BENIGN PROSTATIC HYPERPLASIA

BENIGN PROSTATIC HYPERPLASIA

—  Name : XYZ

—  Age/sex : 70years / male

—  Ward : urology/07

—  DOA : 15/2/2012

—  Weight : 58 kgs.

—  CHIEF COMPLAINTS :

• Difficulty in initiating micturation,
• Progressive increase in frequency in micturation,
• Progressive difficulty in micturation for 6 months.

—  Presenting illness: pt was alright 6 months back. then he developed progressively  urinary symptoms- increased frequency  of urine & nocturnal awakening, sense of incomplete evacuation, difficulty in initiation & dribbling.

—  Pt has no h/o burning micturation, haematuria pyuria,pelvic trauma, wt loss.

—  Pt has no past h/o of DM,TB,COPD,CAD.

—  During queries in personal history gives h/o occasional sutta &khaini for 10-15 yrs ,but non alcoholic.

—  No history of long term drug intake or previous operation.

—  General physical examination:-

—  Concious,alert, cooperative.

—  Average built.

—  No pallor, icterus, clubbing, oedema, lymphadenopathy,neck vein engorgement.

—  Vitals:Pulse:64/min,BP:148/86mm.Hg(supine),  RR:17/min. afebrile.

—  Systemic examination:-

—  Resp: bi-lateral air entry equal, no added sound.

—  CVS:S1,S2  normal, no murmur.

—  CNS: within normal limit.

—  Per abdomen: soft, bowel sound +ve.

—  Per rectal exam: unifomly firm, median sulcus and upper border palpable, no discrete nodule,rectal mucosa not fixed.

—  Investigations:-

—  Hb% - 11.0 g%,

—  TLC- 4200, DLC- P62,L23,E04,M01.

—  Blood sugar – 84 mg/dl.

—  S. urea- 40 mg/dl, S.creatinine-0.8mg/dl.

—  S.Na⁺-142, S.K⁺-4.8, S.Ca⁺⁺-3.14

—  Chest x ray-WNL

—  ECG-WNL.

—  PSA & alkaline phosphatase.(rule out ca prostate)

—  Differential diagnosis:-

—  BPH.

—  CA Prostate.

—  Urethral stricture.

—  Bladder neck hypertrophy.

—  Neurogenic bladder.

—  Positive finding

—  Progressive increase in frequency.

—  Frequent nocturnal awakening.

—  Progressive increase in difficulty in initiation & micturation.

—  Sense of incomplete evacuation.

—  Median sulcus palpable in PR exam.

—  Negative finding:-

•       No weight loss, anorexia.

•       No h/o trauma.

•       No haematuria/pyuria.

•       No palpable nodules.

—  Understanding the prostate

q  Walnut-shaped gland, composed of  glandular tissue in fibromuscular stroma that forms part of the male reproductive system.

Size:4cmx3cmx2 cm.

Wt: 8 gm.

q  Lobes:-anterior,median(imp for BPH),posterior(imp for CA),2 lateral lobes.

q  2 capsule is present(a)anatomical capsule formed by visceral layer of peritoneum.(b)surgical-condensation of prostatic tissue.

—  understanding the prostate

—  Nerve supply:-

q  Sympathetic supply from T11-L2 sympathetic chain.

q  Parasympathetic supply from S 2,3,4 through pelvic splanchnic nerve.

—  Blood supply:-

q  Arterial supply: inferior vesical artery,internal pudendal artery, middle rectal artery

q  Venous supply:vesicle plexus,internal pudendal veins,vertebral venous plexus.

—  What causes BPH?

q  BPH is part of the natural aging process, like getting gray hair. Half of all men over the age of 60 will develop an enlarged prostate.

q  BPH cannot be prevented.

q  BPH can be treated.

—  Common symptoms

Obstructive symtoms:-

q  Hesitancy.

q  Poor flow.

q  Dribbling or leaking after urination

q  Feeling that the bladder never completely empties

Irritative symtoms:-

q  Frequency

q  Nocturia

q  Urgency

q  Nocturnal incontinence

UTI:- burning sensation during urination

—  what causes these symptoms?

—  how is BPH diagnosed?

Medical history

Physical examination

Prostate exam

Urinalysis

PSA blood test

Transrectal ultrasound of

 prostate

—  When should BPH be treated?

BPH needs to be treated ONLY IF:

Symptoms are severe enough to affect the patient’s quality of life.

Patient has h/o frequent urinary tract infections.

—  Treatment options

“Watchful waiting”-decrease fluid intake

Medication

(1)alpha adrenergic antagonist

(2)5@ reductase inhibitors

Heat therapies

Surgical approaches

—  choosing the right treatment

Consider risks, benefits and effectiveness of each treatment

Consider your outcome and lifestyle needs

—  surgical treatment

—  The “gold standard”- TURP

Benefits

Widely available

Effective

Long lasting

Disadvantages

Greater risk of side effects and complications

1-4 days hospital stay

1-3 days catheter

4-6 week recovery

—  ANESTHETIC CONSIDERATION:-

—  Patient related problems:-

• Geriatric age group.
• Associated co-morbid condition.

—  Problems due to disease:-

• Back pressure changes to kidney.
• UTI.

—  Problems due to surgical procedure:-

—  Pre operative preparation:-

—  Optimizing the pre existing co- morbid condition.

—  Consideration of ongoing drug therapy.

—  Advise regarding fasting status.

—  Arrange blood.

—  Preoperative  sedation :-alprazolam.

—  Pre operative antibiotics if-

1. Preexisting urine retention.
2. Pts with prosthetic material in situ.

—  Choice of anesthesia :-

—  Regional anesthesia is preferred.

—  GA when RA is contraindicated.

—  Advantages of regional anesthesia?

ü  Allows monitoring of mentation, early signs of TURP syndrome, bladder perforation.

ü  Promotes vasodilatation & reduce circulatory overload.

ü  Reduce bleeding by reducing B.P.

ü  Low incidence of intra op MI & post operative DVT.

ü  Adequate post op analgesia.

—  Anesthesia for TURP:-

—  Level of anesthesia:-

• T 10 dermatome is blocked to reduce discomfort during bladder distension.
• T9 dermatome is required to eliminate pain on rupture of prostatic capsule.(capsular sign)

Ø  Disadvantage of regional block?

ü  It does not abolish obturator reflex=external rotation & adduction of thigh 2ndary to stimulation of obturator nerve by electrocautery through lateral pelvic wall. Blocked during GA.

—  Advantages of subarachnoid block?

—  Easy to perform.(single shot)

—  Better relaxation of pelvic floor muscle due to dense motor blockade.

—  Sacral sparing in epidural anesthesia is avoided.

—  Continuous epidural anesthesia is not needed  as duration of surgery is short.

—  Monitoring?

—  Orientation.

—  ECG.

—  Blood pressure.

—  Pulse oximetry.

—  Temperature.

—  Serum electrolyte.

—  Blood loss.

—  ETCO2 if GA is used.

— 
Problem due to surgical procedure:-

—  Lithotomy position.

—  TUR syndrome.

—  Bladder perforation (1%)

—  Bleeding and coagulation abnormality.

—  Hypothermia.(1*C/hr)

—  Transient bacterial septicemia.

—  Problems due to Lithotomy position

—  Injury to brachial plexus, saphenous ,common peroneal,siatic, femoral & obturator nerves.

—  Injury to major vessels near the joint.

—  Compartment syndrome.

—  Precipitation of CHF.

—  Breathing difficulty in patients with already diseased lung.

—  Hypotension if legs are rapidly lowered.

—  Physiological alterations in Lithotomy :-

—  Decrease FRC leads to more atelectasis & hypoxia which is further accentuated during trendelenberg & old age.

—  Elevation of legs –increase circulatory overload-rise in mean BP.

—  Decrease venous return due to lowering of legs-hypotension.

—  Irrigating fluids:-

—  Purpose of irrigation:-

ü  Distends bladder and prosthetic urethra.

ü  Improving visibility.

ü  Washout tissue debris and blood.

ü  decrease bleeding.

—  Characteristics of ideal irrigating fluid:-

1. Clear.                        5.Isotonic.
2. Cheap.                      6.Nonhemolytic.
3. Electrically inert.        7.Nontoxic.
4. No metabolism.         8.Rapidly excreted 

—  Factors affecting amount & rate of absorbtion:-

—  Size of gland.

—  Hydrostatic pressure of irrigating.(max height 60cm)

—  Duration of procedure.(max150 mins){20-120 ml/min}

—  Intigrity of capsule.

—  No of open sinuses.

—  Skill of operating sergeon.

—  Intravesical pressure (max 15 cm water)

—  Congestion of gland.

—  TURP SYNDROME:-

—  Incidence 1-8%.

—  Can occur 15 mins after starting to 24 hrs after end of surgery.

—  Rapid absorption of fluid leads to:-

Ø  Acute hypoosmolality.

Ø  Pulmonary oedema.

Ø  Hyponatremia.

Ø  Hyperglycinemia.

Ø  Hyperamonemia.

Ø  Visual disturbances.

Ø  Hemolysis.

—  Signs/symptoms of TURP syndrome

—  During R. Aneasthesia:-

• Restlessness,dizziness, tightness in chest, nausea,confusion.
• Hypertension, bradycardia, cyanosis, slugish reaction with dialated pupil.
• Tonic clonic convulsions, coma, cardiac arrest.

—  During G. Anesthesia:-

• Rise followed by fall in B.P.
• ST changes, nodal rhythm, widening of QRS complex in ECG
• Delayed recovery.
• Cardiac & respiratory arrest.

—  Prevention of TURP syndrome

—  Correct fluid & electrolyte imbalance.

—  Cautious administration of fluids.

—  Reduce surgical time<90 mins.

—  Max height of fluid bag 60 cms.

—  Max intra vesical pressure-15 cm water.

—  Use of vasoconstrictor at operative site.

q  Estimation of absorbed fluid?

Pre-op Na conc./post-op Na conc.    ECF-ECF.

—  Treatment of TURP syndrome

ü  Terminate surgery as soon as possible.

ü  Supplement oxygen.

ü  Pulmonary oedema?

     --ventilate the patient.

ü  Consider frusemide if-

    --pulmonary oedema develops.

    --to induce diuresis.

ü  Send sample for ABG,Na,osmolality.

—  Treatment of TURP syndrome

ü  Seizures:-BZD, thiopentone, phenytoin, muscle relaxants.

ü  Bradycardia &cardiac arrest:-atropine, adrenergic agonists, iv calcium.

ü  Invasive monitoring in pulmonary oedema& hypotension.

ü  If significant blood loss, transfuse packed RBCs

ü  Visual disturbances resolve spontaneously within 24 hrs.

—  Hypertonic saline:-

—  Overt signs of Hyponatremia. Na<120mg/dl.

—  Safe rate of administration?<10mmol/lit/24hr. Not more than 100ml/hr. Rapid administration causes central pontine myelinolysis. (quadriplegia & pseudobulbar palsy occurs without inflammation)

q  Mechanism of action:-

—  Corrects Hyponatremia.

—  Combats cerebral oedema.

—  Expands plasma volume.

—  Reduce cellular oedema.

—  Blood loss

—  Depends upon:-

1. Wt of resected tissue.
2. Surgical time:2-5 ml/min of resection time.
3. No of open prostatic sinuses.
4. Blood pressure.

—  Classical signs of hypotension &blood pressure are not seen immediately as there is increase in blood volume.

—  Postoperative care:-

—  Advisable to monitor in PACU.

—  Monitor vitals in particular CNS.

—  Continue irrigation.

—  As the pain after TURP is not severe routine  analgesia is usually sufficient.

ü  NSAIDS

ü  Opioids like tramadol, fentanyl may suffice.