description i/v/o anesthesia

1. TRANSURETHRAL
RESECTION OF PROSTATE
By
Dr VISHAL KR. KANDHWAY

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
-1.Transitional
-2.Central
-3.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-
1.Transparent- allows visualization
2.Isotonic
3.Electrically non conductive- allows diathermy to work.
4.Non-hemolytic
5.Non metabolised
6.Non-toxic
7.Inexpensive
8.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 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

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
1.Useful in patients with
significant respiratory disease
1.Does not prevent penile erection
which can interfere with surgery
2.For good post-op analgesia
3.Allows to monitor level of
consciousness and detect early
signs of TURP syndrome
4.Earlier recognition of bladder
perforation or capsular tear
5.Possible reduced blood loss
GENERAL
ANAESTHESIA
1.Useful in patients who are
unable to lie supine for a long
time.
1.Position reduces FRC
2.Penile erection can be
prevented by deepening of
anesthesia
2.Increased risk of aspiration
3.Allows better control of CO2-
reduced bleeding
3.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 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.

21. INTRA-OPERATIVE
COMPLICATIONS
1-Hypotension
2-TURP syndrome
3-Haemorrhage
4-Perforation of bladder/prostatic capsule
5-Hypothermia
6-Bacteremia and sepsis
7-Complications of positioning
8-Erection

22. 1-Hypotension
-hypotension following sympathetic blockade of SAB.
-uncommon with blocks extending to T10, but high blocks causes resistant
hypotension and bradycardia.
2-Haemorrhage
-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.

23. 3-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. 4-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.
5-Bacteraemia and sepsis
Septic shock following TURP is rare.
-Antimicrobial prophylaxis - single dose of Gentamicin 3 - 4mg/kg on
induction.

25. 6-Complications due to Positioning
-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)
7-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:
1-Duration of the procedure-
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.
2-Height of the irrigation fluid bag above the patient (increased height
implies increased hydrostatic pressure driving the fluid
intravenously)
3-Vascularity of the diseased prostate
4-Capsular or bladder perforation allowing large volumes of irrigation
fluid into peritoneal cavity from where it is absorbed

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

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

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

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

32. 4-Initial management of fluid overload and hyponatraemia involves
stopping IV fluids.
5-Inj frusemide 40mg IV to promote diuresis.
6-Patients should be closely monitored on an intensive care unit.
7-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(
8-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. 9-Convulsions should be acutely treated with a benzodiazepine (e.g.
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. 1-Bladder spasm
2-Blood loss – Usually about 500 ml (2.4-4.6 ml/ min of resection(
3-Clot retention – resulting in bladder distension causing vagal
stimulation and pain(
4-Deep vein thrombosis
5-MI
6-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.