TURP trans urethral resection of prostate

Turp

1. TURP and its anesthetic considerations Presenter-Dr. N aina Kumari (PG-2) Moderator- Dr. Pradeep Tiwari (Assoc. Professor) Dept. of Anesthesiology & critical care NMCH Patna

2. Anatomy Location: in the pelvis, below neck of urinary bladder Shape: inverted cone Weight: 20 gm 5 Lobes: median, anterior,2 lateral, posterior

3. Blood supply: Arterial supply Inferior vesical artery Middle rectal artery Internal pudendal artery Venous supply Vesical plexus Internal pudendal vein Vertebral venous plexus

4. Nerve supply: Sympathetic supply T11- L2 Inferior hypogastric plexus Parasympathetic supply S2,3,4 Pelvic splanchnic nerve

5. TURP TURP is resecting prostatic tissue with an electrically powered cutting- coagulating metal loop performed by inserting a recetoscope through the urethra As much prostatic tissue is resected but the prostatic capsule is usually preserved An irrigation fluid flows into to distend bladder and to bathe surgical site washing away blood and debris

6. IRRIGATION FLUIDS Characteristics Transparent Isotonic Electrically inert Non hemolytic Inexpensive Rapidly excretable Non toxic

7. Uses: Distends bladder and prostatic urethra Flushes out blood and tissue debris Improves visibility

8. Factors affecting amount and rate of fluid absorption Size of gland Number and size of open sinuses Hydrostatic pressure of irrigation fluid Duration of procedure Integrity of capsule Vascularity of prostate

9. Preoperative evaluation Pt. for TURP are frequently elderly with coexistent diseases Cardiovascular diseases COPD Diabetes mellitus Hypertension Long standing urinary obstruction can lead to impaired renal function and UTI

10. Investigations: CBC , KFT, ECG ,CXR , blood sugar and other required investigations Optimization of pre-existing comorbid conditions Antibiotic prophylaxis Arrangement of blood

11. Choice of anesthesia Regional anesthesia is preferred over GA: Allow early detection of TURP syndrome and bladder perforation Reduces blood loss Avoids side effects of GA Good and early recovery Lower cost Decreased incidence of DVT GA is preferred when regional anesthesia is contraindicated

12. Intraoperative complications Due to lithotomy position TURP syndrome Bladder perforation Hypothermia Hemorrhage and coagulopathy

13. Due to lithotomy position Decreased FRC Increased venous return Injury to nerves Compression of major vessels at joint Aggravation of pre existing lower back pain

14. TURP SYNDROME Due to rapid absorption of large volume of irrigation fluid Can occur 15 min after resection or upto 24 hrs postop Clinical features: Circulatory overload Hyponatremia Hypoosmolarity Hyperglycinemia Hyperammonemia Hemolysis

15. Prevention of TURP Syndrome Early diagnosis and prompt treatment Cautious administration of fluid Restrict the duration to 60 min Limitation of hydrostatic pressure of irrigation fluid Bipolar resectoscope Local vasoconstrictor

16. Management Notify the surgeon and terminate surgery Ensure oxygenation, if required then intubation can be done Restrict fluids Bradycardia, hypotension: Atropine ,adrenergic agents Control of seizure Send blood sample for electrolyte and ABG Treatment of Hyponatremia as per protocol

17. Bladder perforation Causes Trauma by surgical instrument Overdistention of bladder with irrigation fluid Manifestations: Sudden decrease in irrigation fluid solution from bladder Types: Extra peritoneal perforation Intraperitoneal perforation

18. Blood loss Difficult to quantify blood loss Visual estimation of blood loss is difficult due to dilution with irrigation fluid Warning signs like tachycardia, hypotension is to be addressed early