TURP

1. T R A N S U R E T H R A L
R E S E C T I O N OF PROSTATE
PRESENTATION : DR SHALINI
MODERATOR : DR NISHANT

2. 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

3. 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
-
Central
-
periphery zone

4. 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

5. 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-

6. 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

7. 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

8. IRRIGATION FLUIDS
Properties of ideal Irrigation Solution-
• Transparent- allows visualization
• Isotonic
• Electrically non conductive- allows diathermy to work
• Non-hemolytic
• Non
metabolised
• Non-toxic
• Inexpensive
• Easy to sterilize

9. NO SUCH
IRRIGATION
SOLUTION
CURRENTLY
EXISTS

10. -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
(Sorbitol 2.7% + Mannitol 0.54%)
178
Glucose, 2.5% 139
Urea, 1% 167

11. 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

12. -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

13. ANAESTHETIC
CONSIDERATIONS
Preoperative Assessment
Investigations
Choice of Anaesthesia technique

14. PREOPERATIVE ASSESSMENT
:History and Examination
Cardiovascular- Major risk factors for IHD ,HTN, DM,
Smoking,Hypercholesterolemia and family histor 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

15. 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

16. 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-

17. CHOICE OF ANAESTHESIA TECHNIQUE
ADVANTAGES DISADVANTAGES
REGIONAL
ANAESTHESIA
Useful in patients with
significant respiratory disease
Does not prevent penile erection
which can interfere with surgery
For good post-op analgesia
Allows to monitor level of
consciousness and detect early
signs of TURP syndrome
Earlier recognition of bladder.
perforation or capsular tear
Possible reduced blood loss.
GENERAL
ANAESTHESIA
Useful in patients who are
unable to lie supine for a long
.time
Position reduces FRC
Penile erection can be
prevented by deepening of
anesthesia
Increased risk of aspiration
Allows better control of CO
reduced bleeding
Post op analgesia needed

18. 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

19. 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.

20. -
GENERAL ANAESTHESIA
Either a spontaneously breathing technique
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

21. IN TRA-OPERATIVE
COMPLICATIONS
Hypotension
TURP syndrome
Haemorrhage
Perforation of bladder/prostatic capsule
Hypothermia
Bacteremia and sepsis
Complications of positioning
Erection

22. Hypotension
hypotension following sympathetic blockade of SAB- uncommon with
blocks extending to T10, but high blocks causes resistant-
hypotension and bradycardia
Haemorrhage
Depends on resection time (2-5ml/min) and size of gland (20-50ml/gm)
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

23. Bladder Perforation-
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-

24. Hypothermia
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

25. Complications due to Positioning
Lithotomy position- causes nerve compression (especially common-
peroneal )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
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

26. 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.

27. :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 implies increased hydrostatic pressure driving the
fluid intravenously.
Vascularity of the diseased prostate
Capsular or bladder perforation allowing large volumes of irrigation-4
fluid into peritoneal cavity from where it is absorbed

28. Factors which increase the risk of TURP syndrome-
Pre-existing hyponatraemia or pulmonary oedema
Prostate size larger than 60-100g
Reduced venous pressure
Procedures longer than 1 hour
Hydrostatic pressure > 60cm H2O /height of bag above patient
Inexperienced or slow surgeon

29. -:Classical triad of features of TURP syndrome
Hypertension
Bradycardia
Altered mental status

30. -Investigations required for diagnosis-
Serum Sodium- levels below 120mEq/l
ECG – QRS widening, ST segment elevation, T wave inversion
below sodium levels of 115 mEq/l
(Hyperammonemia : by-product of glycine metabolism

31. Management of TURP syndrome
Initial management follows the airway, breathing and circulation
ABC guidelines. Awake patients need to be sedated and
ventilated
Anesthetised patients with mask airways may need intubation and
positive pressure ventilation
Surgeon should be informed and surgery terminated

32. Initial management of fluid overload and hyponatraemia involves
stopping IV fluids
Inj frusemide 40mg IV to promote diuresis
Patients should be closely monitored on an intensive care unit
Hypertonic saline solutions , 3% or 5% should be used to increase
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
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

33. Convulsions should be acutely treated with a benzodiazepine /
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

34. Bladder spasm
Blood loss – Usually about 500 ml (2.4-4.6 ml/ min of resection)
Clot retention – resulting in bladder distension causing vagal
stimulation and pain
Deep vein thrombosis
MI
TURP syndrome
POSTOPERATIVE
COMPLICATIONS

35. 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.