2. TURP - INTRODUCTION
The current gold standard surgical treatment for benign
prostatic hyperplasia (BPH).
TURP is the 2nd most common procedure in men over 65
yrs of age.
BPH affects 50% of males at 60 years and 90% of 85-
year-olds, so TURP is most commonly performed on
elderly patients, a population group with a high
incidence of cardiac, respiratory and renal disease.
TURP carries unique complications because of the need
to use large volumes of irrigating fluid for the endoscopic
resection.
3. ANATOMY OF PROSTATE
LOCATION: in the pelvis, below neck of
urinary bladder
SHAPE : inverted cone
SIZE : 4x3x2 cm
Weight : 8 gm
5 LOBES:
BPH – median, anterior, 2 lateral
Prostatic carcinoma – posterior,
lateral
Composed of glandular tissue in
fibromuscular stroma.
2 capsules:
True – formed by condensation of
prostatic tissue
False – formed by visceral layers of
pelvic fascia.
5. Performed in the lithotomy
position using a resectoscope,
through which a diathermy loop
is passed.
The prostatic tissue is resected in
small strips under direct vision
using the diathermy loop.
The bladder is continuously
irrigated with fluid.
At end of the procedure, a
three-lumen catheter is inserted
and irrigation is continued for up
to 24 h after operation.
The procedure usually takes 30–
90 min.
TURP - PROCEDURE
6. IRRIGATION FLUIDS
Uses
distends bladder and
prostatic urethra
flushes out blood and
tissue debris
improves visibility
Characteristics of
Ideal irrigation
fluid:
1. Transparent
2. Isotonic
3. Electrically inert
4. Non hemolytic
5. Inexpensive
6. Not metabolizable
7. Rapidly excretable
8. Non toxic
9. Easy to sterilise
8. SOLUTION OSMOLALITY
(mOsm/kg)
ADVANTAGES DISADVANTAGES
DISTILLED
WATER
0 (hypo) Electrically inert
Improved
visibility
Inexpensive
Hemolysis
Hemoglobinuria
Hemoglobinemia
Hyponatremia
GLYCINE
(1.5%)
GLYCINE
(1.2%)
220 (iso)
175
(hypo)
Less likelihood of
TURP syndrome
Transient
postoperative visual
syndrome,
Hyperammonemia,
Hyperoxaluria
NORMAL
SALINE
(0.9%)
308 (iso) Less incidence of
TURP syndrome
Ionized, cannot be
used with cautery
RINGER
LACTATE
273 (iso) Ionized, cannot be
used with cautery
9. Factors affecting amount and
rate of fluid absorption
Size of gland (25ml/gm of prostate)
Number and size of open sinuses
Hydrostatic pressure of irrigating fluid
Duration of procedure (@ 20-30 ml/min)
Integrity of capsule
Venous pressure at irrigant-blood interface
Vascularity of diseased prostate
10. PREOPERATIVE
CONSIDERATIONS
Patients for TURP are frequently elderly with coexistent diseases.
- cardiac disease 67%
- cardiovascular disease 50%
- abnormal electrocardiogram (ECG) 77%
- chronic obstructive pulmonary disease 29%
- diabetes mellitus 8%
Occasionally, patients are dehydrated and depleted of essential
electrolytes (long-term diuretic therapy and restricted fluid intake).
Long standing urinary obstruction can lead to impaired renal
function and chronic urinary infection.
About 30% of TURP patients have infected urine preoperatively
11. PREOPERATIVE EVALUATION
History and examination of all organ systems
INVESTIGATIONS
Hb, TLC, DLC, platelet count
Blood sugar
Blood urea, S. Creatinine, S. Electrolytes
Urine R/M
ECG
Chest X-ray
Blood grouping and cross matching
12. PREOPERATIVE PREPARATION
Optimization of pre-existing co-morbid conditions
Consideration of ongoing drug therapy
Antibiotic prophylaxis (in case of urinary tract infection
or urinary obstruction)
Arrangement of blood
13. CHOICE OF ANAESTHESIA
Regional anaesthesia is the technique of choice for TURP.
Advantages of regional over general anaesthesia
1. Allows monitoring of mentation and early signs of TURP syndrome
and bladder perforation
2. Promotes peripheral vasodilation , reducing circulatory overload
3. Reduces blood loss, requiring fewer transfusions
4. Avoids effects of general anaesthesia on pulmonary pathology
5. Good early post-operative analgesia
6. Reduced incidence of post-operative DVT/PE
7. Neuroendocrine and immune response are better preserved
8. Lower cost
General anaesthesia preferred when regional is contraindicated.
14. REGIONAL ANAESTHESIA
TECHNIQUES:
Subarachnoid block
Epidural block
Caudal block
Saddle block
Level of sensory block
T10 dermatome level – to eliminate discomfort caused by
bladder distention
T9 dermatome level – enable to elicit capsular sign (pain
on perforation of prostatic capsule)
15. REGIONAL ANAESTHESIA
Subarachnoid block is preferred.
Advantages of SAB over epidural anaesthesia:
Technically easier to perform
Dense motor blockade
No sacral sparing
Lower incidence of PDPH
16. MONITORING
ECG
Blood pressure
Pulse oximetry
Temperature
Mentation
Blood loss
S. electrolytes (serial)
EtCO2 if GA is used
18. LITHOTOMY POSITIONING
Both lower limbs raised
together, flexing the hips and
knees simultaneously.
Ensure proper padding at
edges and angulations.
While lowering, legs brought
together at knees and then
lowered slowly to prevent
stress on spine and sudden
fall in BP.
19. LITHOTOMY POSITIONING
Physiologic changes with
lithotomy
Decreased FRC
Increased venous return
on elevation of legs
Decreased venous
return following
lowering of legs
Exaggeration of
hypotension with SAB
Problems with lithotomy
position
Injury to nerves
Injury to fingers
Compression of major
vessels at joints
Lower extremity
Compartment syndrome
Aggravation of preexisting
lower back pain
20. TURP SYNDROME
Rapid absorption of a large-volume irrigation solution.
Can occur 15 min after resection or upto 24 hrs postop.
Incidence : 1 – 8%
Characterized by intravascular volume shifts and plasma-
solute (osmolarity) effects:
Circulatory overload
Water intoxication
Hyponatremia
Hypoosmolality
Hyperglycinemia
Hyperammonemia
Hemolysis
25. TURP SYNDROME -
HYPERGLYCINEMIA
Glycine, a non essential amino acid, is an inhibitory
neurotransmitter in spinal cord and retina.
Metabolized in liver by oxidative deamination to ammonia
and glyoxylic and oxalic acid.
When absorbed in large amounts, has direct toxic effects on
heart and retina.
Manifestations of glycine toxcity: nausea, headache,
malaise, weakness, visual distubances ( transient
blindness), seizures, encephalopathy.
26. TURP SYNDROME -
HYPERAMMONEMIA
Excessive absorption of
glycine may lead to
hyperammonemia (blood
NH3> 500mmol/L).
S/S: nausea, vomiting,
comatose for 10-12 hrs
and awakens when blood
NH3 < 150 mmol/L.
Explanation : arginine
deficiency
27. TURP SYNDROME – CLINICAL FEATURES
System Signs and Symptoms Cause
Neurologic Nausea, restlessness, visual
disturbances, confusion,
somnolence,
seizures,coma,death
Hyponatremia and
hypoosmolality
Hyperglycinemia
Hyperammonemia
Cardiovascular Hypertension, reflex bradycardia,
pulmonary edema, CVS collapse
Hypotension
ECG changes(wide QRS, elevated
ST segments, vent arrhythmia)
Rapid fluid absorption
Third spacing
Hyponatremia
Respiratory Tachypnea, oxygen desaturation,
cheyne- stokes breathing
Pulmonary edema
Hematologic Disseminated intravascular
hemolysis
Hyponatremia and
hypoosmolality
Renal Renal failure Hypotension, hemolysis,
hyperoxaluria
Metabolic Acidosis Deamination of glycine
28. MEASUREMENT OF FLUID
ABSORPTON
1. Volume absorbed = (preoperative Na+/ postoperative
Na+ ) ECF - ECF
2. Volumetric fluid balance (diff. b/w amt of irrigation fluid
used and volume recovered.)
3. Gravimetry (measure rise in body weight)
4. CVP monitoring
5. Breath ethanol measurement
6. Isotopes
29. TURP SYNDROME - PREVENTION
Early diagnosis and prompt treatment
Correction of fluid and electrolyte abnormalities
preoperatively
Cautious adminstration of IV fluids
Limitation of hydrostatic pressure of irrigation fluid to
60cm
Restrict duration of TURP to 1 hr
Bipolar resectoscope
Vaporization methods
Local vasoconstrictors
30. TURP SYNDROME -
MANAGEMENT
Notify surgeon and terminate surgery.
Ensure oxygenation
Restrict fluids
Pulmonary edema : intubate and IPPV
Bradycardia, hypotension: atropine, adrenergic agents
Seizures : BZD, thiopentone, phenytoin, i.v.Mg2+
Invasive monitoring of arterial and CVP
Send blood sample for electrolytes, arterial blood gas
analysis.
31. TURP SYNDROME -
MANAGEMENT
Treat mild symptoms (if S. Na+ > 120 mEq/L) with fluid
restriction and loop diuretic (furosemide)
Treat severe symptoms (if S. Na+ <120 mEq/L) with 3%
NaCl IV at rate < 100 ml/ hr.
32. BLADDER PERFORATION
Incidence – 1%
Causes
Trauma by surgical instrument
Overdistention of bladder with irrigation fluid
Manifestation
Early sign : sudden decrease in return of irrigation solution
from bladder
Extraperitoneal perforations : pain in periumbilical, inguinal
or suprapubic region
Intraperitoneal : generalised abdominal pain, shoulder tip
pain, abdo rigidity
33. BLOOD LOSS
Difficult to quantify blood loss.
Visual estimation of haemorrhage may be difficult due to
dilution with irrigation fluid.
Usual warning signs (tachycardia, hypotension) masked by
overhydration and effects of regional anaesthesia.
Blood loss can be estimated on the basis of
Resection time (2-5ml/min)
Size of prostate (7-20ml/g)
No. of open venous sinuses
Intraoperative BT should be based on preop Hb, duration
and difficulty of resection and clinical assessment of pt
condition.
34. COAGULOPATHY
Causes of excessive bleeding
Dilutional thrombocytopenia
DIC as a result of release of prostatic particles rich in
thromboplastin into blood
Local release of fibrinolytic agents (plasminogen and
urokinase)
Treatment – administration of FFP, platelets blood
transfusion
35. HYPOTHERMIA
Continuous fluid irrigation causes loss of temp @1oC/hr.
Elderly patients have reduced thermoregulatory capacity.
Unintentional hypothermia is asso. with a significantly
higher incidence of postoperative MI.
Postoperative shivering asso. with hypothermia may
dislodge clots and promote postoperative bleeding.
Monitor body temp of patient to maintain normothermia.
Appropriate measures to reduce heat loss are: warming
blankets, heated irrigation solution and warm I/V fluids.
36. BACTEREMIA AND SEPTICEMIA
INCIDENCE – 6-7%
Causes
Release of bacteria from prostatic tissue
Preoperative indwelling urinary catheter
Preoperative UTI
C/F – chills, fever, tachycardia
T/T – antibiotic, supportive care
38. REFERENCES
Miller’s Anesthesia 7th Editon. Anesthesia and renal and
genitourinary system.
Barasch’s Clinical Anesthesia 5th Edition. The renal
system and anesthesia for urologic surgery.
Yao and Artusio’s Anesthesiology problem oriented
patient management. 6th Edition.
Clinical anesthesiology by Morgan and Mikhail. 4th
Edition. Anesthesia for genitourinary surgery.
Dietrich Gravenstein. Transurethral resection of prostate
(TURP) syndrome: a review of pathophysiology and
management. Anesth Analg 1997;84:438-46.
