ANAESTHETIC MANAGENT

OF TURP
Presentor : Ritika Gupta
Moderator : Dr Trishala Jain
TURP - INTRODUCTION
 The current gold standard surgical treatment for benign
prostatic hyperplasia (BPH).

 TURP is the 2nd most common procedure in men over 65

yrs of age.

 BPH affects 50% of males at 60 years and 90% of 85-

year-olds, so TURP is most commonly performed on
elderly patients, a population group with a high
incidence of cardiac, respiratory and renal disease.

 TURP carries unique complications because of the need

to use large volumes of irrigating fluid for the endoscopic
resection.
 ANATOMY OF PROSTATE
 LOCATION: in the pelvis, below neck of
urinary bladder
 SHAPE : inverted cone
 SIZE : 4x3x2 cm
 Weight : 8 gm
 5 LOBES:
 BPH – median, anterior, 2 lateral
 Prostatic carcinoma – posterior,
lateral
 Composed of glandular tissue in
fibromuscular stroma.
 2 capsules:
 True – formed by condensation of
prostatic tissue
 False – formed by visceral layers of
pelvic fascia.
ANATOMY OF PROSTATE
BLOOD SUPPLY
NERVE SUPPLY
 Arterial supply
 Sympathetic supply
 Inferior vesical artery
 T11-L2
 Middle rectal artery
 Inferior hypogastric
 Internal pudendal artery
plexus
 Venous supply
 Parasympathetic supply
 Vesical plexus
 S2,3,4
 Internal pudendal veins
 Pelvic splanchnic nerve
 Vertebral venous plexus
 TURP - PROCEDURE

 Performed in the lithotomy

position using a resectoscope,
through which a diathermy loop
is passed.
 The prostatic tissue is resected in
small strips under direct vision
using the diathermy loop.
 The bladder is continuously
irrigated with fluid.
 At end of the procedure, a
three-lumen catheter is inserted
and irrigation is continued for up
to 24 h after operation.
 The procedure usually takes 30–
90 min.
IRRIGATION FLUIDS
Characteristics of
Ideal irrigation
Uses fluid:
1. Transparent
2. Isotonic
 distends bladder and
3. Electrically inert
prostatic urethra
4. Non hemolytic
 flushes out blood and
tissue debris 5. Inexpensive
 improves visibility 6. Not metabolizable
7. Rapidly excretable
8. Non toxic
9. Easy to sterilise
SOLUTION OSMOLALITY ADVANTAGES DISADVANTAGES
(mOsm/kg)

MANNITOL 275 (iso) Isomolar Osmotic diuresis,

(5%) solution Acute intravascular
Not expansion
metabolized
SORBITOL 165 (hypo) Same as Hyperglycemia,
(3.5%) glycine Lactic acidosis
Osmotic diuresis
GLUCOSE 139 (hypo) Hyperglycemia
(2.5%)
UREA 167 (hypo) Increases blood
(1%) urea
CYTAL 178 (iso) Expensive, not
(sorbitol easily available
2.7%
+mannitol
0.54%)
SOLUTION OSMOLALITY ADVANTAGES DISADVANTAGES
(mOsm/kg)

DISTILLED 0 (hypo) Electrically inert Hemolysis

WATER Improved Hemoglobinuria
visibility Hemoglobinemia
Inexpensive Hyponatremia

GLYCINE 220 (iso) Less likelihood of Transient

(1.5%) TURP syndrome postoperative visual
GLYCINE 175 syndrome,
(1.2%) (hypo) Hyperammonemia,
Hyperoxaluria

NORMAL 308 (iso) Less incidence of Ionized, cannot be

SALINE TURP syndrome used with cautery
(0.9%)

RINGER 273 (iso) Ionized, cannot be

LACTATE used with cautery
Factors affecting amount and
rate of fluid absorption

 Size of gland (25ml/gm of prostate)

 Number and size of open sinuses
 Hydrostatic pressure of irrigating fluid
 Duration of procedure (@ 20-30 ml/min)
 Integrity of capsule
 Venous pressure at irrigant-blood interface
 Vascularity of diseased prostate
PREOPERATIVE
CONSIDERATIONS
 Patients for TURP are frequently elderly with coexistent diseases.
- cardiac disease 67%
- cardiovascular disease 50%
- abnormal electrocardiogram (ECG) 77%
- chronic obstructive pulmonary disease 29%
- diabetes mellitus 8%

 Occasionally, patients are dehydrated and depleted of essential

electrolytes (long-term diuretic therapy and restricted fluid intake).

 Long standing urinary obstruction can lead to impaired renal

function and chronic urinary infection.
 About 30% of TURP patients have infected urine preoperatively
PREOPERATIVE EVALUATION

 History and examination of all organ systems

 INVESTIGATIONS
 Hb, TLC, DLC, platelet count
 Blood sugar
 Blood urea, S. Creatinine, S. Electrolytes
 Urine R/M
 ECG
 Chest X-ray
 Blood grouping and cross matching
PREOPERATIVE PREPARATION

 Optimization of pre-existing co-morbid conditions

 Consideration of ongoing drug therapy
 Antibiotic prophylaxis (in case of urinary tract infection
or urinary obstruction)
 Arrangement of blood
CHOICE OF ANAESTHESIA
 Regional anaesthesia is the technique of choice for TURP.

 Advantages of regional over general anaesthesia

1. Allows monitoring of mentation and early signs of TURP syndrome
and bladder perforation
2. Promotes peripheral vasodilation , reducing circulatory overload
3. Reduces blood loss, requiring fewer transfusions
4. Avoids effects of general anaesthesia on pulmonary pathology
5. Good early post-operative analgesia
6. Reduced incidence of post-operative DVT/PE
7. Neuroendocrine and immune response are better preserved
8. Lower cost

 General anaesthesia preferred when regional is contraindicated.

REGIONAL ANAESTHESIA
 TECHNIQUES:
 Subarachnoid block
 Epidural block
 Caudal block
 Saddle block

 Level of sensory block

 T10 dermatome level – to eliminate discomfort caused by
bladder distention
 T9 dermatome level – enable to elicit capsular sign (pain
on perforation of prostatic capsule)
REGIONAL ANAESTHESIA

 Subarachnoid block is preferred.

 Advantages of SAB over epidural anaesthesia:
 Technically easier to perform
 Dense motor blockade
 No sacral sparing
 Lower incidence of PDPH
MONITORING
 ECG
 Blood pressure
 Pulse oximetry
 Temperature
 Mentation
 Blood loss
 S. electrolytes (serial)
 EtCO2 if GA is used
 INTRAOPERATIVE
CONSIDERATIONS

 Lithotomy position
 TURP syndrome
 Bladder perforation
 Hypothermia
 Transient bacterial septicemia
 Hemorrhage and coagulopathy
 LITHOTOMY POSITIONING

 Both lower limbs raised

together, flexing the hips and
knees simultaneously.
 Ensure proper padding at
edges and angulations.
 While lowering, legs brought
together at knees and then
lowered slowly to prevent
stress on spine and sudden
fall in BP.
LITHOTOMY POSITIONING

Problems with lithotomy

 Physiologic changes with position
lithotomy
 Decreased FRC
 Increased venous return
on elevation of legs
 Decreased venous
return following
lowering of legs
 Exaggeration of
hypotension with SAB
 Injury to nerves
 Injury to fingers
 Compression of major
vessels at joints
 Lower extremity
Compartment syndrome
 Aggravation of preexisting
lower back pain
TURP SYNDROME
 Rapid absorption of a large-volume irrigation solution.
 Can occur 15 min after resection or upto 24 hrs postop.
 Incidence : 1 – 8%
 Characterized by intravascular volume shifts and plasma-
solute (osmolarity) effects:
 Circulatory overload
 Water intoxication
 Hyponatremia
 Hypoosmolality
 Hyperglycinemia
 Hyperammonemia
 Hemolysis
MECHANISM OF TURP SYNDROME
TURP SYNDROME – WATER
INTOXICATION
 Cause : cerebral edema
 Signs and symp:

Somnolence, restlessness, seizures, coma

CNS – decerebrate posture, clonus, +ve
babinski’s reflex
Eyes – papilloedema, dilated and non
reactive pupils
EEG – low voltage b/l.
TURP SYNDROME -
HYPONATREMIA
 Cause : excessive absorption of Na free irrigation
fluid
 During TURP, S.Na falls by 3 to 10 meq/l.
 SIGNS AND SYMPTOMS OF Acute Hyponatremia
 Nausea
 Vomiting
 Irritability
 Mental confusion
 Cardiovascular collapse
 Pulmonay edema
 Seizures
 Manifestations of hyponatremia
SERUM Na+ CNS CVS ECG
(mEq/l) changes changes Changes

120 Confusion Hypotension wide QRS

Restlessness bradycardia complex

115 Somnolence Cardiac Bradycardia

Nausea depression Wide QRS
complex
Elevated ST
segment
110 Seizures CHF Ventricular
Coma tachycardia or
fibrillation
TURP SYNDROME -
HYPERGLYCINEMIA

 Glycine, a non essential amino acid, is an inhibitory

neurotransmitter in spinal cord and retina.

 Metabolized in liver by oxidative deamination to ammonia

and glyoxylic and oxalic acid.

 When absorbed in large amounts, has direct toxic effects on

heart and retina.

 Manifestations of glycine toxcity: nausea, headache,

malaise, weakness, visual distubances ( transient
blindness), seizures, encephalopathy.
 TURP SYNDROME -
HYPERAMMONEMIA
 Excessive absorption of
glycine may lead to
hyperammonemia (blood
NH3> 500mmol/L).

 S/S: nausea, vomiting,

comatose for 10-12 hrs
and awakens when blood
NH3 < 150 mmol/L.

 Explanation : arginine
deficiency
 TURP SYNDROME – CLINICAL FEATURES
System Signs and Symptoms Cause
Neurologic Nausea, restlessness, visual Hyponatremia and
disturbances, confusion, hypoosmolality
somnolence, Hyperglycinemia
seizures,coma,death Hyperammonemia
Cardiovascular Hypertension, reflex bradycardia, Rapid fluid absorption
pulmonary edema, CVS collapse
Hypotension Third spacing
ECG changes(wide QRS, elevated Hyponatremia
ST segments, vent arrhythmia)

Respiratory Tachypnea, oxygen desaturation, Pulmonary edema

cheyne- stokes breathing

Hematologic Disseminated intravascular Hyponatremia and

hemolysis hypoosmolality
Renal Renal failure Hypotension, hemolysis,
hyperoxaluria

Metabolic Acidosis Deamination of glycine

MEASUREMENT OF FLUID
ABSORPTON
1. Volume absorbed = (preoperative Na+/ postoperative
Na+ ) ECF - ECF
2. Volumetric fluid balance (diff. b/w amt of irrigation fluid
used and volume recovered.)
3. Gravimetry (measure rise in body weight)
4. CVP monitoring
5. Breath ethanol measurement
6. Isotopes
TURP SYNDROME - PREVENTION
 Early diagnosis and prompt treatment
 Correction of fluid and electrolyte abnormalities
preoperatively
 Cautious adminstration of IV fluids
 Limitation of hydrostatic pressure of irrigation fluid to
60cm
 Restrict duration of TURP to 1 hr
 Bipolar resectoscope
 Vaporization methods
 Local vasoconstrictors
TURP SYNDROME -
MANAGEMENT
 Notify surgeon and terminate surgery.
 Ensure oxygenation
 Restrict fluids
 Pulmonary edema : intubate and IPPV
 Bradycardia, hypotension: atropine, adrenergic agents
 Seizures : BZD, thiopentone, phenytoin, i.v.Mg2+
 Invasive monitoring of arterial and CVP
 Send blood sample for electrolytes, arterial blood gas
analysis.
TURP SYNDROME -
MANAGEMENT

 Treat mild symptoms (if S. Na+ > 120 mEq/L) with fluid
restriction and loop diuretic (furosemide)
 Treat severe symptoms (if S. Na+ <120 mEq/L) with 3%
NaCl IV at rate < 100 ml/ hr.
BLADDER PERFORATION
 Incidence – 1%
 Causes
 Trauma by surgical instrument
 Overdistention of bladder with irrigation fluid
 Manifestation
 Early sign : sudden decrease in return of irrigation solution
from bladder
 Extraperitoneal perforations : pain in periumbilical, inguinal
or suprapubic region
 Intraperitoneal : generalised abdominal pain, shoulder tip
pain, abdo rigidity
BLOOD LOSS
 Difficult to quantify blood loss.
 Visual estimation of haemorrhage may be difficult due to
dilution with irrigation fluid.
 Usual warning signs (tachycardia, hypotension) masked by
overhydration and effects of regional anaesthesia.

 Blood loss can be estimated on the basis of

 Resection time (2-5ml/min)
 Size of prostate (7-20ml/g)
 No. of open venous sinuses

 Intraoperative BT should be based on preop Hb, duration

and difficulty of resection and clinical assessment of pt
condition.
COAGULOPATHY

 Causes of excessive bleeding

 Dilutional thrombocytopenia
 DIC as a result of release of prostatic particles rich in
thromboplastin into blood
 Local release of fibrinolytic agents (plasminogen and
urokinase)

 Treatment – administration of FFP, platelets blood

transfusion
HYPOTHERMIA
 Continuous fluid irrigation causes loss of temp @1oC/hr.

 Elderly patients have reduced thermoregulatory capacity.

 Unintentional hypothermia is asso. with a significantly
higher incidence of postoperative MI.
 Postoperative shivering asso. with hypothermia may
dislodge clots and promote postoperative bleeding.

 Monitor body temp of patient to maintain normothermia.

 Appropriate measures to reduce heat loss are: warming
blankets, heated irrigation solution and warm I/V fluids.
BACTEREMIA AND SEPTICEMIA

 INCIDENCE – 6-7%
 Causes
 Release of bacteria from prostatic tissue
 Preoperative indwelling urinary catheter
 Preoperative UTI
 C/F – chills, fever, tachycardia
 T/T – antibiotic, supportive care
POSTOPERATIVE
COMPLICATIONS
 Hypothermia
 Hypotension
 Haemorrhage
 Septicaemia
 TURP syndrome
 Bladder spasm
 Clot retention
 Deep vein thrombosis
 Postoperative cognitive impairment
 REFERENCES
 Miller’s Anesthesia 7th Editon. Anesthesia and renal and
genitourinary system.
 Barasch’s Clinical Anesthesia 5th Edition. The renal
system and anesthesia for urologic surgery.
 Yao and Artusio’s Anesthesiology problem oriented
patient management. 6th Edition.
 Clinical anesthesiology by Morgan and Mikhail. 4th
Edition. Anesthesia for genitourinary surgery.
 Dietrich Gravenstein. Transurethral resection of prostate
(TURP) syndrome: a review of pathophysiology and
management. Anesth Analg 1997;84:438-46.