Patients should be asked about all previous general and local anaesthetic episodes and where possible independent verification sought by obtaining previous anaesthetic records. Specific information of interest is a history of a difficult airway or allergy to any medication used e.g. muscle relaxants. Hyperthermic reactions under anaesthesia raise the possibility of malignant hyperthermia. This is a rare (1:20,000) but life threatening inherited disorder, which must be identified pre-operatively (by obtaining a muscle biopsy and testing the tissue) [2]. Special precaution must be taken in patients with medical history to avoid a variety of drugs in particular the volatile inhalational anaesthetics that trigger a catastrophic hypermetabolic reaction within skeletal muscles. Another rare genetic disease with anaesthetic implication is a suxamethonium apnoea. Patients have an abnormal variant of the enzyme pseudocholinesterase and metabolise the muscle relaxant suxamethonium very slowly. As a result they have prolonged motor block and require intubation and ventilation until the drug is slowly metabolised and excreted (upto 5 h). The incidence of significant suxamethonium apnoea is estimated at 1:2,800 [3].

All existing medical conditions must be identified and stabilised. A detailed history of the cancer together with any metastatic disease must also be identified.

Polypharmacy is common amongst elderly patients. A record must be made of medication taken including dosage and frequency. The majority of medication can be continued preoperatively. Special care must be taken with the drugs listed in Table 11.1, which are relevant to urology patients. Patients in addition may have received treatment with chemotherapy, the implication of which is discussed below. Drugs such as warfarin, clopidogrel and ticlopidine can have impact on surgery and should only be discontinued with in consultation with an anaesthetist and/or cardiologist (in patients with coronary stents).

All drug allergies needs to be documented and a red allergy bracelet allocated. Patients with urological disease frequently require repeated medical/surgical procedures involving the use latex. As a result they can become sensitised and develop a latex allergy. A history of allergies to contrast, dressings and tape should also be sought.

Smoking history should be recorded including all past episodes of smoking. Smoking is a risk factor for both cardiorespiratory disease and urological cancer. Cigarette consumption is classified in pack years; that is the product of number packs per day (20 cigarettes per pack) smoked by the number of years.

Consumption of alcohol is widespread in western society and a common co-factor in many diseases. Anaesthetists consider the acute and chronic effects of alcohol at all stages of the patient pathway. The alcohol intake is recorded in units and the Royal College of Physicians (U.K.) recommends no more then 21 units of alcohol for men and 14 units for women per week. In addition all patients must have 2 to 3 days of non alcohol consumption in order for the liver to recover.

Opioid and cocaine use both have an impact on anaesthesia and need to be documented. Herbal remedies can also have impact on postoperative course (e.g. garlic pills and bleeding tendency).

Functional status and exercise tolerance are important and can be measured in metabolic equivalent of task (MET) levels. The term MET is a physiological measure of the energy cost of physical activity based on population studies. The range is from 1 to 18 MET’s with 1 MET being the oxygen consumed at rest whilst 18 that whilst running flat out. Four MET’s is associated with climbing one flight of stairs whilst 7 with a light jog [4]. Patients with >7 MET’s usually have a lower risk of complications following major surgery. Those with <4 MET’s have a high risk of perioperative cardiovascular complications. MET’s have now been superseded by formal cardio-pulmonary exercise testing (CPET) which gives a more accurate assessment of cardiorespiratory status (see below).

A history of breathlessness on minimal exertion or at rest is a symptom of cardiorespiratory disease and requires further investigation. Nocturnal awakening with dyspnoea and complaints of swollen ankles suggest cardiac failure that requires an urgent cardiology referral. Similarly any patient complaining of exertional chest pain or syncopal episodes must also be referred to a cardiologist for review prior to undergoing general anaesthesia for major surgery.

It is important to ensure a fully equipped difficult airway trolley is present for difficult airway cases including a fibre-optic bronchoscope.

Lungs should be examined for evidence of wheeze (asthma/COPD), crackles (pulmonary fibrosis) and heart failure.

Those with a BMI >35 are likely to have underlying medical conditions including hypertension, diabetes, hypercholesterolaemia and ischaemic heart disease [6]. They are a greater challenge both anaesthetically and surgically. Heavy patients need special arrangements in the operating room to ensure that the operating table can support extra weight. An intensive therapy unit/high dependency bed may be required for obese patients, particularly those with symptoms of obstructive sleep apnoea, such as daytime somnolence, headache on waking (CO₂ retention), or loud snoring. Anaesthetists grade the patient’s overall condition according to the American Society of Anaesthesiologists (ASA) scheme shown in Table 11.2 [7]. Although the ASA scale does not correlate linearly with mortality, it is simple to apply.

Anaemia, polycythaemia, thrombocytopaenia, leucopenia and leukocytosis should be identified.

Pre-operative anaemia (Hb <13 g/dl in men; Hb <12 g/dl in women) should be investigated and corrected as this can further increase transfusion requirements during major surgery.

Necessary in those patients who are taking anti-coagulants or have liver disease. Also to be considered in patients undergoing central neuraxial block and prior to major surgery.

Patients taking digoxin, diuretics, steroids, and those with diabetes, hypertension and renal disease must have venous electrolytes measured and any anomalies corrected pre-operatively.

It is considered in all patients with chronic respiratory disease. An arterial PaO₂ <8.0 KPa on room air has been associated with an increased risk of perioperative respiratory complications and the need for postoperative ventilatory support [9].

Patient with a history of hepatic disease, high alcohol intake (>50 units/week), metastatic disease, or evidence of malnutrition must have LFT’s checked.

Sickledex® kit (Diagnostic Solutions NZ) detects the presence of Haemoglobin S. Sickledex testing should be carried out in those whose ancestry is African, Afro-Caribbean, Asian, Middle-Eastern, east Mediterranean or those who cannot provide evidence of their sickle status.

Chest imaging is considered in those patients with a history of cardio-respiratory symptoms or diseases and those suspected of having lung metastases/lymphoma. It is not necessary to obtain chest X-ray routinely in every patient.

It is safer to do electrocardiogram in all males >50 and females >60 years of age. It is also indicated in patients who have irregular pulse and known cardio-respiratory disease or symptoms.

Pulmonary function is assessed by spirometry, flow & volume loops and bronchodilator testing. There is no single test that predicts intra or postoperative pulmonary complications. Data from patients undergoing lung resection suggest perioperative complications increase when FEV1 <40 % predicted or <0.8 l [9–11]. Reversible airways disease is defined as 12 % improvement or increase of 0.2 l of FEV1 following bronchodilator treatment. All such patients must be optimised pre-operatively [12].

Cardiovascular and respiratory systems are assessed by non-invasive methods prior to major surgery. CPET is more objective and accurate in the assessment of patients than MET values. Older and colleagues demonstrated patients undergoing major surgery with an anaerobic threshold (AT) of less than 11 ml/kg/min had an increased mortality (18 %) versus those with greater than 11 ml/kg/min (0.8 %) [13, 14].

Some of the cardiac investigations including exercise and pharmacological stress testing, angiography and cardiac MRI’s are better performed under the guidance of a cardiologist.

It is important to review previous anaesthetic charts and operative notes for all patients to identify any problems on previous occasions and plan the appropriate care.

There are four options for the provision of anaesthesia in patients with genitourinary cancer undergoing surgery. These include local, general, regional and a combination of general and regional techniques. The exact choice depends on both patient and surgical factors.

Regardless which anaesthetic technique is chosen the following factors must be considered: