Benign Prostatic Hyperplasia (BPH) and Transurethral Resection of the Prostate (TURP)

Case Presentation and Diagnosis of BPH

What were the presenting complaints of the 65-year-old patient?

The patient presented with difficulty passing urine for 8 months. He also complained of increased frequency of urination, nocturia (waking at night to urinate), a feeling of incomplete bladder emptying, and dribbling of urine.

What are the positive clinical points that suggest a diagnosis of BPH?

The patient's age (65 years old male) is a key factor. His symptoms, including difficulty passing urine, increased frequency, nocturia, and feeling of incomplete voiding, are all classic features of bladder outlet obstruction caused by an enlarged prostate gland.

Describe the anatomy of the prostate gland.

The prostate is an accessory gland of the male reproductive system, and its secretions form the bulk of the seminal fluid. It lies in the apex of the bladder, surrounding the prostatic urethra. It is pyramidal in shape, weighs around 20 grams, and has four zones: peripheral, central, transitional, and anterior fibromuscular. It can also be described as having five lobes: anterior, posterior, median, and two lateral lobes.

Which zone of the prostate is most commonly involved in BPH?

BPH most commonly arises from the transitional zone of the prostate.

What is the blood and nerve supply of the prostate?

The blood supply arises from the anterior division of the internal iliac artery via the middle rectal, inferior pudendal, and inferior vesical arteries.

Venous drainage is to the internal iliac vein.

The nerve supply consists of sympathetic fibers from T12 to L2 and parasympathetic fibers from S2, S3, and S4.

What are the common co-morbidities associated with elderly patients with BPH?

Common co-morbidities in elderly patients include type 2 diabetes mellitus, hypertension, coronary artery disease, and a history of cerebrovascular accidents (CVA).

What is the first-line medical management for BPH?

The first-line medical therapy for BPH is alpha-blockers. They work by relaxing the smooth muscles in the prostate and bladder neck, which are rich in alpha receptors, thereby relieving obstructive symptoms.

Another modality is 5-alpha reductase inhibitors (like finasteride and dutasteride), which prevent the conversion of testosterone to dihydrotestosterone (DHT), the key mediator of prostate growth.

What are the newer, alternative modalities for treating BPH?

Newer modalities for treating BPH include various laser techniques such as laser resection and holmium laser enucleation. Other options include plasma microwave ablation and aqua ablation.

These techniques are associated with decreased bleeding and a lower chance of TURP syndrome but can be more costly.

Preoperative Assessment and Preparation for TURP

What preoperative investigations are planned for this patient and why?

Complete Blood Count (CBC): To check baseline hemoglobin (elderly are prone to anemia) and to assess for infection via the total count. Platelets and BT/CT are done to evaluate the coagulation profile.
Serum Electrolytes: Baseline sodium levels are crucial because a major complication of TURP is TURP syndrome, which causes hyponatremia.
Renal Function Tests (RFT): To check for obstructive uropathy and get a baseline creatinine value due to chronic obstruction from the enlarged prostate.
Urine Analysis: Because these patients are more prone to urinary tract infections (UTIs).
ECG and Chest X-ray: As the patient is 65 years old, a baseline ECG is needed to check for underlying cardiovascular disease, and a chest X-ray to look for changes like COPD.
Random Blood Sugar (RBS): To get baseline sugar values.
Imaging: Transabdominal or transrectal USG to assess the size of the gland and validate the resected volume.
PSA Test: To screen for prostate cancer.
Uroflowmetry and Post-Void Residual Volume: To assess the severity of obstruction.

How does an enlarged prostate lead to changes in renal function?

An enlarged prostate can cause chronic obstruction to urinary flow. This can lead to urinary retention, hydronephrosis (swelling of a kidney due to a build-up of urine), and finally, obstructive uropathy, which impairs kidney function.

What is the role of sodium in the body and what are its normal levels?

Sodium is the major cation in the extracellular fluid. Its normal level is 135 to 145 milliequivalents per liter. It is a major ion for the excitation of brain and heart cells and plays a key role in acid-base balance, electrolyte balance, and the functioning of the sodium-potassium pump.

How would you prepare the patient preoperatively for a TURP?

Preoperative preparation includes:

Optimizing the patient's medical condition.
Building rapport with the patient and explaining the procedure and its risks.
Explaining NPO guidelines (2 hours for clear fluids, 6-8 hours for solids).
Obtaining a detailed, written informed consent after explaining all potential complications.

What specific risks and complications must be explained to the patient when obtaining informed consent for TURP?

The consent process must cover complications such as TURP syndrome, bladder perforation, significant bleeding risk, and, due to the patient's age, the potential for intraoperative adverse cardiac events and pulmonary edema.

What are the overnight and morning-of-surgery orders for a patient scheduled for TURP?

Overnight orders:

Anxiolytics like alprazolam (0.25 or 0.5 mg).
Aspiration prophylaxis with pantoprazole (40 mg).
Metoclopramide (10 mg) to promote gastric emptying.

Morning-of-surgery orders:

Recheck investigations like serum electrolytes.
Verify the patient's NPO status and the signed informed consent.
Advise antibiotic prophylaxis.
Note that morning sedatives are generally avoided to maintain the patient's mentation, which is crucial for monitoring for TURP syndrome.

Intraoperative Management and Anesthesia for TURP

What is the planned anesthesia for this TURP procedure and why?

The plan is a subarachnoid block (spinal anesthesia) using 1.8-2 ml of 0.5% heavy bupivacaine with 60 mcg of buprenorphine to achieve a sensory level of T10.

A T10 level is targeted to eliminate discomfort from bladder distension while preserving the patient's ability to report capsular pain (shoulder or abdominal pain), which can be an early sign of bladder perforation or over-distension.

What precautions should be taken during patient positioning for spinal anesthesia and lithotomy?

After giving spinal anesthesia, it is crucial to wait for 5 to 10 minutes to allow the drug to "fix" and prevent it from ascending to a higher level, which could cause a high spinal block.

What are the potential problems associated with the lithotomy position?

Venous stasis: Due to acute flexion of the thighs, causing obstruction of veins.
Nerve injury: From direct compression or compression of blood vessels supplying nerves.
Cardiorespiratory changes: Reduction in vital capacity (by about 18%), functional residual capacity (FRC), and total lung capacity, which can compromise the respiratory system.

Can you briefly summarize the TURP procedure?

TURP is the transurethral resection of the prostate. A resectoscope with a movable electrocautery wire loop is used to visualize and carve away prostatic tissue.

An irrigating fluid is instilled to distend the bladder and wash away debris and blood. Postoperatively, a three-way catheter is placed, and normal saline irrigation is continued for about 24 hours.

What are the main anesthetic concerns during a TURP procedure?

Anesthetic concerns include intraoperative bleeding, hypotension, hypothermia, problems related to patient positioning, and the unique challenges of managing a geriatric patient with potential co-morbidities. The primary concern, however, is the development of TURP syndrome.

What are the key intraoperative monitoring points for a patient undergoing TURP?

Close monitoring of vital signs (heart rate, blood pressure, SpO2) is essential. The patient's mentation and level of consciousness must be continuously assessed as a key indicator for TURP syndrome. It is also important to note the surgical start time and remind the surgeon to finish the procedure within an hour.

What are the different types of irrigating fluids used in TURP and their implications?

Common irrigating fluids include:

Glycine (1.2% or 1.5%): Preferred as it's non-conductive, non-hemolytic, and transparent. Disadvantages include glycine toxicity, transient visual loss, and byproducts (oxalate, ammonia) that can cause hyperoxaluria and hyperammonemia.
Distilled water: Inexpensive, transparent, and non-conducting but highly hypotonic, which can cause hemolysis, hemoglobinuria, renal toxicity, water intoxication, and cerebral edema.
Others: Mannitol, sorbitol, glucose, and urea solutions.

How can the development of TURP syndrome be prevented?

Preventive factors include:

Keeping the height of the irrigating fluid less than 60 cm above the bladder to minimize hydrostatic pressure.
Limiting the procedure duration to less than 60 minutes.
Resecting glands smaller than 45 grams.
Avoiding over-distension of the bladder.
Preoperatively optimizing the patient's sodium levels.

TURP Syndrome: Diagnosis and Management

What is TURP syndrome and how does it present intraoperatively?

TURP syndrome is a complication caused by the excessive absorption of hypotonic irrigating fluid through prostatic venous sinuses.

It can present with sudden hypertension, bradycardia, confusion, agitation, and a decreasing level of consciousness.

How would you manage a patient who develops TURP syndrome?

Management is immediate and multi-faceted:

Alert the surgeon to complete the procedure as soon as possible.
Change the irrigating fluid to warm normal saline.
Ensure adequate oxygenation and ventilation.
Manage hemodynamics: Use pressors for hypotension and atropine for bradycardia.
Manage seizures with midazolam, lorazepam, or sodium thiopental if intractable.
Correct hyponatremia with 3% hypertonic saline if symptomatic and severe.

How do you calculate and correct the sodium deficit in TURP syndrome?

Calculate Sodium Deficit: Sodium deficit = Total Body Water (TBW) x (Desired Sodium - Observed Sodium). TBW is approximately 60% of body weight (0.6 x weight in kg).
Example for a 60 kg patient with serum sodium of 110 mEq/L, desiring 120 mEq/L: Deficit = (0.6 x 60) x (120 - 110) = 36 x 10 = 360 mEq.
3% Hypertonic saline contains approximately 513 mEq of sodium per liter. Therefore, 1 ml contains ~0.513 mEq. To correct 1 mEq of sodium, roughly 2 ml of 3% saline is required.

What is the postoperative management plan for a patient after TURP?

Postoperatively, the patient should be closely monitored, including NIBP, pulse rate, oxygen saturation, and mentation. Post-operative investigations should include a complete blood count, serum electrolytes, and renal function tests.