TURP Anesthesia

• Benign prostatic hyperplasia (BPH)

• Benign prostatic enlargement (BPE)
• Benign prostatic obstruction (BPO)
• Bladder outlet obstruction (BOO)
• Lower urinary tract symptoms (LUTS)
• Transurethral microwave thermotherapy (TUMT)
ANATOMY OF THE PROSTATE
• Walnut shaped
• Peripheral (PZ) – Approximately 70 percent of the
normal prostate gland is contained within the peripheral
zone.
• Central (CZ)– The central zone comprises 25 percent of
the volume of the normal prostate. The stroma of the
prostate gland is most dense in this zone.
• Transition (TZ)– The transition zone comprises 5 percent
of the normal volume of the prostate and is the site of
benign prostatic hyperplasia.
When to refer to urologist
• Symptoms in the setting of autonomic or severe peripheral
neuropathy
• Symptoms following invasive treatment of the urethra or prostate
• Men <45 years old
• Abnormality on prostate exam (nodule, induration, or asymmetry)
• Presence of hematuria in the absence of infection
• Men with incontinence
• Severe symptoms (IPSS ≥20)
INITIAL MEDICAL MONOTHERAPY
• Alpha-1-adrenergic antagonists
• 5-alpha-reductase inhibitors
• Anticholinergic agents
• Phosphodiesterase-5 inhibitors
Alpha-1-adrenergic antagonists
• Terazosin,
• Doxazosin
• Tamsulosin
• Alfuzosin
• Silodosin

Terazosin and doxazosin generally need to be initiated at bedtime (to reduce postural
lightheadedness soon after starting the medication), and the dose should be titrated up over
several weeks
Alpha-1-adrenergic antagonists - Side effects
and interactions
• orthostatic hypotension
• Interaction with phosphodiesterase-5 inhibitors
• Ejaculatory dysfunction
• Other side effects – Other common side effects include headache,
dizziness, and nasal congestion.

Alpha-1-adrenergic antagonist use has also been associated with intraoperative floppy iris
syndrome during cataract surgery.
5-alpha-reductase inhibitors
• Finasteride
• initiated and maintained at 5 mg once daily.
• Dutasteride
5-alpha-reductase inhibitors – Side effects
• Sexual dysfunction – The major side effects of 5-alpha-reductase
inhibitors are decreased libido and ejaculatory or erectile dysfunction
• Depression
Anticholinergic agents
• Tolterodine
• Oxybutynin
• Darifenacin
• Solifenacin
• Fesoterodine
• Trospium
Phosphodiesterase-5 inhibitors
• Tadalafil
• Daily dosing of tadalafil should not be prescribed in men with a creatinine
clearance <30 mL/minute.
• consider treatment with PDE-5 inhibitors in patients who have erectile
dysfunction and mild or moderate symptoms (IPSS <20) of BPH
INDICATIONS FOR SURGICAL TREATMENT
• Lower urinary tract symptoms
• increased frequency of urination, nocturia, hesitancy, urgency, and weak
urinary stream
• Refractory urinary retention
• Renal insufficiency secondary to BPH
Preoperative evaluation
• postvoid residual (PVR) assessment
• uroflowmetry and/or pressure flow studies
• transrectal prostate ultrasound
• to assess the size (volume) and configuration of the prostate
• renal ultrasound to assess the kidneys
• Cystoscopy
• free and total serum prostate-specific antigen
• serum creatinine
• urinalysis and culture to exclude a urinary tract infection
Antithrombotic therapy
• Approximately one third of patients requiring a transurethral
procedure for BPH are taking some form of antithrombotic therapy
(eg, vitamin K antagonist, antiplatelet agents)
• An increased risk of bleeding with TURP
• However, the decision to stop any antithrombotic therapy still
depends on the patient's indication for the therapy and in turn the
risks associated with stopping it. Lower bleeding rates may favor non-
TURP procedures in patients for whom the risks of stopping the
antithrombotic regimen are deemed too high.
 • Isotonic
• electrically inert
• Nontoxic
• Transparent
• easy to sterilize
• inexpensive
Irrigation
Solutions
Advantages of Regional Anesthesia over
General Anesthesia
• Spinal anesthesia provides
• adequate anesthesia for the patient, with
• good relaxation of the pelvic floor and the perineum for the surgeon
• Accidental bladder perforation also is recognized easily if the spinal level is
limited to T10
• Allows monitoring the patient’s mental status intraoperatively
• Provides an early indication of electrolyte disturbances. Bladder
perforation is recognized earlier in a conscious or lightly sedated patient
• The incidence of deep vein thrombosis is decreased
• Amount of operative blood loss is reduced
? continuous epidural anesthesia
• technically easier to perform SA in elderly patients
• the duration of surgery is generally not long.
• The incomplete block of sacral nerve roots may occur with epidural
Caudal and sacral blockade for limited TURP
• bladder distention is avoided with the use of continuous irrigation
• Hemodynamic stability is the main advantage
• Local infiltration of the perineum and the prostatic fossa also has
been advocated
GA for TURP?
• patients who require ventilatory or hemodynamic support
• have a contraindication to regional anesthesia
• or refuse regional anesthesia
Complications of TURP
• Absorption of Irrigating Solution
• Excessive Circulatory Volume, Hyponatremia, and Hypoosmolality
• Glycine Toxicity
• Ammonia Toxicity
• Perforation
• Transient Bacteremia and Septicemia
• Hypothermia
• Bleeding and Coagulopathy 220toto550
mL/min of resection time
mL/g
Transurethral Resection of
the Prostate Syndrome
Monitoring for TUR syndrome
• Awake patient – sensorium
• Volumetric fluid balance
• Estimating the amount of irrigation fluid that is ab- sorbed during an
endoscopic procedure
• Ethanol monitoring method
• Ethanol may be added to the irrigating fluid and its level can be measured in
exhaled breath
• detect approximately 75 mL of fluid absorption per 10 minutes of surgery
• Central venous pressure monitoring
• Approximately 500 mL of fluid must be absorbed within 10 minutes to
increase the CVP by 2 mm Hg
Prevention of TUR syndrome
• Patient position on the operating table
• Trendelenburg position (20 degrees)
• Decreasing both the hydrostatic pressure within the blad- der and the
prostatic venous pressure leads to a reduction in the volume of irrigating fluid
that is absorbed into the circulation.
• Operative time be limited to less than 60 minutes
• gland sizes larger than 45 g were at a greater risk of TURP
• optimum height of fluid bag should be 60 cm above the patient
• Bipolar TURP
Lithotomy position with a slight
Trendelenburg tilt
• changes in pulmonary blood volume
• a decrease in pulmonary compliance
• a cephalad shift of the diaphragm
• a decrease in lung volume parameters such as residual volume,
functional residual volume, tidal volume, and vital capacity.
• Cardiac preload may increase.
• Nerve injuries to the common peroneal, sciatic, and femoral nerves
can occur.
TURP
complications
B-TURP Advantages
• allows normal saline to be used as the bladder irrigating fluid
• statistically significant decrease in overall complication rate,
transfusion rate, and TURP syndrome
• comparable urologic efficacy in prostate symptom scores
• fewer postoperative readmissions, faster postoperative recovery, and
equivalent long-lasting results
• General anesthesia is acceptable because of the decreased risk of
TURP syndrome
L-TURP
• Laser therapy delivers vaporization energy creating a thin resecting
coagulation treatment zone during prostate resection.
• minimal blood loss (50 to 70 mL) and minimal fluid absorption
• Protective eyewear and a means to evacuate the smoke plume are
needed
• In critically ill patients, caudal anesthesia has been used successfully
for L-TURP because the use of continuous irrigation combined with
minimal bleeding obviates the need for copious irrigation and
minimizes bladder distention
Classification – Old age

• young-old (approximately 65–74),

• middle-old (ages 75–84)
• old-old (over age 85)
UNITED NATIONS (UN)
60+ years to refer to the older or elderly persons
oldest old (normally those 80+)
centenarian (100+)
super-centenarian (110+)