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  2. 2. 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)
  3. 3. Four Areas of the Prostate  Transition Zone  Anterior Zone  Peripheral Zone  Central Zone
  4. 4. Sagittal View of the Prostate Plexus of Anterior Middle lobe lobe Posterior lobe Santorini Seminal vesicle Base of prostate Rectum Pubic bone Puboprostatic ligament Apex of prostate Denonvillier's Penis and fascia Urethra Deep transverse perineal muscle
  5. 5. Arterial supply From the anterior division of the internal iliac artery Inferior vesical artery, Middle rectal artery Internal pudendal artery originates (hypogastric) artery. The capsular artery is the second main branch of the prostate. Supply the glandular tissue. Venous drainage Prostatic plexus of veins Valveless communication exists between the prostatic and vertebral plexus through which prostatic carcinoma spread 5
  6. 6. Innervations from pelvic plexuses formed by the parasympathetic, visceral, efferent, and preganglionic fibers that arise from the sacral levels(S2-S4) sympathetic fibers from the thoracolumbar levels (L1- L2). The pudendal nerve is the major nerve supply leading to Somatic innervations of the striated sphincter and the levator ani. The preprostatic sphincter and the vesicle neck or internal sphincter is under alpha-adrenergic control. Lymphatic drainage 6
  7. 7. What is Benign Prostatic Hyperplasia? Peripheral zone Transition zone Urethra
  8. 8. Peripheral zone Transition zone Urethra
  10. 10. what causes BPH? n BPH is part of the natural aging process (increase in androgen receptor) n Dihydrotestosterone (DHT) may play a role n BPH cannot be prevented n BPH can be treated
  11. 11. 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 retention LUTS is not specific to BPH – not everyone with LUTS has BPH and not everyone with BPH has LUTS
  12. 12. common symptoms n decrease in the n Hesitancy urinary stream n Pain or burning n Dribbling or leaking during urination after urination n Feelingthat the n Intermittency bladder never completely empties
  13. 13. what causes these symptoms? n Prostate grows with age n Pressure on the urethra restricts urine flow
  14. 14. 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
  15. 15. 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 life n Renal insufficiency n Frequent urinary tract infections
  16. 16. enlarged prostate treatment options n Medication n Heat therapies n Surgical approaches
  17. 17. medication n First line of defense against bothersome urinary symptoms n Manage the condition - don’t fix it n 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)
  18. 18. possible side effects of medication n  Impotence n  Dizziness n  Headache n  Fatigue n  Loss of sexual drive
  19. 19. heat therapies n Destroy prostate tissue with heat n 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)
  20. 20. possible side effects of heat therapies n Urinary Tract Infection n Impotence n Incontinence
  21. 21. surgical treatment
  22. 22. SURGICAL PROCEDURES  TURP  Transurethral electro-vaporisation  Transurethral incision  Transurethral laser technique(holmium,KTP)  Balloon dilatation  Prostate stents  Prostatectomy:- suprapubic,retropubic,perineal  Laproscopic
  23. 23. PREOPERATIVE MANAGEMENT • Patients for TURP are frequently elderly with coexistent diseases. • cardiac disease 67% • abnormal electrocardiogram (ECG) 77% • chronic obstructive pulmonary disease 29% • diabetes mellitus 8%
  24. 24. 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.
  25. 25. 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
  26. 26. ANESTHETIC TECHNIQUE •Spinal anesthesia is the •Spinal anesthesia dose of technique of choice Bupivacaine 0.75% is 1.6 •sensory supply to the ml bladder is from T10 - T12 •Sensory supply to prostate L1-L2 . •sensory supply to the urethra, prostate and bladder neck is from S2 - S4. •for satisfactory anesthesia, a block to T10 is required.
  27. 27. 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 the obturator reflex. •The reflex blocked by muscle paralysis during general anesthesia or obturator nerve block
  28. 28. ANESTHETIC TECHNIQUE Regional anesthesia is the anesthetic of choice: •monitoring of the patients mentation •vasodilation and peripheral pooling of blood •It reduces blood loss •It provides postoperative analgesia. •reinfarction rate for SA has been reported to be less than 1%, versus 2% to 8% for GA. •Decreased hypercoagulable tendency in the postoperative period •homeostasis of the neuroendocrine system & immune response. •Early recognition of turp syndrome &bladder perforation
  29. 29. 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
  30. 30. MONITERING  Pulse  NIBP  Oximetery  ECG  Blood loss-Hb, Hematocrit  S. Sodium conc.  CVP  Mental status  Temperature
  31. 31. GENERAL ANAESTHESIA  Induction:- Propofol or bariturate,benzodiazepine,opioides  Intubation:-smooth,short duration Measures to attenuate pressor responses. Maintenance:-Oxygen and nitrous oxide,muscle relaxant,volatile or opioid based. Reversal and smooth extubation Fluid:-NS,RL,Colloid and blood according to need.
  32. 32. TURP (transurethral resection of the prostate) n ―Gold Standard‖ of care for BPH n Uses an electrical ―knife‖ to surgically cut and remove excess prostate n tissue Effective in relieving symptoms and
  33. 33. SURGICAL PROCEDURE • Operation is performed through a modified cystoscope • Prostatic tissue is resected using an electrically energized wire loop. • the Prostatic capsule is usually preserved. • Continuous irrigation is necessary to distend the bladder and to wash away blood and dissected prostatic tissue.
  34. 34. IRRIGATION FLUID Ideally the irrigation solution should be: • Isotonic • electrically inert • Nontoxic • Transparent • inexpensive • Nonhemolytic • Nonmetabolized
  35. 35. PROPERTIES OF IRRIGATION SOLUTIONS USED FOR TRANSURETHRAL RESECTION OF THE PROSTATE Solution Osmolality (mOsm/L) Disadvantages Water, 0 Hemolysis, hyponetremia Glycine, 1.5% 220 Transient blindness, hyper ammonemia, hyperoxaluria Sorbitol, 3.5% 165 Hyperglycemia Mannitol, 5% 275 Osmotic diuresis Cytal ( sorbitol 178 Osmotic diuresis 2.7%+ Intravascular volume mannitol0.54%) expansion Glucose, 2.5% 139 Hyperglycemia Urea, 1% 167 Intravascular volume expansion,crystal formation
  36. 36. COMPLICATIONS •TURP can be associated with a number of complications: •TURP Syndrome (2%) •Hemorrhage •Bladder perforation (1%) •Hypothermia •Septicemia (6%) •DIC •The main challenges are blood loss and TURP Syndrome due to excessive absorption of irrigant fluid
  37. 37. 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
  38. 38. TURP SYNDROME: EPIDEMIOLOGY • Irrigant absorption may occur in up to 46% of resections • 5-10% of patients absorbing 1 liter or more • observed in 2-10% of all prostate resections • Of approximately 400,000 TURP procedures each year, 10% to 15% incur TURP syndrome and the mortality is 0.2% to 0.8% • Syndrome may occur as quickly as 15 minutes after resection starts or up to 24 hours postoperatively • A simple canalization or balloon dilation of the urethra or a staged TURP is less likely to provoke TURP syndrome.
  39. 39. TURP SYNDROME: IRRIGATION FLUID • The irrigation solution enters the bloodstream directly through open prostatic venous sinuses. • primarily when prostatic capsule is violated during surgery. • As many as 8L of irrigation solution can be absorbed by the patient during TURP. • The average rate of aborption is 20mL per minute and may reach 200mL per minute • average weight gain by the end of surgery is 2 kg.
  40. 40. TURP SYNDROME: IRRIGATION FLUID •Distilled water is transparent and electrically inert. •Extremely Hypotonic: may cause hemolysis, shock and renal failure. •Several nearly isotonic irrigation solutions that have replaced plain distilled water. •The more commonly used solution today is Glycine. •Cytal is a solution occasionally used. •To maintain their transparency, these solutions are prepared moderately hypotonic.
  41. 41. TURP SYNDROME: IRRIGATION FLUID Glycine has direct toxic effects on the: •Heart: decrease of 17.5 % in cardiac output, arginine reversed myocardial depression •Retina: transient visual disturbance (blindness) •Encephalophathy & seizures: via NMDA potentiation •Magnesium exerts a negative control on the NMDA receptor •hypomagnesemia caused by dilution may increase the susceptibility to seizures.
  42. 42. 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.
  43. 43. TURP SYNDROME: IRRIGATION FLUID •Hyperammonemia manifestations appear within 1 hour after surgery. •Blood ammonia level > 500 mmol/L. •nauseated, vomits, and then becomes comatose. •Ammonia level < 150 mmol/L pt awakens
  44. 44. TURP SYNDROME: IRRIGATION FLUID •Cytal is a mixture of sorbitol and mannitol •Bacterial containmination: This is secondary to the sugars in the cytal solution make it a rich medium for bacteria •Exacerbate hyperglycemia in diabetic patients •pulmonary edema in cardiac patients: mannitol rapidly expands the blood volume
  48. 48. HYPONATREMIA CARDIAC 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
  49. 49. TURP SYNDROME: MANIFESTATION UNDER GENERAL ANESTHESIA • Presenting signs are a rise and then fall in BP, and bradycardia. • The ECG may show nodal rhythm, ST-segment changes U waves, and widening of the QRS complex. • Recovery from general anesthesia is usually delayed.
  51. 51. 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.
  52. 52. 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.
  53. 53. 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.
  55. 55. 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)
  56. 56. 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 complications Paula Bishop "Bipolar transurethral resection of the prostate—a new approach". AORN Journal. . FindArticles.com. 03 Apr. 2008.
  57. 57. 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
  58. 58. TURP SYNDROME: TREATMENT •Ensure oxygenation and circulatory support •Notify surgeon and terminate procedure •Consider invasive monitors if CV instability occurs •Send blood for electrolytes, 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 are particularly ominous signs •GA in the presence of TURP syndrome can lead to severe complications and even death.
  59. 59. TURP SYNDROME: TREATMENT •Treat mild symptoms: Na>120 mEq/L •Fluid restriction and loop diuretic (furosemide 20mg) •Treat severe symptoms: Na< 120 mEq/L •3% NaCl IV at a rate of <100ml/hr •Discontinue 3% NaCl when Na > 120 mEq/L •Rate of Na increase should not exceed 12 mEq/L in 24 hr period
  60. 60. TURP SYNDROME: TREATMENT •Rapid administration of hypertonic saline has been associated with central pontine myelinolysis •To reduce the hazards of saline administration, serum osmolarity should be monitored and corrected aggressively only until symptoms substantially resolve •then hyponatremia should be corrected at a rate no faster than 1.5 mEq/L per hour
  61. 61. TURP SYNDROME: DIFFERENTIAL DIAGNOSIS The differential diagnosis of hypotension followingTURP should always include 1. Hemorrhage 2. TURP syndrome 3. Bladder perforation 4. Myocardial infarction or ischemia 5. Septicemia 6. Disseminated intravascular coagulation (DIC). 7. Anaphylaxis
  62. 62. PERFORATION  EXTRAPERITONEAL  INTRAPERITONEAL  Cause :-1.instrument 2.overdistention of bladder Diagnosed by pain,rigid ,tender,distended abdomen and irregular return of irrigation fluid, reflex limb movement at time of perforation
  63. 63. BLEEDING AND COAGULOPATHY  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
  64. 64. HYPOTHERMIA  Absorption of Irrigation fluid stored at room temperature -shivering.  Altered behaviour of hypothalemic thermoregulatory centres in brain.  Warming of fluid & opioids decreases shivering.
  65. 65. 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.
  66. 66. Postural complications  Compartment syndrome  Nerve damage  Vital capacity and FRC decrease  False impression of CVS status  Deep vein thrombosis
  67. 67. MORTALITY AND MORBIDITY  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
  68. 68. the ―gold standard‖- TURP Benefits Disadvantages n Widely available n Greater risk of side effects and complications n Effective n 1-4 days hospital stay n Long lasting n 1-3 days catheter n 4-6 week recovery
  69. 69. possible side effects of TURP n Impotence n Incontinence n Bleeding n Electrolyte imbalance (TUR Syndrome) n