Anesthesia for TURP
Claudio Melloni
Servizio di Anestesia e Rianimazione
Ospedale di Faenza(RA)

Servizio di Anestesia e R...
Anesthesia for Turp is not
always routine
Major KO: 2.5 - 20% of patients
perioperative mortality rate :0.5 - 6%,
Holtgrew...
Risk factors in anesthesia for
TURP
Patients,their intrinsic risk factors and
anesthesia related risks
Surgical Procedure;...
Turp Syndrome
Cardiovascular;hypotension,hypertension,dysryth
mias,shock,pulmonary edema,cardiac arrest….
Respiratory;tigh...
Late Turp syndrome
4 - 24 hours later
Some of these cases could be ascribed to instrumental perforation of
the prostatic c...
TURP symptoms associated with 2000 or + ml glycine
absorption(Hahn et al.J.Ethanol monitoring of the TURS.Clin.Anesth.1996...
Ideal requirements of an
Irrigating solution
♦Purpose:give the surgeon a clear view of the
operating field by removing blo...
Irrigating fluids
H2O distilled
glycine 1.2-1.5%
mannitol 3%
mannitol –sorbitol(2.7-0.54 %
respectively)mixtures.

Servizi...
Toxicity of irrigating fluids
♦glycine :
♦significant cardiac and retinal toxicity
♦may cause hyperammonemia because its
m...
Volume absorption
the intravesical pressure (governed by the height of
the irrigation bag above the prostatic sinuses)
the...
Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
entrainment of the solution
Circulatory overload
haemodilution
hypotonia and hypoosmolality
…………. haemolysis,shock ,renal ...
Vol.absorbed= ((preop serum Na/postop
serum NA)*ECF in KG))-ECF in KG.
P es,if a preop sodium was 140 and postop
is 110,th...
Hypotension-hypertension...
Perioperative hypotension during TURP is sometimes
preceded by hypertension . Profound hyponat...
Atallah et al.Does spinal anesthesia affect cerebral
oxygenation during transurethral
prostatectomy?.Reg.Anesth.Pain med. ...
Atallah et al.Does spinal anesthesia affect cerebral
oxygenation during transurethral
prostatectomy?.Reg.Anesth.Pain med. ...
Biphasic absorption of fluids
H 2 0 e n t r a in m e n t
H y p o o s m o la lit y

Ca++

N A

d iu r e s is

B P

Atrial n...
Hypoosmolality >
hyonatremia
In a series of 72 patients undergoing TURP,
serum sodium concentration decreased by 10
to 54 ...
Blood loss
Total blood loss after TURP is significantly correlated
with the prostatic tissue weight
but when the tissue we...
Smyth R, Cheng D, Asokumar B et al. Coagulopathies in
patients after transurethral resection of the prostate: spinal
versu...
Therapy of Turp syndrome

diuretics?
Saline
hypertonic saline?
Inotropes/vasopressors(?)
The most feared complication of c...
Treatment of symptomatic hyponatremia

Safest treatment;symptomatic
slow therapy ( <=0.7 mmolLt/h) , has been associated w...
Hyperglycinemia

Incidence and severity of circulatory and nervous
symptoms(nausea, vomiting, headache, malaise
weakness,s...
Glycine toxicity
Retina
cardiomyocites
kidney(Hyperoxaluria from metabolism into oxalate and glycolate)
hyperammoniemia

S...
Treatment of hyperglycinemia
Mg?
NMDA antagonists
L-arginine

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
Olsson J, Nilsson A, Hahn RG. Symptoms of the
transurethral resection syndrome using glycine as the
irrigant. J Urol 1995;...
Nilsson A,Olsson J,Hahn RG.Symptoms of the TURP
syndrome using glycine as the irrigant.J Urol 1995;154:123-128

glycine
Se...
Fluid absorption during TURP;influence of operating

time(Hahn RG, Ekengren J. Patterns of irrigating fluid absorption dur...
Urine composition 90 min after i.v infusion of 15 ml/kg of
irrigating fluids(10 healthy male volunteers)

Nilsson A, Randm...
Urinary excretion of sodium during and after iv infusion of
glycine solution in sheep and humans.

(Hahn RG Trapping of

e...
Trepanier,CA,Lessard,MR,Brochu,J,Turcotte,G.Another
feature of TURP syndrome:hyperglycemia and lactic acidosis
caused by m...
Gehring et al.Irrigation fluid absorption during TURP;spinal
vs general anesthesia.AAS 1999;43:458-63.
Blood ethanol maxim...
Gehring et al.Irrigation fluid absorption during
TURP;spinal vs general anesthesia.AAS 1999;43:45863.

Extent of irrigatin...
Why regional anesth.is to be
preferred
It allows the appearance of the full clinical
manifestation of symptoms
» (under GA...
significant fluid absorption has taken
place when ethanol concentration in
plasma exceeeds 0.1/1000.Plasma and
exhaled eth...
Recommendations for anesth.
continuous warming of i.v. fluids
(warming of the patient)
lab monit :Hb,Na ,glyc ;coag in sus...
Recommendations for surgery
Minimize absorption
» Limiting the height of the irrigation bag to 40 cm above the
prostate
» ...
Difficulties for the anesthesiologist who wants to introduce a
method for monitoring of fluid absorption in their hospital...
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anesthesia for TURP transurethral resection of prostate

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Anest turp

  1. 1. Anesthesia for TURP Claudio Melloni Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  2. 2. Anesthesia for Turp is not always routine Major KO: 2.5 - 20% of patients perioperative mortality rate :0.5 - 6%, Holtgrewe HL, Valk VVL. Factors influencing the mortalityand morbidity of transurethral prostatectomy: a study of 2,015 cases.J.Urol 1962; 87: 450‑9. Roos, N. P., Wennberg, J. E., Malenka, D. J. et al: Mortality and,.re‑operation after open and transurethral resection of the prostate for benign prostatic hyperplasia. N Engl J Med, 320: 1120,1989 Malenka, D. J., Roos, N., Fisher, E. S. et al: Further study of the increased risk of mortality following transurethral resection of the prostate: a chart‑based analysis. J Urol, 144: 224, 19 Seagroatt, V.: Mortality after prostatectomy: selection and surgical approach. Lancet, 346: 1521, 1995 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  3. 3. Risk factors in anesthesia for TURP Patients,their intrinsic risk factors and anesthesia related risks Surgical Procedure;its complication,some peculiar to the technique used; Utilization of irrigating fluids. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  4. 4. Turp Syndrome Cardiovascular;hypotension,hypertension,dysryth mias,shock,pulmonary edema,cardiac arrest…. Respiratory;tight feeeling in the chest or throat ,shortness of breath,hyperventilation,dyspnea,pulmonary edema…. Cerebral;dizziness,mental confusion, and lethargy lapsing into coma,headaches,nausea, ,restlessness ,retching,blindness,twitches and seizures. ; bacteremia…... e Rianimazione Ospedale di Faenza(RA) Servizio di Anestesia
  5. 5. Late Turp syndrome 4 - 24 hours later Some of these cases could be ascribed to instrumental perforation of the prostatic capsule ( and more rarely of the bladder) fluid deposited in a pool in the retroperitoneal space the fluid may comprime the caval veins and diffuse through the peritoneal membrane again creating flows according the Starling laws;electrolytes entering the pool of fluid and solutes contributing to plasma volume decrease as the solute travel in the opposite direction,i.e.toward the cell,where they are metabolized or accumulate In these case moderate hyponatremia and hypoosmolality develop with a time delay ,some hours following the operation.Clinically there is a tendency toward an increased incidence of abdominal pain,bradycardia eand hypotension di Faenza(RA) Servizio di Anestesia Rianimazione Ospedale
  6. 6. TURP symptoms associated with 2000 or + ml glycine absorption(Hahn et al.J.Ethanol monitoring of the TURS.Clin.Anesth.1996;8:652-655) Intraop symptoms freq(20-60%):BP ,HR,BP common(1020%):prickling skin,nausea,tirednes s.uneasiness rare (<10%):blurred vision,chest pain,confusion Postop symptoms confusion,BP,nause a,transient anuria bradyc,diarrhea,free zing,vomiting blurred vision,depressed consciousness,abdo minal pain Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  7. 7. Ideal requirements of an Irrigating solution ♦Purpose:give the surgeon a clear view of the operating field by removing blood and pieces of resected tissues. ♦Electrolyte free to allow cutting with a resectoscope ♦Isotonic ♦electrically inert ♦non toxic, ♦clear transparent ♦easy to sterilize and handle ♦not too expensive…. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  8. 8. Irrigating fluids H2O distilled glycine 1.2-1.5% mannitol 3% mannitol –sorbitol(2.7-0.54 % respectively)mixtures. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  9. 9. Toxicity of irrigating fluids ♦glycine : ♦significant cardiac and retinal toxicity ♦may cause hyperammonemia because its metabolites overload the urea synthesis cycle ♦ glucose may cause severe hyperglycemia ♦mannitol and sorbitol may cause lactic acidosis and hyerglycemia due to shifts in the glycolysis pathways Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  10. 10. Volume absorption the intravesical pressure (governed by the height of the irrigation bag above the prostatic sinuses) the number of prostatic sinuses opened retroperitoneal and paravescical spaces,even in absence of surgical perforation – length of the procedure, – experience of the surgeon(or inexperience) – difficult resections Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  11. 11. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  12. 12. entrainment of the solution Circulatory overload haemodilution hypotonia and hypoosmolality …………. haemolysis,shock ,renal failure…….. acidosis hypoperfusion shock circulatory failure hypoxemia Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  13. 13. Vol.absorbed= ((preop serum Na/postop serum NA)*ECF in KG))-ECF in KG. P es,if a preop sodium was 140 and postop is 110,the calculation yelds for an estimate of EC as 30% of body weight for a 70 kg man=21 kg: 1)140/110=1,2 2)1,2*21=26,6 3)26,6-21=5.6,volume gain in KG(or lt). Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  14. 14. Hypotension-hypertension... Perioperative hypotension during TURP is sometimes preceded by hypertension . Profound hyponatremia by itself does not explain the hypotension;however, hyponatremia with hypertension may lead to net water flux along osmotic and hydrostatic pressure gradients out of the intravascular space and into the lungs, which triggers pulmonary edema and hypovolemic shock . This concept is consistent with the findings of Hahn(17) who hypothesized that the absorption of fluids derives from two sources;one from direct Servizio di Anestesia e Rianimazione Ospedale di phase?)and the absorption into the circulation(early Faenza(RA)
  15. 15. Atallah et al.Does spinal anesthesia affect cerebral oxygenation during transurethral prostatectomy?.Reg.Anesth.Pain med. 1998;23:115-8. 100 12 90 11,5 80 11 70 60 10,5 jug.bulb O2 sat art-jug O2 diff 50 CPP 10 40 30 9,5 20 9 10 0 8,5 basal after spi chri 30 chirend post30 post60 post120 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) jug bulb O2 content
  16. 16. Atallah et al.Does spinal anesthesia affect cerebral oxygenation during transurethral prostatectomy?.Reg.Anesth.Pain med. 1998;23:115-8. CPP decrease and SjbO2 decrease,a-jbO2 increase:CBF decrease,CMRO2 unaffected:impaired cerebral oxygenation patients with symptoms more affected by decrease in SjbO2 Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  17. 17. Biphasic absorption of fluids H 2 0 e n t r a in m e n t H y p o o s m o la lit y Ca++ N A d iu r e s is B P Atrial natriuretic factor H 2 O in t e r s t A P O edem a glycine H y p o v o le m ic s h o c k Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  18. 18. Hypoosmolality > hyonatremia In a series of 72 patients undergoing TURP, serum sodium concentration decreased by 10 to 54 mmol/L in 19 (26%), while osmolality changed in only two (3%): the 2 patients who had both hyponatremia (serum sodium concentration decreases of 27 and 30 mmol/L) and hypoosmolality (serum osmolality of 260 and 256 mmol/L) developed pulmonary edema and encephalopathy. The five patients in this series with the largest decreases in serum sodium concentration (by 34 to 54 mmol/L) had no changes in serum osmolality and no signs of TURP syndrome. (Desmond J. Serum osmolality and plasma electrolytes in patients who develop dilutional hyponatremia during transurethral resection. Can J Surg 1970; 13:116-21). A review of a series of 2000 consecutive patients( Henderson DJ,Middleton RG.Coma from hyponatremia following transurethral resection of prostate.Urology 15;267-71,1980) revealed 14 coma cases potoperatively,with sodium levels 1520 meq/lt below normal level:the coma was ,at that time , correctly,ascribed to water intoxication and associated surgical risk factors were identified,because in 9 of these cases the prostatic capsule was surgically violated or large venous sinuses were opened;all 14 patients eventually awoke without sequelae. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  19. 19. Blood loss Total blood loss after TURP is significantly correlated with the prostatic tissue weight but when the tissue weight resected exceeds 35 gr,blood loss was in excess of the linear correlation(Smyth R, Cheng D, Asokumar B et al. Coagulopathies in patients after transurethral resection of the prostate: spinal versus general anaesthesia. Anesth Analg 1995; 81: 680‑5) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  20. 20. Smyth R, Cheng D, Asokumar B et al. Coagulopathies in patients after transurethral resection of the prostate: spinal versus general anaesthesia. Anesth Analg 1995; 81: 680‑ 5 . There was no significant difference in measured coagulation variables (fibrinogen, factor V, plasminogen, antithrombin III, and FDP) between the spinal and GA groups, but there were significant decreases in postoperative fibrinogen and Factor V levels compared to preoperative values in both spinal and general anesthesia groups. 3 pts (6%) had increased FDP levels 1 h postop. The prostatic tissue weight and the surgical duration was significantly higher in these patients. The authors concluded that perioperative blood loss in TURP patients is not affected by the anesthetic technique,but 6% of TURP patients developed subclinical intravascular coagulopathies which correlated with mass of resected prostate tissue. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  21. 21. Therapy of Turp syndrome diuretics? Saline hypertonic saline? Inotropes/vasopressors(?) The most feared complication of correcting hyponatremia is central pontine myelinolysis (CPM Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  22. 22. Treatment of symptomatic hyponatremia Safest treatment;symptomatic slow therapy ( <=0.7 mmolLt/h) , has been associated with a higher morbidity and mortality than has rapid correction (=>1.0 mmol/lt/hr) Many reports suggesting that a 1.5- to 2.0-mmol /Lt/hr correction rate is safe have failed to consider changes in osmolality. Several investigators have suggested that osmotic stress is probably greater when correcting chronic compared with acute hyponatremia a prompt treatment with increases in the serum Na concentration not > 2 mmol/lt/hr;in general the correction Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  23. 23. Hyperglycinemia Incidence and severity of circulatory and nervous symptoms(nausea, vomiting, headache, malaise weakness,seizures, from blurred vision to complete blindness…) proportional to the amount of glycine absorbed: » serum glycine concentration threshold for symptomatic visual impairment (>4000 mmol/L) and blindness (>13,734 mmol/L) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  24. 24. Glycine toxicity Retina cardiomyocites kidney(Hyperoxaluria from metabolism into oxalate and glycolate) hyperammoniemia Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  25. 25. Treatment of hyperglycinemia Mg? NMDA antagonists L-arginine Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  26. 26. Olsson J, Nilsson A, Hahn RG. Symptoms of the transurethral resection syndrome using glycine as the irrigant. J Urol 1995; 154: 123‑ 8 6 5 4 0-300 1-2 lt >3 lt %3 2 1 0 glycine absorption Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  27. 27. Nilsson A,Olsson J,Hahn RG.Symptoms of the TURP syndrome using glycine as the irrigant.J Urol 1995;154:123-128 glycine Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  28. 28. Fluid absorption during TURP;influence of operating time(Hahn RG, Ekengren J. Patterns of irrigating fluid absorption during transurethral resection of the prostate as indicated by ethanol. I Urol 1993: 149: 502‑6 60 50 40 >2000 1001-2000 501-1000 151-500 30 20 10 0 op-time <= 60 min op time > 60 min Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  29. 29. Urine composition 90 min after i.v infusion of 15 ml/kg of irrigating fluids(10 healthy male volunteers) Nilsson A, Randmaa 1, Hahn RG. Haemodynamic effects of irrigating fluids studied by Doppler ultrasonography in volunteers. Br I Urol 1996; 77: 541‑6 Osmotic gap represents negatively charged ions not measured Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  30. 30. Urinary excretion of sodium during and after iv infusion of glycine solution in sheep and humans. (Hahn RG Trapping of electrolytes during fluid absorptionin transurethral resection of the prostate. Scand j Urol Nephrol, in press) Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  31. 31. Trepanier,CA,Lessard,MR,Brochu,J,Turcotte,G.Another feature of TURP syndrome:hyperglycemia and lactic acidosis caused by massive absorption of sorbitol.Brit. J. Anaesth. 87;316-9:2001 hyperglycaemia and lactic acidosis Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  32. 32. Gehring et al.Irrigation fluid absorption during TURP;spinal vs general anesthesia.AAS 1999;43:458-63. Blood ethanol maximum levels Blood ethanol area under the curve Blood ethanol absorption rate Estimated volume of absorption(Hah Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  33. 33. Gehring et al.Irrigation fluid absorption during TURP;spinal vs general anesthesia.AAS 1999;43:45863. Extent of irrigating fluid absorption significantly higher in absorption afflicted patients undergoing spinal anesthesia….;lower CVP may be the cause Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  34. 34. Why regional anesth.is to be preferred It allows the appearance of the full clinical manifestation of symptoms » (under GA only rise and fall in blood pressure ,respiratory arrest and severe bradycardia,with a variety of ECG modifications) possibility of early detection of TUR syndrome Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  35. 35. significant fluid absorption has taken place when ethanol concentration in plasma exceeeds 0.1/1000.Plasma and exhaled ethanol demonstrated a linear correlation ,while plasma ethanol correlated inversely with plasma sodium .The measurements were consistent both in patients under spinal and ga ,undergoing mechanical ventilation;but ethanol levels were not predictive of Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  36. 36. Recommendations for anesth. continuous warming of i.v. fluids (warming of the patient) lab monit :Hb,Na ,glyc ;coag in susp.cases PVC? NIBP,SaO2,etcO2,ethanol EGA,lactate consciousness be vigilant Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  37. 37. Recommendations for surgery Minimize absorption » Limiting the height of the irrigation bag to 40 cm above the prostate » use continuous irrigating resectoscopes » use suprapubic trocar drainage keep intravesical pressure < 15 cm H2O continuous warming of irrigating fluid Resection time < 1 hour leave a rim of tissue on the capsule until near the end of the procedure Rianimazione Ospedale di Faenza(RA) Servizio di Anestesia e
  38. 38. Difficulties for the anesthesiologist who wants to introduce a method for monitoring of fluid absorption in their hospital Urologist often regard fluid absorption as a complication indicating poor operative skills » address this point cautiously because this determines the success of the project... many clinicians believe TUR syndrome is too rare to warrant routine monitoring: » prepare by reading some prospective studies where the incidence of the mild form of the syndrome have actually been studied…. – Hahn,RG,Editorial.The transurethral resection syndromenot yet a finished story.Reg.Anesth.Pain Med.1998;23:115Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
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