zeiter F, Piubellini D, Kirkham KR, Albrecht E. The analgesic efficacy of transverse abdominis plane block versus epidural analgesia: a systematic review with meta-analysis. Medicine (Baltimore) 2018;97:e11261.
    1. Cacciamani GE, Menestrina N, Pirozzi M, Tafuri A, Corsi P, De Marchi D, et al. Impact of combination of local anesthetic wounds infiltration and ultrasound transversus abdominal plane block in patients undergoing robot-assisted radical prostatectomy: perioperative results of a double-blind randomized controlled trial. J Endourol. 2019;33:295–301.
    1. Dal Moro F, Aiello L, Pavarin P, Zattoni F. Ultrasound-guided transversus abdominis plane block (US-TAPb) for robot-assisted radical prostatectomy: a novel ‘4-point’ technique-results of a prospective, randomized study. J Robot Surg. 2019;13:147–51.
    1. Güner Can M, Göz R, Berber İ, Kaspar Ç, Çakır Ü. Ultrasound/laparoscopic camera-guided transversus abdominis plane block for renal transplant donors: a randomized controlled trial. Ann Transplant. 2015;20:418–23.
    1. Hosgood SA, Thiyagarajan UM, Nicholson HF, Jeyapalan I, Nicholson ML. Randomized clinical trial of transversus abdominis plane block versus placebo control in live-donor nephrectomy. Transplantation. 2012;94:520–5.
    1. Parikh BK, Waghmare VT, Shah VR, Mehta T, Butala BP, Parikh GP, et al. The analgesic efficacy of ultrasound-guided transversus abdominis plane block for retroperitoneoscopic donor nephrectomy: a randomized controlled study. Saudi J Anaesth. 2013;7:43–7.
    1. Matulewicz RS, Patel M, Jordan BJ, Morano J, Frainey B, Bhanji Y, et al. Transversus abdominis plane blockade as part of a multimodal postoperative analgesia plan in patients undergoing radical cystectomy. Bladder Cancer. 2018;4:161–7.
    1. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth. 1997;78:606–17.
    1. Vukovic N, Dinic L. Enhanced recovery after surgery protocols in major urologic surgery. Front Med (Lausanne) 2018;5:93.
    1. Bai Y, Wang X, Li X, Pu C, Yuan H, Tang Y, et al. Management of catheter-related bladder discomfort in patients who underwent elective surgery. J Endourol. 2015;29:640–9.
    1. Yu D, Chai W, Sun X, Yao L. Emergence agitation in adults: risk factors in 2,000 patients. Can J Anaesth. 2010;57:843–8.
    1. Park M, Jee CH, Kwak KH, Park JM, Kim JH. The effect of preoperative nefopam treatment on postoperative catheter-related bladder discomfort in patients undergoing transurethral bladder tumor resection: a randomized double-blind study. Scand J Urol. 2018;52:389–94.
    1. Cheon YW, Kim SH, Paek JH, Kim JA, Lee YK, Min JH, et al. Effects of nefopam on catheter-related bladder discomfort in patients undergoing ureteroscopic litholapaxy. Korean J Anesthesiol. 2018;71:201–6.
    1. Jendoubi A, Aissi W, Abbes A, Bouzouita A, Fourati S, Necib H, et al. Efficacy and safety of parecoxib for prevention of catheter-related bladder discomfort in patients undergoing transurethral resection of bladder tumor: prospective randomised trial. Indian J Anaesth. 2018;62:461–5.
    1. Kwon SY, Joo JD, Cheon GY, Oh HS, In JH. Effects of dexmedetomidine infusion on the recovery profiles of patients undergoing transurethral resection. J Korean Med Sci. 2016;31:125–30.
    1. Stanfa LC, Singh L, Williams RG, Dickenson AH. Gabapentin, ineffective in normal rats, markedly reduces C-fibre evoked responses after inflammation. Neuroreport. 1997;8:587–90.
    1. Yoshimura N, Chancellor MB. Current and future pharmacological treatment for overactive bladder. J Urol. 2002;168:1897–913.
    1. Bala I, Bharti N, Chaubey VK, Mandal AK. Efficacy of gabapentin for prevention of postoperative catheter-related bladder discomfort in patients undergoing transurethral resection of bladder tumor. Urology. 2012;79:853–7.
    1. Kim JA, Min JH, Lee HS, Jo HR, Je UJ, Paek JH. Effects of glycopyrrolate premedication on preventing postoperative catheter-related bladder discomfort in patients receiving ureteroscopic removal of ureter stone. Korean J Anesthesiol. 2016;69:563–7.
    1. Gray M, Vasdev N, Gowrie-Mohan S, McNicholas T. The management of unplanned erection during endoscopic urological surgery. Curr Urol. 2017;10:113–7.
    1. Miller PD, Galizia EJ. Management of erections during transurethral surgery using ethyl chloride spray. Br J Urol. 1993;71:105.
    1. Seftel AD, Resnick MI, Boswell MV. Dorsal nerve block for management of intraoperative penile erection. J Urol. 1994;151:394–5.
    1. Jang D, Lim CS, Shin YS, Ko YK, Park SI, Song SH, et al. A comparison of regional and general anesthesia effects on 5 year survival and cancer recurrence after transurethral resection of the bladder tumor: a retrospective analysis. BMC Anesthesiol. 2016;16:16.
    1. Choi WJ, Baek S, Joo EY, Yoon SH, Kim E, Hong B, et al. Comparison of the effect of spinal anesthesia and general anesthesia on 5-year tumor recurrence rates after transurethral resection of bladder tumors. Oncotarget. 2017;8:87667–74.
    1. Koumpan Y, Jaeger M, Mizubuti GB, Tanzola R, Jain K, Hosier G, et al. Spinal anesthesia is associated with lower recurrence rates after resection of nonmuscle invasive bladder cancer. J Urol. 2018;199:940–6.
    1. Tavare AN, Perry NJ, Benzonana LL, Takata M, Ma D. Cancer recurrence after surgery: direct and indirect effects of anesthetic agents. Int J Cancer. 2012;130:1237–50.
    1. Hole A, Unsgaard G, Breivik H. Monocyte functions are depressed during and after surgery under general anaesthesia but not under epidural anaesthesia. Acta Anaesthesiol Scand. 1982;26:301–7.
    1. Markovic SN, Knight PR, Murasko DM. Inhibition of interferon stimulation of natural killer cell activity in mice anesthetized with halothane or isoflurane. Anesthesiology. 1993;78:700–6.
    1. Wada H, Seki S, Takahashi T, Kawarabayashi N, Higuchi H, Habu Y, et al. Combined spinal and general anesthesia attenuates liver metastasis by preserving TH1/TH2 cytokine balance. Anesthesiology. 2007;106:499–506.
    1. Piegeler T, Votta-Velis EG, Liu G, Place AT, Schwartz DE, Beck-Schimmer B, et al. Antimetastatic potential of amide-linked local anesthetics: inhibition of lung adenocarcinoma cell migration and inflammatory Src signaling independent of sodium channel blockade. Anesthesiology. 2012;117:548–59.

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa