TRANSURETHRAL

RESECTION OF PROS TATE

By
Dr VISHAL KR. KANDHWAY
 INTRODUCTION
Benign prostate hyperplasia is responsible for majority of urinary 
symptoms in men over 50 yrs of age

TURP is a type of prostate surgery done to relieve moderate to severe 

(urinary symptoms caused by an enlarged prostate(BPH

TURP uses cystoscopy and a resectoscope to remove tissue protruding -

. into the prostatic urethra

So this procedure is most commonly performed on elderly patients- a -

. population with high incidence of cardiac, respiratory and renal disease

Safe anaesthesia depends on detection and optimisation of co-existing -

diseases, and weighing the relative risks and benefits of regional and
.general anaesthesia for each patient
 ANATOMY OF PROSTATE GLAND
Pyramidal shaped organ
Lies below urinary bladder & located
infront of the rectum, posterior to
the pubic symphysis & superior to
the perineal membrane
Normal weight- 20 g
Encircles urethera as it emerges from
.base of bladder
It Is enclosed within a capsule
composed of collagen, elasten &
large no. of smooth muscles
Microscopic anatomy
Transitional.1 -
Central.2 -
periphery zone. 3 -
:Transional zone
.This is the area surrounding the prostatic urethra-
.It is were the BPH occurs
:Central zone
It is the area surrounding the ejaculatory duct
:Peripheral zone
This zone covers the posterior & lateral zone aspects of the prostate. It is the
.most common area affected by chronic prostatitis & adenocarcinoma
The Prostate Gland is rich in blood supply, mainly from inferior vesical
artery
The prostatic venous plexus drains into internal iliac vein & communicates
with the vertebral plexus, thereby allowing neoplastic spread to
vertebrae
The prostatic vessels & the autonomic innervations run between the
.layers of the lateral prostatic fascia & the prostate
.Arteries and veins penetrate the capsule and branch inside the gland -
.The venous sinuses adjacent to the capsule are particularly large -
Nerve Supply
Prostatic plexus-Sympathetic- T12-L2(contraction of smooth muscles of -
(capsule & stroma
(Parasympathetic- S2-S4(prostatic secretion-
Pain fibres from Prostate, Prostatic Urethra and Bladder mucosa- S2-S4 -
Bladder distension pain – T12-L2-
SURGICAL PROCEDURE
TURP - performed by inserting a-
.Resectoscope through urethra

Prostatic tissue is resected into pieces-

with an electrically powered cutting-
.coagulating metal loop

.Pieces washed out by irrigating solution-

Prostatic capsule preserved- If violated,-

large amounts of irrigating fluid is
absorbed into circulation, periprostatic
.and retroperitoneal spaces
Surgery normally takes 30-60 mins--
depending on size of gland and
.experience of surgeon

Position- Lithotomy position-

At the end of surgery- a 3-lumen-

catheter placed to allow continuous
irrigation using normal saline for
upto 24 hours after surgery
 IRRIGATION FLUIDS
-Properties of ideal Irrigation Solution-
Transparent- allows visualization.1
Isotonic.2
.Electrically non conductive- allows diathermy to work.3
Non-hemolytic.4
Non metabolised.5
Non-toxic.6
Inexpensive.7
Easy to sterilize.8
 NO SUCH
IRRIGATION
SOLUTION
CURRENTLY
EXISTS
 -Commonly used Irrigation Solutions are

SOLUTION (OSMOLALITY (mOsm/Kg

%Glycine, 1.2 175

%Glycine, 1.5 220

%Sorbitol, 3.5 165

Mannitol, 5% 275

Cytal 178
(Sorbitol 2.7% + Mannitol 0.54%)
Glucose, 2.5% 139

Urea, 1% 167
 COMPLICATIONS OF
IRRIGATION FLUIDS
-Glycine-
Normal plasma glycine levels are 13 to 17 mg/L-
.Transient blindness is attributed to glycine toxicity-
Glycine is a major inhibitory-transmitter acting in the spinal cord and brain- -
.stem
Glycine also has been implicated in the myocardial depression and -
.hemodynamic changes associated with TURP syndrome

-Ammonia Toxicity-
Absorption of glycine can result in CNS toxicity because-
.of oxidative bio-transformation of glycine to ammonia
-Mannitol-
Rapidly expands blood volume and causes pulmonary edema in cardiac -
.patients

-Glucose-
Causes severe hyperglycemia in diabetic patients-

Distilled Water is electrically inert and inexpensive and has excellent optical
properties.

-Extremely Hypotonic.

-When absorbed into the circulation in large amounts,

plain water causes Hemolysis, Shock, and Renal failure.

-Thus Isotonic fluids are preferred- ) these solutions are kept slightly
hypotonic to preserve transparency(
 ANAESTHETIC
CONSIDERATIONS

Preoperative Assessment

Investigations

Choice of Anaesthesia technique

PREOPERATIVE ASSESSMENT
:History and Examination
Cardiovascular- Major risk factors for IHD )HTN, DM,-
Smoking,Hypercholesterolemia and family history( – can lead to
.silent perioperative MI
Heart failure- fluid overload increases risk-
Respiratory- Inability to lie flat due to dyspnoea will make awake-
.spinal anaesthesia poorly tolerated
.CNS- Confused patients may not lie still during spinal anaesthesia-
Musculoskeletal- Degenerative changes in vertebral column-
makes SAB technically difficult. Arthritic joints may get damaged in
.lithotomy position
Endocrine- rule out h/o DM
Drug history- Beta blockers, ACE inhibitors, Alpha blockers,-
Warfarin
 INVESTIGATIONS
-Routine tests required are
Complete blood count-

Creatinine and electrolytes )to detect renal impairment due-

(to obstructive uropathy

Urine analysis to screen UTI ) increased risk of-

(postoperative septicaemia if left untreated

ECG for symptomatic patients and routinely for above-

.60years

Blood grouping-
-Special tests for particular circumstances

(Clotting studies )PT-INR if on Warfarin- -

(ABG and PFT )if severe respiratory disease suspected- -
(Chest radiogram )suspicion of metastasis- -
CHOICE OF ANAESTHESIA TECHNIQUE
ADVANTAGES DISADVANTAGES
Useful in patients with.1 Does not prevent penile erection .1
significant respiratory disease which can interfere with surgery
REGIONAL
ANAESTHESIA For good post-op analgesia.2

Allows to monitor level of.3

consciousness and detect early
signs of TURP syndrome

Earlier recognition of bladder.4

perforation or capsular tear

Possible reduced blood loss.5

Useful in patients who are.1 Position reduces FRC.1

unable to lie supine for a long
.time
GENERAL
Penile erection can be.2 Increased risk of aspiration.2
ANAESTHESIA prevented by deepening of
anesthesia
Allows better control of CO2-.3 Post op analgesia needed.3
reduced bleeding
 TECHNIQUE
SUB-ARACHANOID BLOCK-
Check for any contraindications of SAB-

. A fluid preload of 500-1000 ml of warmed NS/RL-

Preloading assists -compensation of spinal induced vasodilatation and -

hypotension
provides a small sodium load to counter hyponatremia -
often occuring with TURP
.A confirmed block till atleast T10, should be done-
Intraoperative sedation with IV Midazolam can be considered for anxious or -
confused patients )Early manifestations of TURP syndrome should be kept
(in mind
Thermometer, Warming blankets and Fluid warmer should be kept available -
.for detection and prevention of hypothermia due to cold irrigation solutions
Subarachanoid anesthesia is generally preferred over
continuous Epidural anesthesia for the following
reasons:

1- It is technically easier to perform in the elderly

2- Duration of surgery is not generally very long.

3- Incomplete block of sacral nerve roots that occasionally

occurs with the epidural technique is avoided with
subarachnoid anesthesia.
GENERAL ANAESTHESIA
Either a spontaneously breathing technique with face- -
mask or Laryngeal mask is used or relaxant technique is
.appropriate

Elderly patients are susceptible to hypotensive effects of - -

.induction and maintainance agents

These patients have a reduced requirement for Volatile- -

.anesthetic agents as well

NDMR’s should be used with consideration of possible- -

.renal impairment
 INTRA-OPERATIVE
COMPLICATIONS
Hypotension-1
TURP syndrome-2
Haemorrhage-3
Perforation of bladder/prostatic capsule-4
Hypothermia-5
Bacteremia and sepsis-6
Complications of positioning-7
Erection-8
Hypotension-1
.hypotension following sympathetic blockade of SAB-
uncommon with blocks extending to T10, but high blocks causes resistant -
.hypotension and bradycardia

Haemorrhage-2
)Depends on resection time (2-5ml/min) and size of gland (20-50ml/g -
. Bleeding requiring transfusion occurs in about 2.5% of procedures -
Serial hematocrit levels are the most sensitive indicators of the need for -
. transfusion
Severe blood loss are the result of clotting abnormalities caused by the -
release of Urokinase from the prostate
Anti-fibrinolytics such as IV Aminocaproic acid (4-5g in first hour, then -
. 1g/hour) IV Tranexamic acid can be used to minimize active blood loss
 Bladder Perforation-3
.Complicates about 1% of cases-
Most perforations are Extra-peritoneal- result in supra-pubic, inguinal or-
peri-umbilical pain in the awake patient. The surgeon may notice reduced
. return of irrigation fluid from the bladder
Intraperitoneal perforation- less common, but more serious. In these cases -
the abdominal pain is generalized, and the patient may complain of
)shoulder-tip pain. (referred from the diaphragm
Pallor, sweating, nausea and vomiting, and associated hypotension -
. depending on the size of the perforation
Perforation may present as sudden, unexpected hypotension under general -
. anesthesia
.Management consists of immediate laprotomy and correction of the defect -
 Hypothermia-4
Use of room-temperature IV fluids and large volumes of irrigation -
. fluids leave elderly patients hypothermic
. All irrigation fluid should be warmed to body temperature prior to use -
Post-operative shivering can cause massively increased myocardial -
.oxygen requirements

Bacteraemia and sepsis-5

.Septic shock following TURP is rare
Antimicrobial prophylaxis - single dose of Gentamicin 3 - 4mg/kg on -
.induction
 Complications due to Positioning-6
Lithotomy position- causes nerve compression (especially common -
)peroneal nerve from pressure effects exerted by the stirrups
.Dislocation of hip prostheses-
Compartment syndrome in lower legs-
Respiratory compromise in patients with pre-existing lung disease -
)(reduction of functional residual capacity

Erection-7
Occurs as a result of surgical stimulation due to light planes of -
anaesthesia
. Makes cystoscopy technically difficult-
. The erection usually subsides with deepening of anaesthesia -
 TURP SYNDROME

-TURP syndrome is a term applied to a constellation of symptoms and

signs caused primarily by excessive absorption of irrigating fluid.

-Occurs in up to 8% of cases in mild form, but is severe in 1-2% of

cases.

-Resection of prostatic tissue opens an extensive network of venous

sinuses, which allows the irrigation fluid to be absorbed into the
systemic circulation.
:Simple principles govern the amount of absorption
-Duration of the procedure-1
10 to 30 mL of fluid is absorbed per minute of resection time, with as
much as 6 to 8 L absorbed in some procedures lasting up to 2
hours.

Height of the irrigation fluid bag above the patient (increased height -2
implies increased hydrostatic pressure driving the fluid
) intravenously

Vascularity of the diseased prostate-3

Capsular or bladder perforation allowing large volumes of irrigation -4

fluid into peritoneal cavity from where it is absorbed
Factors which increase the risk of TURP syndrome-

Pre-existing hyponatraemia or pulmonary oedema-1

Prostate size larger than 60-100g-2

Reduced venous pressure-3

Procedures longer than 1 hour-4

(Hydrostatic pressure > 60cm H2O (height of bag above patient -5

Inexperienced or slow surgeon-6

-:Classical triad of features of TURP syndrome

Hypertension- 1

Bradycardia- 2

Altered mental status- 3

-Investigations required for diagnosis-

.Serum Sodium- levels below 120mEq/l - symptomatic-1

ECG – QRS widening, ST segment elevation, T wave inversion -2

(( below sodium levels of 115 mEq/l

(Hyperammonemia ( by-product of glycine metabolism- 3

Management of TURP syndrome

Initial management follows the airway, breathing and circulation -1

(ABC( guidelines. Awake patients need to be sedated and
. ventilated

Anesthetised patients with mask airways may need intubation and -2

. positive pressure ventilation

Surgeon should be informed and surgery terminated-3

Initial management of fluid overload and hyponatraemia involves -4
.stopping IV fluids

. Inj frusemide 40mg IV to promote diuresis-5

. Patients should be closely monitored on an intensive care unit-6

Hypertonic saline solutions ( 3% or 5%( should be used to increase -7

the serum sodium level by about 1 mmol/l/hour (not exceding an
( increase of 20mmol/l in the first 48 hours of therapy

Sodium levels should be checked every few hours. Therapy with -8

hypertonic saline should be stopped when symptoms cease or the
. sodium level reaches 124-132mmol/l

Rapid correction has been implicated as a cause of central pontine (

(myelinolysis, which causes irreversible brain damage
Convulsions should be acutely treated with a benzodiazepine (e.g. - 9
(. diazepam 5-10mg( or small doses of thiopentone (25 - 100mg

In the presence of intractable seizures, the sodium level may be

corrected more rapidly at a rate of up to 8-10mmol/l/hour for the first
4 hours of therapy
 POSTOPERATIVE
COMPLICATIONS
Bladder spasm- 1

(Blood loss – Usually about 500 ml (2.4-4.6 ml/ min of resection - 2

Clot retention – resulting in bladder distension causing vagal - 3

(stimulation and pain

Deep vein thrombosis- 4

MI- 5

TURP syndrome-6
 SUMMARY
TURP is a procedure carried out on a predominantly elderly population with a -
. higher incidence of coexisting disease

A thorough pre-operative assessment is important in detecting at-risk -

. patients, and helping to choose the anaesthetic technique

SAB is widely considered the most suitable technique, although GA has a -

.similar morbidity and mortality profile

Subarachnoid block to T10 provides excellent anaesthesia without notable -

hypotension

TURP syndrome is a rare but potentially fatal complication . Early recognition -

.and prompt treatment are essential

Blood loss is difficult to quantify and may be significant. Close attention to the -
.patient’s clinical state and communication with the surgeon are vital