TURP

1. ANAESTHETIC CONSIDERATION
OF TURP
 Dr. ZIKRULLAH

2. TURP - INTRODUCTION
 gold standard for BPH.
 most commonly performed on elderly patients.
 TURP carries unique complications
Why?
Because of the need to use large volumes of irrigating fluid .

3. ANATOMY OF PROSTATE
 LOCATION: in the pelvis, below neck of urinary bladder
 SHAPE : inverted cone
 Weight : 20 gm
 5 LOBES:
median, anterior, 2 lateral, posterior

4. ANATOMY OF PROSTATE
NERVE SUPPLY BLOOD SUPPLY
 Sympathetic supply
 T11-L2
 Inferior hypogastric
plexus
 Parasympathetic supply
 S2,3,4
 Pelvic splanchnic nerve
 Arterial supply
 Inferior vesical artery
 Middle rectal artery
 Internal pudendal artery
 Venous supply
 Vesical plexus
 Internal pudendal veins
 Vertebral venous plexus

5. WHAT IS BPH ?
 Non cancerous enlargement of the prostate gland
 Leads to symptoms of bladder outlet obstruction
 Disease of the old age , starts at ~ 40
( but usually presents between 50 – 70 years )

6. Indications of TURP
 Prostate volume > 40-50 gm but less than 80 gm
 Advanced Ca prostate - to relieve BOO symptoms

7. TURP - PROCEDURE
 Performed in the lithotomy position using a resectoscope,
through which a diathermy loop is passed.
 The bladder is continuously irrigated with fluid.
 irrigation is continued for up to 24 h.
 The procedure usually takes 30–90 min.

8. IRRIGATING FLUID.
 M/C used irrigating fluid.
 1.5 glycine
 Cytal(sarbitol 2.7%+mannitol 0.54%)
Others are..
 Saline
 Ringer lactate
 Glucose(5.4%)
 Urea(1.8%)
 Sarbitol(3.3%)
 Mannitol(3%)
 Distilled water

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
• Elderly with coexistent diseases.
• Dehydrated and depleted of electrolytes
d/t
long-term diuretic therapy and restricted fluid intake.
• impaired renal function and chronic urinary infection
d/t
Long standing urinary obstruction

11. PREOPERATIVE EVALUATION
 History and datail 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. Detection of early signs of TURP syndrome and bladder
perforation
2. Promotes peripheral vasodilation
3. Reduces blood loss
4. Good early post-operative analgesia
5. Reduced incidence of post-operative DVT
6. Neuroendocrine and immune response are better
preserved
7. Lower cost.

14. REGIONAL ANAESTHESIA
 General anaesthesia preferred when regional is
contraindicated.
 Level of sensory block
 T10 dermatome level – to eliminate discomfort caused
by bladder distention

15. MONITORING
 ECG
 Blood pressure
 Pulse oximetry
 Temperature
 Mentation
 Blood loss
 S. electrolytes (serial)
 EtCO2 if GA is used

16. INTRAOPERATIVE CONSIDERATIONS
• Lithotomy position
 TURP syndrome
 Bladder perforation
 Hypothermia
 Transient bacterial
septicemia
 Hemorrhage and
coagulopathy

17. 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

18. TURP SYNDROME
 Rapid absorption of a large-volume irrigation solution.
 Can occur 15 min after resection or upto 24 hrs
postop.
 Incidence : < 1 %
 Characterized by intravascular volume shifts and
plasma-solute (osmolarity) effects:
 Circulatory overload
 Water intoxication
 Hyponatremia
 Hypoosmolality
 Hyperglycinemia
 Hyperammonemia
 Hemolysis

19. TURP SYNDROME-WATER INTOXICATION
 Cause : cerebral edema
 Signs and symp:
 Somnolence, restlessness, seizures, coma
 CNS – decerebrate posture, clonus, +ve
babinski’s reflex
 Eyes – papilloedema, dilated and non reactive
pupils
 EEG – low voltage b/l.

20. HYPERVOLEMIA
 Irrigation fluid enters circulation through open prostatic
venous sinuses
 Average rate – 20ml/min
 May reach upto 200 ml/min
 Literature suggests as much as 8 L fluid can be absorbed
 Average weight gain by end of surgery – 2 kg.

21. 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

22. TURP SYNDROME-HYPONATREMIA
 Cause : excessive absorption of Na free irrigation fluid
 During TURP, S.Na falls by 3 to 10 meq/l.
 SIGNS AND SYMPTOMS OF Acute Hyponatremia
 Nausea
 Vomiting
 Irritability
 Mental confusion
 Cardiovascular collapse
 Pulmonay edema
 Seizures

23. Manifestations of hyponatremia
SERUM Na+
(mEq/l)
CNS changes CVS
changes
ECG Changes
120 Confusion
Restlessness
Hypotension
bradycardia
wide QRS complex
115 Somnolence
Nausea
Cardiac depression
Bradycardia
Wide QRS complex
Elevated ST
segment
110 Seizures
Coma
CHF Ventricular
tachycardia or
fibrillation

24. TREATMENT
 serial sodium measurements must be done whenever
unexplained changes in BP or cerebral irritation is seen.
 Infusion of clear fluids should be suspended.
 Blood loss should be replaced by slow blood transfusion.
 Loop diuretic – furosemide can be given.
For acute hyponatremia with neurological features, rapid
correction till neurological improvement is to be done.

25. Na deficit =
(DESIRED [NA] - CURRENT [NA]) X 0.6 * Bd WT (KG)
(*use 0.6 for men and 0.5 for women).
 Rate of correction should be 0.6 – 1.0 mEq / L / hr until
sodium reaches 125 after that the rate is 1.5 mEq / L / hr.
 Hypertonic (3%) saline – Contains 514 mEq/L of NaCl.
 May precipitate P.Edema in presence of cardiac failure.
 In general, increase of 4-6 mEq/L in serum sodium level is
sufficient to arrest progression of symptoms in severe
hyponatremia. Further rapid increase in serum sodium level
not indicated.

26. TURP SYNDROME-HYPERGLYCINEMIA
 Glycine is metabolized in liver by oxidative
deamination to ammonia and glyoxylic and oxalic
acid.
 Manifestations of glycine toxcity: nausea,
headache, malaise, weakness, visual distubances
( transient blindness), seizures, encephalopathy.

27. TURP SYNDROME -HYPERAMMONEMIA

28. 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, Pulmonary edema
Hematologic Disseminated intravascular hemolysis Hyponatremia and
hypoosmolality
Renal Renal failure Hypotension, hemolysis,
hyperoxaluria
Metabolic Acidosis Deamination of glycine

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
 Local vasoconstrictors

30. TURP SYNDROME - MANAGEMENT
• Notify surgeon and terminate surgery.
 Ensure oxygenation
 Restrict fluids
 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

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
TYPES-
 Extraperitoneal perforations
 Intraperitoneal perforation

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.

34.  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.

35. 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

36. 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.


37.  Postoperative shivering dislodges clots promotes
postoperative bleeding.
 Monitor body temp maintain normothermia.
 measures to reduce heat loss warming blankets, heated
irrigation solution and warm I/V fluids.

38. BACTEREMIAAND 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

39. POSTOPERATIVE COMPLICATIONS
 Hypothermia
 Hypotension
 Haemorrhage
 Septicaemia
 TURP syndrome
 Bladder spasm
 Clot retention
 Deep vein thrombosis
 Postoperative cognitive impairment