The Prostate Gland Male sex gland Pear-shape,wt7- 16gm Size of a walnut Clip Helps control urine flow Produces fluid component of semen Produces Prostate Specific Antigen (PSA)
Four Areas of the Prostate Transition Zone Anterior Zone Peripheral Zone Central Zone
Sagittal View of the Prostate Plexus of Anterior Middle lobe lobe Posterior lobe Santorini Seminal vesicle Base of prostate Rectum Pubic bone Puboprostatic ligamentApex of prostate Denonvilliers Penis and fascia Urethra Deep transverse perineal muscle
Arterial supplyFrom the anterior division of the internal iliac arteryInferior vesical artery,Middle rectal arteryInternal pudendal artery originates (hypogastric)artery.The capsular artery is the second main branch of theprostate. Supply the glandular tissue.Venous drainageProstatic plexus of veinsValveless communication exists between the prostaticandvertebral plexus through which prostatic carcinomaspread 5
Innervationsfrom pelvic plexuses formed by the parasympathetic,visceral, efferent, and preganglionic fibers that arise fromthe sacrallevels(S2-S4)sympathetic fibers from the thoracolumbar levels (L1-L2).The pudendal nerve is the major nerve supply leadingtoSomatic innervations of the striated sphincter and thelevatorani. The preprostatic sphincter and the vesicle neck orinternal sphincter is under alpha-adrenergic control.Lymphatic drainage 6
What is Benign ProstaticHyperplasia? Peripheral zone Transition zone Urethra
what causes BPH?n BPH is part of the natural aging process (increase in androgen receptor)n Dihydrotestosterone (DHT) may play a rolen BPH cannot be preventedn BPH can be treated
What’s LUTS? Voiding (obstructive) Storage (irritative or symptoms filling) symptoms Hesitancy Urgency Weak stream Frequency Straining to pass urine Nocturia Prolonged micturition Urge incontinence Feeling of incomplete bladder emptying Urinary retentionLUTS is not specific to BPH – not everyone withLUTS has BPH and not everyone with BPH has LUTS
common symptomsn decrease in the n Hesitancy urinary stream n Pain or burningn Dribbling or leaking during urination after urination n Feelingthat then Intermittency bladder never completely empties
what causes these symptoms?n Prostate grows with agen Pressure on the urethra restricts urine flow
Diagnosis of BPH• Symptom assessment – the International Prostate Symptom Score (IPSS) is recommended as it is used worldwide – IPSS is based on a survey and questionnaire developed by the American Urological Association (AUA). It contains: • seven questions about the severity of symptoms; total score 0–7 (mild), 8– 19 (moderate), 20–35 (severe) • eighth standalone question on QoL• Digital rectal examination(DRE) – inaccurate for size but can detect shape and consistency• PV determination- ultrasonography• Urodynamic analysis – Qmax >15mL/second is usual in asymptomatic men from 25 to more than 60 years of age• Measurement of prostate-specific antigen (PSA) – high correlation between PSA and PV, specifically TZV – men with larger prostates have higher PSA levels 1 – PSA is a predictor of disease progression and screening tool for CaP – as PSA values tend to increase with increasing PV and increasing age, PSA may be used as a prognostic marker for BPH
when should BPH be treated? BPH needs to be treated ONLY IF:n The symptoms are severe enough to bother patient and affect the quality of lifen Renal insufficiencyn Frequent urinary tract infections
enlarged prostate treatment options n Medication n Heat therapies n Surgical approaches
medicationn First line of defense against bothersome urinary symptoms n Manage the condition - don’t fix itn Two major types:n (Alpha-1-blocker) - relax the prostate and provide a larger urethral opening (prazosin,terazosin) n Shrink the prostate gland (5-alpha reductase inhibitor) (finasteride)
possible side effects of medication n Impotence n Dizziness n Headache n Fatigue n Loss of sexual drive
heat therapiesn Destroy prostate tissue with heatn Tissue is left in the body and is expelled over time (called sloughing) n Transurethral Microwave Therapy (TUMT) n Transurethral Needle Ablation (TUNA®) n Interstitial Laser Coagulation (ILC) n Water Induced Thermotherapy (WIT)
possible side effects of heat therapiesn Urinary Tract Infectionn Impotencen Incontinence
OBJECTIVES To identify the patient at increased risk of peri- operativeMI, pulmonary edema and renal failure. To determine cardiac reserve or to see the capability of heart and circulation to withstand the stress which accompany anaesthesia and surgery peri-operatively. To make a logical choice of anaesthesia technique and supportive therapy based on understanding the patients haemodynamic status. To explaine the risk to pt. and attendants. To take informed consent with calculated risk for medicolegal purpose.
Preparation of patient Pre anaesthetic examination. Measures to optimize status of patient Antibiotic coverage. Medication of coexisting diseases Back of the patient (preparation) Fasting Blood arrangement and cross-match
ANESTHETIC TECHNIQUE•Spinal anesthesia is the •Spinal anesthesia dose oftechnique of choice Bupivacaine 0.75% is 1.6•sensory supply to the mlbladder is from T10 - T12•Sensory supply toprostate L1-L2 .•sensory supply to theurethra, prostate andbladder neck is from S2 -S4.•for satisfactoryanesthesia, a block to T10is required.
REGIONAL ANESTHESIA•Subarachnoid anesthesia is preferred to epidural •It is technically easier to perform in the elderly •the duration of surgery is generally not very long. •the incomplete block of sacral nerve roots that occasionally occurs with extradural technique is avoided with subarachnoid anesthesia.•Regional anesthesia does not abolish theobturator reflex. •The reflex blocked by muscle paralysis during general anesthesia or obturator nerve block
ANESTHETIC TECHNIQUERegional anesthesia is the anesthetic ofchoice:•monitoring of the patients mentation•vasodilation and peripheral pooling ofblood•It reduces blood loss•It provides postoperative analgesia.•reinfarction rate for SA has beenreported to be less than 1%, versus 2%to 8% for GA.•Decreased hypercoagulable tendencyin the postoperative period•homeostasis of the neuroendocrinesystem & immune response.•Early recognition of turp syndrome&bladder perforation
GENERAL ANESTHESIA•Advantage •Uncooperative patients or in patients who require hemodynamic or ventilatory support. • Abolish Obturator Reflex•Disadvantage •inability to monitor the patient’s level of mentation
MONITERING Pulse NIBP Oximetery ECG Blood loss-Hb, Hematocrit S. Sodium conc. CVP Mental status Temperature
GENERAL ANAESTHESIA Induction:- Propofol or bariturate,benzodiazepine,opioides Intubation:-smooth,short durationMeasures to attenuate pressor responses.Maintenance:-Oxygen and nitrous oxide,muscle relaxant,volatile or opioid based.Reversal and smooth extubationFluid:-NS,RL,Colloid and blood according to need.
TURP (transurethral resection of the prostate)n ―Gold Standard‖ of care for BPHn Uses an electrical ―knife‖ to surgically cut and remove excess prostaten tissue Effective in relieving symptoms and
SURGICAL PROCEDURE• Operation isperformed through amodified cystoscope• Prostatic tissue isresected using anelectrically energizedwire loop.• the Prostatic capsuleis usually preserved.• Continuous irrigationis necessary to distendthe bladder and to washaway blood anddissected prostatictissue.
IRRIGATION FLUIDIdeally the irrigation solution should be:• Isotonic• electrically inert• Nontoxic• Transparent• inexpensive• Nonhemolytic• Nonmetabolized
COMPLICATIONS•TURP can be associatedwith a number ofcomplications: •TURP Syndrome (2%) •Hemorrhage •Bladder perforation (1%) •Hypothermia •Septicemia (6%) •DIC•The main challenges areblood loss and TURPSyndrome due toexcessive absorption ofirrigant fluid
TURP SYNDROME: DEFINITION• TURP syndrome: constellation of signs and symptoms caused by the absorption of large volumes of isotonic irrigating fluids through prostatic veins or breaches in the prostatic capsule.• The syndrome is characterized by • hypervolemia, • hyponatremia • hypo-osmolarity
TURP SYNDROME: EPIDEMIOLOGY• Irrigant absorption may occur in up to 46% ofresections• 5-10% of patients absorbing 1 liter or more• observed in 2-10% of all prostate resections• Of approximately 400,000 TURP procedureseach year, 10% to 15% incur TURP syndrome andthe mortality is 0.2% to 0.8%• Syndrome may occur as quickly as 15 minutesafter resection starts or up to 24 hourspostoperatively• A simple canalization or balloon dilation of theurethra or a staged TURP is less likely to provokeTURP syndrome.
TURP SYNDROME: IRRIGATION FLUID• The irrigation solution enters thebloodstream directly through open prostaticvenous sinuses.• primarily when prostatic capsule is violatedduring surgery.• As many as 8L of irrigation solution can beabsorbed by the patient during TURP.• The average rate of aborption is 20mL perminute and may reach 200mL per minute• average weight gain by the end of surgeryis 2 kg.
TURP SYNDROME: IRRIGATION FLUID•Distilled water is transparent and electricallyinert. •Extremely Hypotonic: may cause hemolysis, shock and renal failure.•Several nearly isotonic irrigation solutions thathave replaced plain distilled water. •The more commonly used solution today is Glycine. •Cytal is a solution occasionally used.•To maintain their transparency, thesesolutions are prepared moderately hypotonic.
TURP SYNDROME: IRRIGATION FLUIDGlycine has direct toxic effects on the:•Heart: decrease of 17.5 % in cardiacoutput, arginine reversed myocardialdepression•Retina: transient visual disturbance(blindness)•Encephalophathy & seizures: via NMDApotentiation •Magnesium exerts a negative control on the NMDA receptor •hypomagnesemia caused by dilution may increase the susceptibility to seizures.
TURP SYNDROME:IRRIGATION FLUID •The most common metabolites of glycine are ammonia and oxalic acids. •Hyperoxaluria could compromise renal function in patients with coexisting renal disease •Hyperammonemia occurs secondary to arginine deficiency.
TURP SYNDROME: IRRIGATION FLUID•Hyperammonemia manifestationsappear within 1 hour after surgery.•Blood ammonia level > 500mmol/L. •nauseated, vomits, and then becomes comatose.•Ammonia level < 150 mmol/L ptawakens
TURP SYNDROME: IRRIGATION FLUID•Cytal is a mixture of sorbitol andmannitol•Bacterial containmination: This issecondary to the sugars in the cytalsolution make it a rich medium forbacteria•Exacerbate hyperglycemia indiabetic patients•pulmonary edema in cardiacpatients: mannitol rapidly expandsthe blood volume
HYPONATREMIACARDIAC SIGNS AND SYMPTOMS•<120mEq/L : •signsof cardiovascular depression QRS widening•<115mEq/L: •bradycardia, widening of the QRS complex, ST-segment elevation, ventricular ectopic beats, and T wave inversion.•<110 mEq/L : •VT or VF •can develop respiratory and cardiac arrest
TURP SYNDROME:MANIFESTATION UNDERGENERAL ANESTHESIA• Presenting signs are a rise and thenfall in BP, and bradycardia.• The ECG may show nodalrhythm, ST-segment changes Uwaves, and widening of the QRScomplex.• Recovery from general anesthesia isusually delayed.
TURP SYNDROME:NEUROLOGICAL MANIFESTATIONS •CNS dysfunction is due to acute hypoosmolarity. •the blood brain barrier is impermeable to sodium but freely permeable to water. •Cerebral edema caused by acute hypoosmolality can increase intracranial pressure: •Bradycardia + hypertension by the Cushing reflex. •The rise in intracranial pressure is directly related to the gain in body weight during TURP.
TURP SYNDROME:NEUROLOGICAL MANIFESTATIONS •In some cases, moderate hyponatremia is associated with severe neurologic symptoms; in others, severe hyponatremia causes no symptoms. •The determining factor is the rate at which the serum sodium level falls rather than the total. •faster the fall the greater the incidence of CNS symptoms. There may be accompanied EEG abnormalities •loss of alpha-wave activity and irregular discharge of high-amplitude slow-wave activity.
TURP SYNDROME:NEUROLOGICAL MANIFESTATIONS •Na <120 meq/L: •confusion and restlessness •Na <115 meq/L: •Somnolence and nausea •Na <110 meq/L: •Tonic-clonic seizures and coma.
TURP SYNDROME: RISK FACTORS TURP syndrome is more likely to occur: 1. The hydrostatic pressure of the irrigation solution is high. 2. An excessively distended bladder 3. Prostatic gland is large. 4. The Prostatic Capsule is violated during surgery. 5. Duration of surgery (>60mins)
BIPOLAR SALINE TURP •The Bipolar technique •Several clinical trials allows the use of saline as have proved that bipolar the irrigation fluid, TURP is as effective as eliminating the risk of conventional TURP, but transurethral resection with a shorter hospital syndrome stay, earlier catheter removal, and fewer complicationsPaula Bishop "Bipolar transurethral resection of the prostate—a new approach". AORN Journal. . FindArticles.com. 03 Apr. 2008.
TURP SYNDROME:EARLY DETECTION Ethanol labeled irrigating fluid can be used to asses the degree of fluid absorption during procedure by measuring the ethanol content of the patients exhaled breath. Vol. absorbed=(preop.S. Na+.∕postop S.Na+×ECF) - ECF
TURP SYNDROME: TREATMENT•Ensure oxygenation and circulatory support•Notify surgeon and terminate procedure•Consider invasive monitors if CV instabilityoccurs•Send blood forelectrolytes, creatinine, glucose, ABG•Obtain 12 lead ECG•Seizures •Use short acting anticonvulsant (midazolam), Next a barbiturate or phenytoin can be added. last resort, use muscle relaxant•Restlessness and incoherence areparticularly ominous signs •GA in the presence of TURP syndrome can lead to severe complications and even death.
TURP SYNDROME: TREATMENT•Treat mild symptoms: Na>120 mEq/L •Fluid restriction and loop diuretic (furosemide 20mg)•Treat severe symptoms: Na< 120mEq/L •3% NaCl IV at a rate of <100ml/hr •Discontinue 3% NaCl when Na > 120 mEq/L•Rate of Na increase should notexceed 12 mEq/L in 24 hr period
TURP SYNDROME: TREATMENT•Rapid administration of hypertonicsaline has been associated with centralpontine myelinolysis•To reduce the hazards of salineadministration, serum osmolarityshould be monitored and correctedaggressively only until symptomssubstantially resolve •then hyponatremia should be corrected at a rate no faster than 1.5 mEq/L per hour
TURP SYNDROME: DIFFERENTIAL DIAGNOSIS The differential diagnosis of hypotension followingTURP should always include1. Hemorrhage2. TURP syndrome3. Bladder perforation4. Myocardial infarction or ischemia5. Septicemia6. Disseminated intravascular coagulation (DIC).7. Anaphylaxis
PERFORATION EXTRAPERITONEAL INTRAPERITONEAL Cause :-1.instrument 2.overdistention of bladderDiagnosed by pain,rigid ,tender,distended abdomen and irregular return of irrigation fluid, reflex limb movement at time of perforation
BLEEDING ANDCOAGULOPATHY Resection time (2-5ml/min) Weight of resected prostate (20-50 ml/gm) Serial Hb level and hematocrit measurement. Release of plasminogen activator to form plasmin which digest fibrinogen leading to fibrinolysis & DIC Systemic absorption of thromboplastin released from prostatic tissue-DIC
HYPOTHERMIA Absorption of Irrigation fluid stored at room temperature -shivering. Altered behaviour of hypothalemic thermoregulatory centres in brain. Warming of fluid & opioids decreases shivering.
SEPTICEMIA Prostate harbors many bacteria – source of bacteremia through venous sinuses Indwelling urinary catheter Symptoms- chills, fever, tachycardia,later on in severe cases bradycardia,hypotention and cardiovascular collapse Aggressive treatment with antibiotics and CVS support.
Postural complications Compartment syndrome Nerve damage Vital capacity and FRC decrease False impression of CVS status Deep vein thrombosis
MORTALITY ANDMORBIDITY Mortality is 0.2-0.8%in 30 days Increased morbidity – In patients with resection time more than 90 min. Gland size larger than 45 gm Acute urinary retention Age older than 80 years
the ―gold standard‖- TURP Benefits Disadvantagesn Widely available n Greater risk of side effects and complicationsn Effective n 1-4 days hospital stayn Long lasting n 1-3 days catheter n 4-6 week recovery
possible side effects of TURPn Impotencen Incontinencen Bleedingn Electrolyte imbalance (TUR Syndrome) n