1. A 58-year-old male presented with increased urinary frequency and difficulty passing urine for the past 6 months. Examination found an enlarged prostate and ultrasound revealed a prostate size of 43.5 x 42.2 x 32 mm. 2. The patient underwent a transurethral resection of the prostate (TURP) under spinal anesthesia. The procedure took 40 minutes with irrigation using glycine solution. 3. Complications of TURP include TURP syndrome from excessive fluid absorption, hemorrhage, hypothermia, bladder or urethral perforation. Care must be taken to prevent high irrigation pressures and prolonged procedures to reduce risks.

1. DR TR SHRESTHA, KMCTH

2. Pt particulars
▪ 58 yr/ Male
▪ Chief complaint
▪ Increased frequency of micturition X 6 months

3. History of present illness
▪ Increased frequency of micturition X 6 months
▪ Difficulty in passing urine
▪ Dribbling at the end of micturition
▪ No history of fever, burning micturition
▪ No abdominal pain, urgency, nocturia,
hematuria, back pain, retention
▪ No weight loss, fatigue

4. Past history
Medical history
No history of any medical illness
No h/o DM, HTN, Asthma, COPD
No bleeding disorders, blood transfusion
Surgical history
No history of anesthetic exposure or any surgeries

5. Family history:
No history of Hypertension, Diabetes mellitus, Bronchial
Asthma , or any chronic Diseases
Personal history:
Non smoker, does not consume alcohol
Sleep, Appetite-Normal
No any allergic history
Drug History:
Taking Tamsulosin since 6 months

6. Examination
▪ Conscious, co-operative, well oriented to time, place, person
▪ Weight: 50 kg, Height: 1.60m, BMI:19.53 kg/m2
▪ GC-Normal, lying comfortably on bed, Foley catheter in situ
▪ Pallor, icterus, lymphadenopathy, cyanosis, clubbing, edema and dehydration-
Absent
▪ Oxygen saturation: 98% in room air
▪ Temperature: 97℉
▪ PR-88/min, regular, all peripheral pulses palpable, no radioradial delay, no
radiofemoral delay
▪ Peripheral veins accessible

7. Airway examination
▪ Nasal patency: Normal, No DNS or visible polyp
▪ Teeth: Normal Dentition
▪ Palate: Normal
▪ Mallampatti: Grade II
▪ Temporomandibular joint movement: Normal
▪ Mouth opening:4 cm
▪ Catch test (upper lip bite test): Class I
▪ Mandibular protrusion test: Class A
▪ Patil’s test (Thyromental distance): 6 cm
▪ Atlantooccipital joint extension movement: Normal

8. Systemic examination
Gastrointestinal system
Inspection
Abdomen not distended, no scar marks, umbilicus is normal in position
External genitalia: Normal, Foley catheter in situ
Palpation
No tenderness, rebound tenderness, palpable mass or organ palpable
Percussion
Tympanic note present. Fluid thrill and shifting dullness absent
No renal angle tenderness
Auscultation
Normal bowel sound heard
DRE: Anal tone normal. Firmly consistent, smooth prostate felt, no nodules.

9. Cardiovascular System
Inspection
No surgical marks, visible pulsation, any chest deformities
Palpation
Apex beat over 5th intercostal space, midclavicular line, No heave, thrill
Auscultation
S1 S2 normal, no murmur

10. Central Nervous System
▪ GCS:15/15, well oriented to time, place and person
▪ Higher mental function: Intact
▪ Sensory, motor: Intact
▪ Reflexes : Intact
▪ Cranial nerves : Intact

11. Respiratory System
Inspection
Normal shape, bilateral symmetrical, No any scar marks, vascular anomalies
Palpation
Trachea centrally placed, chest expansion bilateral equal, no tenderness or any
other abnormalities
Percussion
Bilateral resonant note heard
Auscultation
Bilateral normal vesicular breath sound heard, No added sound

12. Investigations
▪ Hb :14.2 gm/dl
▪ TLC: 8800, N-74,L-24,E-0, M-2
▪ Platelet: 165000
▪ RFT: Urea:21,Cr:1.1,Na:134,K:4.0
▪ RBS: 93mmol/l
▪ PT/INR: 14/1.2
▪ Blood group: A+ve
▪ Viral markers: Non reactive
▪ LFT: Normal

13. ▪ Urine RE: WNL
▪ Urine CS: No growth
▪ CXR: Normal lung fields
▪ ECG: 73 / min, regular rhythm, no axis deviation,
no ischemic changes , within normal limits

14. ▪ USG abdomen pelvis
▪ Mildly enlarged prostate with size of 43.5 mm X 42.2
mm X 32 mm, weight 42 gms

15. Preoperative advice
▪ Graded as ASA I and planned for TURP under Spinal
Anaesthesia
▪ NPO 6 hours for solid foods and 2 hours for clear liquid
▪ Premedication
▪ Tab Ranitidine 150 mg and Tab Metoclopramide 10 mg HS and
6:30am in the morning of surgery
▪ Tab Alprazolam 0.25mg HS
▪ Patient/ patient party counseled about the mode of
anaesthesia

16. In OT
▪ Ventilator, breathing system checked
▪ Emergency drugs prepared
▪ Airway equipment, intubation set made ready
▪ IV access with 18G cannula LHS, Inj NS started
▪ Monitors attached (ECG, pulse oximeter, NIBP)
▪ Heart Rate, SpO2, BP monitored every 5 min

17. ▪ Baseline vital paramers:
▪ BP 130/76mmHg, HR 82 bpm, SpO2 98%
▪ Under aseptic precautions, 27G Whitacre needle inserted
in L3-L4 space in sitting position
▪ Free flow of CSF appreciated
▪ 0.5% hyperbaric bupivacaine 3 ml given over 30 seconds
▪ Patient turned supine
▪ Sensory level T7

18. Surgical technique
▪ Lithotomy position
▪ Use of resectoscope, through which diathermy loop passed
▪ Resection of hyperplastic tissue, sparing surgical capsule
▪ Continuous irrigation with glycine (10 L)
▪ At the end, a three-lumen catheter inserted and irrigation
continued
▪ Surgery duration: 40 min

19. DISCUSSION

20. Prostate anatomy
▪ Prostate gland (20 g)
▪ Encircles urethra as it emerges
from the base of bladder
▪ Glandular and non-glandular
components enclosed by a
fibrous capsule
▪ Venous drainage via the large,
thin-walled venous plexus
▪ Zones: TZ, PZ, CZ

21. Nerve supply
▪ Prostatic plexus (from inferior hypogastric plexus)
carries both SNS and PNS
▪ Pain from prostate, prostatic urethra, and bladder
mucosa →sacral nerves S2 to S4
▪ Pain signals from bladder distension travel with
sympathetic fibers (T11–L2)

22. Irrigation fluid
▪ Isotonic
▪ Electrically inert
▪ Non-toxic
▪ Transparent
▪ Easy to sterilize
▪ Inexpensive

23. Commonly used irrigating solutions
Solution Osmolality
(mOsm/kg)
Disadvantage
Glycine,1.2% 175 Transient visual loss, Hyperammonemia
Hyperoxaluria
Glycine,1.5% 220
Mannitol,3% 275 Osmotic diuresis, Acute intravascular
volume expansion
Cytal (sorbitol 2.7% and
mannitol 0.54%)
178 Expensive, not easily available
Glucose, 2.5% 139 Hyperglycemia

24. Pre operative consideration
▪ Elderly with co-existing disease
▪ Dehydrated with electrolyte imbalances
▪ Impaired renal function d/t long standing urinary
obstruction and chronic UTI
▪ History and examination
▪ Investigations

25. Pre operative preparation
▪ Optimization of existing disease condition
▪ Consideration of on going drug therapy
▪ Arrangement of adequate blood products
▪ Antibiotic prophylaxis (in case of UTI)

26. Spinal anesthesia
▪ Early detection of TURP syndrome
▪ Reduce stress response to surgery
▪ Early detection of accidental bladder perforation
▪ Decreased blood loss
▪ Decreased incidence of DVT
▪ Post operative analgesia
▪ Can be used safely in patients with respiratory
disease

27. Intraoperative problems
▪ TURP syndrome
▪ Haemorrhage
▪ Myocardial ischaemia
▪ Hypothermia
▪ Prostatic capsular perforation
▪ Bladder or urethral perforation

28. TURP syndrome
▪ 1–8% of Patients
▪ Excessive absorption of irrigating fluid
▪ Changes in intravascular volume, plasma solute
concentrations, and osmolality, and direct effects of the
irrigation fluid used
▪ Early: restlessness, headache, and tachypnea, or a burning
sensation in the face and hands
▪ Increasing severity: respiratory distress, hypoxia,
pulmonary edema, nausea, vomiting, confusion,
convulsion, and coma

29. A higher rate of absorption
▪ Height of the bag< 60 cm
▪ Low venous pressure
▪ Prolonged surgery, especially>1 h
▪ Large blood loss, implying a large number of open
veins
▪ Capsular perforation, or bladder perforation

30. Volume changes
▪ Rapid absorption→ Hypertension, Reflex
bradycardia
▪ Acute cardiac failure and pulmonary edema
▪ Rapid equilibration of hypotonic fluid with the
extracellular fluid compartment may precipitate
sudden hypotension in a/w hypovolaemia

31. Solute changes
▪ Acute hyponatraemia→initially dilutional, later by
natriuresis
▪ Headache, altered level of consciousness, nausea
and vomiting, seizures, coma, and death
▪ Osmolality if normal→no intervention

32. Glycine and metabolites
▪ Glycine toxicity: nausea, headache, malaise,
weakness, transient blindness
▪ NMDA receptor activity potentiated
→encephalopathy, seizures
▪ Metabolized to ammonia
▪ Cerebral depressant

33. Treatment
▪ Stop surgery, stop fluids
▪ 100% O2
▪ Airway: Intubate if necessary
▪ Circulation: Vassopressors
▪ Seizures: BZDs
▪ Blood sample: Na+, Hb, osmolality
▪ Pulmonary edema: Furosemide 40mg, mannitol 20% 100 ml
▪ Arterial line, CVP line
▪ Na+<120 mmol/L or severe symptoms→3% NaCl

34. Bladder perforation
▪ Extraperitoneal: pain in periumbilical, inguinal or
supra-pubic region
▪ Intraperitoneal: pain in the upper part of the
abdomen or referred pain to shoulder

35. Hypothermia
▪ Heat loss as a result of irrigation and significant
absorption of the fluid
▪ Post-op shivering can lead to dislodgement of clot
leading to excessive bleeding

36. Haemorrhage
▪ 2.4 - 4.6 ml of blood per minute of resection
▪ Excessive bleeding
▪ Large gland
▪ Extensive resection (>40–60 gm of prostate chippings)
▪ Coexisting infection
▪ Prolonged surgery (>1 h)
▪ Presence of a preoperative urinary catheter
▪ Urokinase from prostate→fibrinolysis→bleeding

37. Bacteremia and septicemia
▪ Incidence:6-7%
▪ Release of bacteria through prostatic venous
sinuses
▪ Presence of indwelling urinary catheter

38. Post operative complications
▪ TURP syndrome
▪ Bladder spasm
▪ Ongoing bleeding
▪ Clot retention
▪ Deep venous thrombosis
▪ Myocardial ischaemia
▪ Postoperative cognitive impairment