BENIGN PROSTATIC

HYPERPLASIA
(BPH)
The Prostate Gland
 Male sex gland
 Pear-shape,wt7-
16gm
 Size of a walnut
Clip
 Helps control urine
flow
 Produces fluid
component of
semen
 Produces Prostate
Specific Antigen
(PSA)
Four Areas of the Prostate

 Transition Zone  Anterior Zone

 Peripheral Zone  Central Zone
 Sagittal View of the Prostate
Plexus of Anterior Middle
lobe lobe Posterior lobe
Santorini

Seminal vesicle

Base of
prostate Rectum
Pubic bone
Puboprostatic
ligament
Apex of prostate Denonvillier's
Penis and fascia
Urethra

Deep transverse
perineal muscle
Arterial supply
From the anterior division of the internal iliac artery
Inferior vesical artery,
Middle rectal artery
Internal pudendal artery originates (hypogastric)
artery.

The capsular artery is the second main branch of the

prostate. Supply the glandular tissue.

Venous drainage

Prostatic plexus of veins

Valveless communication exists between the prostatic

and
vertebral plexus through which prostatic carcinoma
spread 5
Innervations
from pelvic plexuses formed by the parasympathetic,
visceral, efferent, and preganglionic fibers that arise from
the sacral
levels(S2-S4)

sympathetic fibers from the thoracolumbar levels (L1-

L2).

The pudendal nerve is the major nerve supply leading

to
Somatic innervations of the striated sphincter and the
levator
ani. The preprostatic sphincter and the vesicle neck or
internal sphincter is under alpha-adrenergic control.

Lymphatic drainage
6
What is Benign Prostatic
Hyperplasia?

Peripheral zone

Transition zone

Urethra
Peripheral zone

Transition zone

Urethra
ANATOMY OF PROSTATE
what causes BPH?

n BPH is part of the natural aging

process (increase in androgen
receptor)

n Dihydrotestosterone (DHT) may

play a role

n BPH cannot be prevented

n BPH can be treated

 What’s LUTS?
Voiding (obstructive) Storage (irritative or
symptoms filling) symptoms
 Hesitancy  Urgency
 Weak stream  Frequency
 Straining to pass urine  Nocturia
 Prolonged micturition  Urge incontinence
 Feeling of incomplete
bladder emptying
 Urinary retention
LUTS is not specific to BPH – not everyone with
LUTS has BPH and not everyone with BPH has LUTS
common symptoms

n decrease in the n Hesitancy

urinary stream
n Pain or burning
n Dribbling or leaking during urination
after urination
n Feelingthat the
n Intermittency bladder never
completely empties
 what causes these symptoms?

n Prostate grows with age

n Pressure on the urethra restricts urine flow
 Diagnosis of BPH
• Symptom assessment
– the International Prostate Symptom Score (IPSS) is recommended
as it is used worldwide
– IPSS is based on a survey and questionnaire developed by the
American Urological Association (AUA). It contains:
• seven questions about the severity of symptoms; total score 0–7 (mild), 8–
19 (moderate), 20–35 (severe)
• eighth standalone question on QoL
• Digital rectal examination(DRE)
– inaccurate for size but can detect shape and consistency
• PV determination- ultrasonography
• Urodynamic analysis
– Qmax >15mL/second is usual in asymptomatic men from 25 to more
than 60 years of age
• Measurement of prostate-specific antigen (PSA)
– high correlation between PSA and PV, specifically TZV
– men with larger prostates have higher PSA levels 1

– PSA is a predictor of disease progression and screening tool for CaP

– as PSA values tend to increase with increasing PV and increasing
age, PSA may be used as a prognostic marker for BPH
when should BPH be treated?

BPH needs to be treated ONLY IF:

n The symptoms are severe enough
to bother patient and affect the
quality of life
n Renal insufficiency
n Frequent urinary tract infections
enlarged prostate
treatment options

n Medication
n Heat therapies
n Surgical approaches
 medication
n First line of defense against
bothersome urinary symptoms
n Manage the condition - don’t fix it

n Two major types:

n (Alpha-1-blocker) - relax the
prostate and provide a larger
urethral opening (prazosin,terazosin)
n Shrink the prostate
gland (5-alpha
reductase inhibitor)
(finasteride)
possible side effects of
medication
n
 Impotence
n
 Dizziness
n
 Headache
n
 Fatigue
n
 Loss of sexual
drive
heat therapies
n Destroy prostate tissue with heat

n Tissue is left in the body and is

expelled over time (called sloughing)
n Transurethral Microwave Therapy (TUMT)
n Transurethral Needle Ablation (TUNA®)
n Interstitial Laser Coagulation (ILC)
n Water Induced Thermotherapy (WIT)
possible side effects of
heat therapies
n Urinary Tract Infection

n Impotence

n Incontinence
surgical treatment
SURGICAL PROCEDURES
 TURP
 Transurethral electro-vaporisation
 Transurethral incision
 Transurethral laser
technique(holmium,KTP)
 Balloon dilatation
 Prostate stents
 Prostatectomy:-
suprapubic,retropubic,perineal
 Laproscopic
 PREOPERATIVE MANAGEMENT

• Patients for TURP are

frequently elderly with
coexistent diseases.
• cardiac disease 67%
• abnormal
electrocardiogram (ECG)
77%
• chronic obstructive
pulmonary disease 29%
• diabetes mellitus 8%
OBJECTIVES
 To identify the patient at increased risk of
peri- operativeMI, pulmonary edema and
renal failure.
 To determine cardiac reserve or to see the
capability of heart and circulation to withstand
the stress which accompany anaesthesia and
surgery peri-operatively.
 To make a logical choice of anaesthesia
technique and supportive therapy based on
understanding the patients haemodynamic
status.
 To explaine the risk to pt. and attendants.
 To take informed consent with calculated risk
for medicolegal purpose.
Preparation of patient

 Pre anaesthetic examination.

 Measures to optimize status of patient
 Antibiotic coverage.
 Medication of coexisting diseases
 Back of the patient (preparation)
 Fasting
 Blood arrangement and cross-match
 ANESTHETIC TECHNIQUE

•Spinal anesthesia is the •Spinal anesthesia dose of

technique of choice Bupivacaine 0.75% is 1.6
•sensory supply to the ml
bladder is from T10 - T12
•Sensory supply to
prostate L1-L2 .
•sensory supply to the
urethra, prostate and
bladder neck is from S2 -
S4.
•for satisfactory
anesthesia, a block to T10
is required.
REGIONAL ANESTHESIA
•Subarachnoid anesthesia is preferred to epidural
•It is technically easier to perform in the
elderly
•the duration of surgery is generally not very
long.
•the incomplete block of sacral nerve roots
that occasionally occurs with extradural
technique is avoided with subarachnoid
anesthesia.
•Regional anesthesia does not abolish the
obturator reflex.
•The reflex blocked by muscle paralysis
during general anesthesia or obturator nerve
block
 ANESTHETIC TECHNIQUE

Regional anesthesia is the anesthetic of

choice:
•monitoring of the patients mentation
•vasodilation and peripheral pooling of
blood
•It reduces blood loss
•It provides postoperative analgesia.
•reinfarction rate for SA has been
reported to be less than 1%, versus 2%
to 8% for GA.
•Decreased hypercoagulable tendency
in the postoperative period
•homeostasis of the neuroendocrine
system & immune response.
•Early recognition of turp syndrome
&bladder perforation
 GENERAL ANESTHESIA

•Advantage
•Uncooperative patients
or in patients who
require hemodynamic
or ventilatory support.
• Abolish Obturator
Reflex
•Disadvantage
•inability to monitor the
patient’s level of
mentation
MONITERING
 Pulse
 NIBP
 Oximetery
 ECG
 Blood loss-Hb, Hematocrit
 S. Sodium conc.
 CVP
 Mental status
 Temperature
GENERAL ANAESTHESIA
 Induction:- Propofol or
bariturate,benzodiazepine,opioides
 Intubation:-smooth,short duration
Measures to attenuate pressor responses.
Maintenance:-Oxygen and nitrous
oxide,muscle relaxant,volatile or opioid
based.
Reversal and smooth extubation
Fluid:-NS,RL,Colloid and blood according
to need.
TURP
(transurethral resection of the
prostate)

n ―Gold Standard‖ of care for BPH

n Uses an electrical ―knife‖ to surgically
cut and remove excess prostate
n tissue
Effective in relieving symptoms and
 SURGICAL PROCEDURE
• Operation is
performed through a
modified cystoscope
• Prostatic tissue is
resected using an
electrically energized
wire loop.
• the Prostatic capsule
is usually preserved.
• Continuous irrigation
is necessary to distend
the bladder and to wash
away blood and
dissected prostatic
tissue.
 IRRIGATION FLUID

Ideally the irrigation

solution should be:
• Isotonic
• electrically inert
• Nontoxic
• Transparent
• inexpensive
• Nonhemolytic
• Nonmetabolized
PROPERTIES OF IRRIGATION SOLUTIONS USED FOR
TRANSURETHRAL RESECTION OF THE PROSTATE

Solution Osmolality (mOsm/L) Disadvantages

Water, 0 Hemolysis, hyponetremia

Glycine, 1.5% 220 Transient blindness,

hyper ammonemia,
hyperoxaluria
Sorbitol, 3.5% 165 Hyperglycemia

Mannitol, 5% 275 Osmotic diuresis

Cytal ( sorbitol 178 Osmotic diuresis

2.7%+ Intravascular volume
mannitol0.54%) expansion

Glucose, 2.5% 139 Hyperglycemia

Urea, 1% 167 Intravascular volume

expansion,crystal
formation
 COMPLICATIONS

•TURP can be associated

with a number of
complications:
•TURP Syndrome (2%)
•Hemorrhage
•Bladder perforation
(1%)
•Hypothermia
•Septicemia (6%)
•DIC
•The main challenges are
blood loss and TURP
Syndrome due to
excessive absorption of
irrigant fluid
 TURP SYNDROME:
DEFINITION

• TURP syndrome: constellation of

signs and symptoms caused by
the absorption of large volumes of
isotonic irrigating fluids through
prostatic veins or breaches in the
prostatic capsule.
• The syndrome is characterized by
• hypervolemia,
• hyponatremia
• hypo-osmolarity
 TURP SYNDROME:
EPIDEMIOLOGY
• Irrigant absorption may occur in up to 46% of
resections
• 5-10% of patients absorbing 1 liter or more
• observed in 2-10% of all prostate resections
• Of approximately 400,000 TURP procedures
each year, 10% to 15% incur TURP syndrome and
the mortality is 0.2% to 0.8%
• Syndrome may occur as quickly as 15 minutes
after resection starts or up to 24 hours
postoperatively
• A simple canalization or balloon dilation of the
urethra or a staged TURP is less likely to provoke
TURP syndrome.
 TURP SYNDROME:
IRRIGATION FLUID

• The irrigation solution enters the

bloodstream directly through open prostatic
venous sinuses.
• primarily when prostatic capsule is violated
during surgery.
• As many as 8L of irrigation solution can be
absorbed by the patient during TURP.
• The average rate of aborption is 20mL per
minute and may reach 200mL per minute
• average weight gain by the end of surgery
is 2 kg.
 TURP SYNDROME:
IRRIGATION FLUID

•Distilled water is transparent and electrically

inert.
•Extremely Hypotonic: may cause
hemolysis, shock and renal failure.
•Several nearly isotonic irrigation solutions that
have replaced plain distilled water.
•The more commonly used solution today
is Glycine.
•Cytal is a solution occasionally used.
•To maintain their transparency, these
solutions are prepared moderately hypotonic.
 TURP SYNDROME:
IRRIGATION FLUID
Glycine has direct toxic effects on the:
•Heart: decrease of 17.5 % in cardiac
output, arginine reversed myocardial
depression
•Retina: transient visual disturbance
(blindness)
•Encephalophathy & seizures: via NMDA
potentiation
•Magnesium exerts a negative control on
the NMDA receptor
•hypomagnesemia caused by dilution may
increase the susceptibility to seizures.
TURP SYNDROME:
IRRIGATION FLUID

•The most common

metabolites of glycine
are ammonia and oxalic
acids.
•Hyperoxaluria could
compromise renal
function in patients with
coexisting renal disease
•Hyperammonemia
occurs secondary to
arginine deficiency.
 TURP SYNDROME:
IRRIGATION FLUID

•Hyperammonemia manifestations
appear within 1 hour after surgery.
•Blood ammonia level > 500
mmol/L.
•nauseated, vomits, and then
becomes comatose.
•Ammonia level < 150 mmol/L pt
awakens
 TURP SYNDROME:
IRRIGATION FLUID

•Cytal is a mixture of sorbitol and

mannitol
•Bacterial containmination: This is
secondary to the sugars in the cytal
solution make it a rich medium for
bacteria
•Exacerbate hyperglycemia in
diabetic patients
•pulmonary edema in cardiac
patients: mannitol rapidly expands
the blood volume
 TURP SYNDROME:
SIGNS AND SYMPTOMS
 TURP SYNDROME:
PATHOPHYSIOLOGY
 TURP SYNDROME:
PATHOPHYSIOLOGY
 HYPONATREMIA
CARDIAC SIGNS AND SYMPTOMS

•<120mEq/L :
•signsof cardiovascular depression QRS
widening
•<115mEq/L:
•bradycardia, widening of the QRS
complex, ST-segment elevation, ventricular
ectopic beats, and T wave inversion.
•<110 mEq/L :
•VT or VF
•can develop respiratory and cardiac arrest
 TURP SYNDROME:
MANIFESTATION UNDER
GENERAL ANESTHESIA

• Presenting signs are a rise and then

fall in BP, and bradycardia.
• The ECG may show nodal
rhythm, ST-segment changes U
waves, and widening of the QRS
complex.
• Recovery from general anesthesia is
usually delayed.
 TURP SYNDROME:
PATHOPHYSIOLOGY
 TURP SYNDROME:
NEUROLOGICAL MANIFESTATIONS
•CNS dysfunction is due to acute
hypoosmolarity.
•the blood brain barrier is impermeable to
sodium but freely permeable to water.
•Cerebral edema caused by acute
hypoosmolality can increase intracranial
pressure:
•Bradycardia + hypertension by the
Cushing reflex.
•The rise in intracranial pressure is directly
related to the gain in body weight during TURP.
 TURP SYNDROME:
NEUROLOGICAL MANIFESTATIONS
•In some cases, moderate hyponatremia is
associated with severe neurologic symptoms;
in others, severe hyponatremia causes no
symptoms.
•The determining factor is the rate at which
the serum sodium level falls rather than
the total.
•faster the fall the greater the incidence of
CNS symptoms.
There may be accompanied EEG
abnormalities
•loss of alpha-wave activity and irregular
discharge of high-amplitude slow-wave
activity.
 TURP SYNDROME:
NEUROLOGICAL MANIFESTATIONS

•Na <120 meq/L:

•confusion and restlessness
•Na <115 meq/L:
•Somnolence and nausea
•Na <110 meq/L:
•Tonic-clonic seizures and coma.
TURP SYNDROME:
PREVENTION
TURP SYNDROME:
RISK FACTORS

TURP syndrome is more likely

to occur:
1. The hydrostatic pressure of the
irrigation solution is high.
2. An excessively distended
bladder
3. Prostatic gland is large.
4. The Prostatic Capsule is
violated during surgery.
5. Duration of surgery (>60mins)
 BIPOLAR SALINE TURP

•The Bipolar technique •Several clinical trials

allows the use of saline as have proved that bipolar
the irrigation fluid, TURP is as effective as
eliminating the risk of conventional TURP, but
transurethral resection with a shorter hospital
syndrome stay, earlier catheter
removal, and fewer
complications

Paula Bishop "Bipolar transurethral resection of the prostate—a new approach". AORN Journal. . FindArticles.com. 03 Apr. 2008.
TURP SYNDROME:
EARLY DETECTION
 Ethanol labeled irrigating fluid can be
used to asses the degree of fluid
absorption during procedure by
measuring the ethanol content of the
patients exhaled breath.
 Vol. absorbed=(preop.S. Na+.∕postop
S.Na+×ECF) - ECF
 TURP SYNDROME:
TREATMENT
•Ensure oxygenation and circulatory support
•Notify surgeon and terminate procedure
•Consider invasive monitors if CV instability
occurs
•Send blood for
electrolytes, creatinine, glucose, ABG
•Obtain 12 lead ECG
•Seizures
•Use short acting anticonvulsant
(midazolam), Next a barbiturate or
phenytoin can be added. last resort, use
muscle relaxant
•Restlessness and incoherence are
particularly ominous signs
•GA in the presence of TURP syndrome
can lead to severe complications and
even death.
 TURP SYNDROME:
TREATMENT

•Treat mild symptoms: Na>120 mEq/L

•Fluid restriction and loop diuretic
(furosemide 20mg)
•Treat severe symptoms: Na< 120
mEq/L
•3% NaCl IV at a rate of <100ml/hr
•Discontinue 3% NaCl when Na >
120 mEq/L
•Rate of Na increase should not
exceed 12 mEq/L in 24 hr period
 TURP SYNDROME:
TREATMENT

•Rapid administration of hypertonic

saline has been associated with central
pontine myelinolysis
•To reduce the hazards of saline
administration, serum osmolarity
should be monitored and corrected
aggressively only until symptoms
substantially resolve
•then hyponatremia should be corrected at
a rate no faster than 1.5 mEq/L per hour
 TURP SYNDROME:
DIFFERENTIAL DIAGNOSIS
The differential diagnosis of hypotension
followingTURP should always include
1. Hemorrhage
2. TURP syndrome
3. Bladder perforation
4. Myocardial infarction or ischemia
5. Septicemia
6. Disseminated intravascular coagulation (DIC).
7. Anaphylaxis
PERFORATION
 EXTRAPERITONEAL
 INTRAPERITONEAL
 Cause :-1.instrument
2.overdistention of bladder
Diagnosed by pain,rigid
,tender,distended abdomen and
irregular return of irrigation fluid, reflex
limb movement at time of perforation
BLEEDING AND
COAGULOPATHY
 Resection time (2-5ml/min)
 Weight of resected prostate (20-50
ml/gm)
 Serial Hb level and hematocrit
measurement.
 Release of plasminogen activator to
form plasmin which digest fibrinogen
leading to fibrinolysis & DIC
 Systemic absorption of thromboplastin
released from prostatic tissue-DIC
HYPOTHERMIA

 Absorption of Irrigation fluid stored at

room temperature -shivering.
 Altered behaviour of hypothalemic
thermoregulatory centres in brain.
 Warming of fluid & opioids decreases
shivering.
SEPTICEMIA
 Prostate harbors many bacteria –
source of bacteremia through venous
sinuses
 Indwelling urinary catheter
 Symptoms-
chills, fever, tachycardia,later on in
severe cases bradycardia,hypotention
and cardiovascular collapse
 Aggressive treatment with antibiotics
and CVS support.
Postural complications
 Compartment syndrome
 Nerve damage
 Vital capacity and FRC decrease
 False impression of CVS status
 Deep vein thrombosis
MORTALITY AND
MORBIDITY
 Mortality is 0.2-0.8%in 30 days
 Increased morbidity –
 In patients with resection time more
than 90 min.
 Gland size larger than 45 gm
 Acute urinary retention
 Age older than 80 years
 the ―gold standard‖- TURP

Benefits Disadvantages
n Widely available n Greater risk of side effects
and complications
n Effective
n 1-4 days hospital stay
n Long lasting n 1-3 days catheter
n 4-6 week recovery
possible side effects of
TURP
n Impotence

n Incontinence

n Bleeding

n Electrolyte imbalance (TUR Syndrome)

n