An 80-year-old male patient with prostatic carcinoma presented with symptoms including increased frequency of urination, dribbling, and a sense of incomplete bladder emptying. He is a known hypertensive and scheduled for a transurethral resection of the prostate (TURP) surgery. The document outlines the patient's medical history, physical examination findings, surgical preparation, anesthesia options, potential complications of TURP, and post-operative management considerations.

1. Case
A 80 years old man with
prostatic carcinoma scheduled
for transurethral resection of
prostate Presenter : Dr. Vivek Sharma
Modertor: Dr. Shelly Rana

2. HISTORY
Nanak chand 80 year old male patient, resident of shahpur , farmer by
occupation,belongs to lower middle class.
presented with chief complaints of
Increased frequency of micturition x 2 years
Dribbling of urine during micturition x 2 years
And feeling of sensation of incomplete bladder emptying and weak urine stream x
6 months

3. HOPI
Patient was apparently alright two years back when he noticed increased
frequency of micturition. The incremental was insidious in onset, and gradrually
progressive with history of waking up at night leading to disturbed sleep. He also
gave history of dribbling of urine during micturation since last two years with
difficulty in initiating micturition which was gradually progressive.He had sense of
incomplete bladder emptying post micturition.
There was also history of inability to hold urine once the urge initiates.

4. h/o significant weight loss or loss of appetite.
No h/o pain during micturition.
No h/o fever, abdominal pain, vomiting.
No h/o previous catheterization and trauma of urinary tract.
No h/o instrumentation or surgery of urinary tract.

5. Past History
Patient is a known case of hypertension since 6 years on regular medications.
T. Amlodipine + Telmisartan (5+40) OD
No h/o of angina, syncopal attacks, peripheral arterial disease
No h/o of DM, Br. Asthma, stroke, seizure disoreder, IHD
No H/o previous hospitalization or surgical exposure
No H/o snoring, breathlessness, swelling of foot
PERSONAL HISTORY He consumes mixed diet. He has disturbed sleep due to awakening to
pass urine. His bowel habits are normal.
Non smoker and non alcoholic.
FAMILY HISTORY Not significant

6. Drug History
The patient is taking:
Tab. Amlodipine 5mg OD since 5 years
Tab. Telmisartan 40mg OD since 5 years
Tab. Tamsulosin 0.4mg OD since 5 month

7. GENERAL PHYSICAL EXAMINATION
Patient is comfortable in sitting as well as supine position . Conscious, well oriented in time,
place and person
• Thin built, well nourished
• No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema,JVP not raised
• Patient is afebrile
• PR- 76bpm, regular in rate, rhythm, normal in volume and character No radio-radial or radio-
femoral delay All peripheral pulses well felt
• BP- 150/80 mmHg in right brachial artery in sitting position
SpO2 – 99% on room air
RR – 14 /min

8. EXAMINATION OF ABDOMEN
INSPECTION
• Abdomen is not distended. Umbilicus central in position
• No sinuses/scars.
• All quadrants are equally moving with respiration
PALPATION
• No organomegaly, no mass per abdomen
PERCUSSION
• Tympanic note all over the abdomen
AUSCULTATION
• Bowel sounds heard

9. Respiratory Examination
Inspection: Chest B/l symmetrical
Accessory muscles not used
Palpation: No swelling / tenderness
Equal expansion of chest
trachea central in position
Percussion: Normal
Auscultation: B/l Normal air entry with no added sound

10. Cardiovascular Examination
Inspection: No engorgement of neck veins, no visible pulsations
Palpation: Non tender, no thrill. Cardiac impulse in 5th
ICS, medial to
midclavicular line
Auscultation: S1S2 Normal. No added sounds

11. Central nervous system
Cranial nerves are all normally functioning
Muscle Built, tone, power, co-ordination = WNL in all 4 limbs
All sensory functions and reflexes are intact
Cerebellar functions = WNL
Gait is normal
Vertebral column- No deformity, no sacral oedema & non tender

12. Airway Examination
Mouth Opening: > 5cm
MPS – Grade II
Neck Movement – adequate
Thyromental Distance - > 6.5 cm
Absent buccal check fat
Edentulous

13. Investigations
● Haemoglobin: 10.5 gm %
● TLC: 9400/cu.mm (N64 L30 M3 E3)
● Platelets: 1.80 lacs/cu.mm
● Urea: 28; Creatinine: 0.8
● Na+: 140; K+: 4.3
● Blood sugar- 106 mg/dl
● Total bilirubin: 0.7 mg/dl
● PT – 16; INR- 0.8
● SGOT/SGPT: 44/50 IU/L, ALP: 83 IU/L
● Urine (routine & microscopy) - WNL
● ECG- WNL
● CXR – WNL

14. PSA- 12.5
USG – Prostate 55 cc with posterior lobe enlargment

15. DIAGNOSIS
80 year old male patient, known hypertensive on regular medications with
complaints of increased frequency, dribbling of urine, sense of incomplete bladder
emptying with hematuria probably involing urinary bladder or prostrate gland which
is not relieved on medical management and with normal systemic examination.

16. Pre-op Advice
NPO after midnight
Tab Ranitidine 150 mg – HS, 6 AM
Arrange blood
Fresh written informed consent

17. OT preparation
• Forced air warmers
• Fluid warmer
• Ambient OT temperature
• Emergency drugs
• Airway equipments
• Suction
• 02 delivery devices

18. Monitoring
• 5 lead ECG
• Pulse-oximeter
• NIBP
• Temperature probe

19. Anaesthesia
Patient taken on OT table
Standard monitoring attached:
SpO2 – 99%, NIBP – 136/84 mm Hg, HR – 86 / min, ECG - WNL
IV line secured with IV cannula 18 G on dorsum of left hand, IVF
started
SAB given with 3.0 cc of 0.5% hyperbaric bupivacaine
Level of SAB maintained at T10

20. Post op Parameters
CNS – Pt conscious, alert, oriented, obeying commands
PR – 96/ min
BP – 142 / 92 mm Hg
SpO2 – 99%
Chest – B/l Normal VBS
CVS – S1S2 N, No added sounds
Respiration - regular
No Post op Pain
No PONV

21. Post Op Order
● NPO for 6 hours
● IVF @ 100 ml / hr till NPO
● Supine position
● Inj. PCM 1000 mg iv TDS
● Inj. Diclofenac 75 mg iv sos
● HR, BP, SpO2, RR, Urine output charting
● Watch for confusion, headache, visual disturbances
● Inform DOD sos

22. Characteristics of ideal irrigation fluid
1.Transparent
2. Isotonic
3. Electrically inert
4. Non haemolytic
5. Inexpensive
6. Not metabolizable
7. Rapidly excreatable
8. Non toxic

24. Factors affecting rate of absorption of fluid
RULE OF 60
• Duration of surgery- 60 minutes
• Age of patient- more than 60 years
• Size of prostate gland - more than 60 grams
• Height of irrigation fluid- 60cm above pubic symphysis
• Hydrostatic pressure- 60 cm of H20
• Integrity of prostatic capsule

25. Choice of anesthesia
CENTRAL NEURAXIAL BLOCKADE
ADVANTAGES
• Allows monitoring of mentation and early signs of TURP Syndrome.
• Detection of bladder perforation.
• Promotes peripheral vasodilatation and reduces circulatory overload.
• Reduces blood loss, requiring fewer blood transfusions.
• Good postoperative analgesia.
• Neuroendocrine and immune responses are better preserved.
• Lower cost

26. DISADVANTAGES
• Hypotension.
• Obturator reflux cannot be obtunded.

27. GENERAL ANAESTHESIA
ADVANTAGES
• Useful for patients who are unable to lie supine.
• Useful for patients with neuromuscular diseases and pulmonary compromise.
DISADVANTAGES
• Unable to monitor mental status.
• Possibility of difficult airway and risk of aspiration.
• Reduced FRC due to lithotomy position.
• Postoperative nausea and vomiting.
• Postoperative analgesia needed.

28. EPIDURAL ANAESTHESIA
BENEFITS OF EPIDURAL ANESTHESIA
• Ability to titrate the drug to the effective level of sensory block.
• Help reduce chronic pain levels.
• Intra-operative anaesthesia and postoperative analgesia.
• Less respiratory depression.
• Less hemodynamic instability.
• Less incidence of higher block.

29. CONCERNS OF LITHOTOMY POSITION
Physiological changes:
• Decreased FRC
• Increased venous return after elevation of legs
• Decreased venous return following lowering of legs
• Exaggeration of hypotension with SAB

30. Problems with lithotomy position:
• Injury to nerves: Common peroneal, posterior tibial, lateral femoral cutaneous
nerve, saphenous nerve, obturator nerve, sciatic nerve
• Venous stasis- Lower extremity compartment syndrome
• Injury to hand and fingers when caudal portion of table is lowered
• Stress on lumbar spine- lower back pain

31. COMPLICATIONS OF TURP
INTRAOPERATIVE COMPLICATIONS
• TURP Syndrome
• Hypothermia
• Myocardial Infarction
• Bleeding and bladder perforation

32. POSTOPERATIVE COMPLICATIONS
• TURP Syndrome
• Clot retention
• DIC, Bleeding
• Postoperative Cognitive Dysfunction

33. TURP SYNDROME
Pathological Triad
- Hypervolemia, Hypoosmolality, Hyponatremia
Symptoms
• Clinical Triad- Hypertension, Bradycardia, Mental Changes • CNS
manifestations- Disorientation, restlessness, confusion, agitation,
drowsiness,convulsions and coma.

34. CVS manifestations- Dyspnoea, pulmonary congestion, pulmonary oedema, and
cardiac overload. Due to fluid overload and the negative ionotropic effect of
hyponatremia.
• Haemolysis
• Hypothermia

35. Presentation of hyponatremia

36. MANAGEMENT
1. Administer 100% oxygen.
2. Ask surgeon to stop the surgery, after achieving hemostasis.
3. Airway, breathing, circulation.
4. Management of hyponatremia
Treat mild symptoms (with serum Na+ concentration >120 mEq/L) with fluid restriction and loop
diuretic (furosemide)
Treat severe symptoms (if serum Na+ <120 mEq/L) with 3% sodium chloride IV at a rate <100
mL/hr
Discontinue 3% sodium chloride when serum Na+ >120 mEq/L

37. Perioperative hemorrhage
CAUSES:
DIC
Dilutional coagulopathy
Hypovolemic shock

38. MANAGEMENT
• Surgical haemostasis
• If blood loss is more than estimated:
Blood and blood product administration
- Activation of massive blood transfusion protocol
1:1:1 ratio ( Blood: FFP: Platelet)

39. Bladder Perforation
Intraperitoneal or Extraperitoneal
• Signs & symptoms:
- Abdominal distension
- Suprapubic pain radiating to shoulder
- Rigidity
- Autonomic signs like pallor, nausea, vomiting, diaphoresis
- Bradycardia, Hypertension
- Non return of irrigating fluid

40. Treatment:
1. Localized, extra peritoneal- Catheterization and antibiotics
2. Intraperitoneal- Surgical exploration, drainage and repair

41. POST OP CONSIDERATIONS
Monitoring for TURP syndrome - Can develop upto 24 hours.
• Serial monitoring of Na+, K+, Ca2+, ABG, Coagulation profile, osmolarity.
• Postoperative Cognitive dysfunction
• Postoperative analgesia