ADDIS ABABA UNIVERSITY,CHS SCHOOL OF ANESTHESIA
anesthesia for patients with prostectomy
By S/A Zekariyas G/Eysus
Advisor ; Mr. Wosenyelehe Admasu
May,2014
outline
objective
Anatomy and Physiology of prostate
Epidemiology, Pathophysiology, Etiology benign prostate hyperplasia
Symptoms
Diagnosis
Management of BPH
Anesthesia and BPH
Pre anesthetic evaluation and premedication
Intraoperative anesthetic management
Postoperative complications of prostectomy
Summary
Reference
Objective
At the end of this presentation you should be able to;
Give basic understanding about BPH
Describe the medical management of BPH
Explain the perioperative anesthetic management of
BPH
Abel to manage complications associated with BPH
Anatomy and Physiology of prostate
Prostate is exocrine gland which is a part of the male
reproductive system that encloses the male urethra.
Its base is located at the bladder neck and has the
size of 20cc in the normal adult
prostate gland Have three zones found in the.
(a) the peripheral zone, covers 70%
(b) the transitional zone, covers 25%
(c) the central zone
Carcinoma, chronic prostatitis, and post inflammatory
atrophy of the prostate usually occur in the peripheral
zone of the prostate.
verumontanum
Function of prostate is to secrete a fluid that is added
together with the spermatozoa from the seminal vesicles
to constitute majority of semen, by regulation under
testosterone
Blood supply
from the inferior vesical artery which is a branch of the
internal iliac artery.
Near the prostate the inferior vesical artery becomes the
prostatic artery. This then divides into urethral group and
capsular artery
The venous drainage ; via the periprostatic plexus to dorsal
venous complex superiorly and the inferior vesical vein to
hypogastric vein. These the both drain into the internal
iliac vein.
The dorsal venous complex (DVC) is the commonest source
of bleeding during a radical prostatectomy.
Nerve supply
The prostate receives both parasympathetic and
sympathetic innervation, the former from the
hypogastric and pelvic nerves which arise from T11
to L2, and the latter from a peripheral hypogastric
ganglion S2 to S4.
benign prostate hyperplasia
Benign prostatic hyperplasia is a term used to
describe enlargement of the prostate associated with
lower urinary tract symptoms.
Bladder is centrally involved in many of the
symptoms associated with the disease.
bladder
rectum
Pubic bone
urethera Enlarged
prostate
Epidemiology
The prevalence of BPH increases with age. From
about 8 to 90%
symptomatic (clinical) BPH is present in
approximately 26% of men in the fifth decade of life,
33% of men in the sixth decade, 41% of men in the
seventh decade, and 46% of men in the eighth decade
of life and beyond
Pathophysiology
Testosterone is produced by the Leydig cells of the
testes and is converted by 5α-reductase to
dihydrotestosterone (DHT).
Testosterone and DHT promote prostatic epithelial
and stromal cell proliferation, apoptosis inhibition,
and prostatic angiogenesis.
DHT imbalance occurs with advancing age, favoring
prostatic epithelial and stromal cell proliferation.
Risk factor
Demographic factors (i.e. advanced age and black
skin color)
Genetic factors (i.e. twins with an affected sibling,
family history)
Behavioral and comorbid (Obesity)
Dietary factors (High intake of polyunsaturated fats,
beef products and fatty acid–rich diet)
Other factors (hypertension or diabetes)
Symptoms
emptying
A weak or slow urinary stream
A feeling of incomplete bladder
A delay in starting urination
Frequent urination
Urinary urgency
awakening frequently at night to urinate
A urinary stream that starts and stops
The need to strain to urinate
burning or pain during urination(If a urinary tract
infection develops)
sudden and complete inability to urinate at all
American Urologic Association (AUA) BPH
Symptom Score Index Not at all Less than 1 Less than About half More than Almost
time in 5 half the the time half the time always
time
1. Over the past month, how often have you had a sensation of not emptying your bladder
completely after you finished urinating?
0 1 2 3 4 5
2. Over the past month, how often have you had to urinate again less than two hours after you
finished urinating? 0 1 2 3 4 5
3. Over the past month, how often have you stopped and started again several times when you
urinated? 0 1 2 3 4 5
4. Over the past month, how often have you found it difficult to postpone urination?
0 1 2 3 4 5
5. Over the past month, how often have you had a weak urinary stream? 0 1 2 3 4 5
6. Over the past month, how often have you had to push or strain to begin urination?
0 1 2 3 4 5
None 1 Time 2 times 2 times 2 times 2 times
7. Over the past month, how many times did you most typically get up to urinate from the time
you went to bed at night until the time you got up in the morning?
0 1 2 3 4 5
Total Symptom Score
Diagnosis
Digital Rectal Examination (DRE)
Urinalysis
Creatinine measurement
Prostate-Specific Antigen (PSA) Blood Test
Cystoscopy
Urine Flow Study.
Rectal Ultrasound and Prostate Biopsy
Medical treatment
Drugs used in the treatment of BPH relieve LUTS
and prevent complications and, in some cases, are an
alternative to surgical intervention.
Drugs used in the treatment of BPH α-blockers, 5-α-
reductase inhibitors, combination Therapy
Surgical treatment
The following complications of BPH are considered
strong indications for surgery
Refractory urinary retention
Recurrent urinary retention
Recurrent hematuria refractory to medical treatment
with 5alpha reductase inhibitor.
Renal insufficiency
Bladder stones
Anesthesia For BPH
Preoperative evaluation and
premedication
co-existing morbidities. Cardiovascular and
respiratory problems are common
The preoperative assessment includes a history,
physical examination and review of the medical chart.
Cardiovascular system
following questions should be addressed
appropriately in perioperative visit
Does the patient have cardiac disease?
Assessing functional capacity ?
Respiratory System
Underlying pulmonary dysfunction, particularly chronic
obstructive pulmonary disorder, places the patient at
higher risk for surgeries that requires special positions
like lithotomy position
Renal system
mental status
hematologic state
Laboratory investigations
Routine preoperative evaluation includes
electrocardiography, chest X-ray, FBC, hematocrit, and
electrolyte
Premedication
Npo
Aspirin and antiplatelet medication are held for two
weeks before the procedure
H2-antagonist and nonparticulate antacid
Antibiotic
Intraoperative anesthetic management
Transurethral resection of the prostate (TURP)
TURP involves the surgical removal of the prostate’s
inner portion via an endoscopic approach through the
urethra, with no external skin incision.
Irrigation Solutions
During TURP the surgical field is continuously
irrigated with warmed fluid to distend the bladder and
wash away blood and dissected prostatic tissue.
The ideal irrigation fluid properties are:
Transparent (allows visualisation)
Isotonic
Electrically non- conductive (to allow diathery to work)
Non-haemolytic
Not metabolized
Non- toxic
Inexpensive and Sterile But No such irrigation fluid
currently exists.
The anesthetist must know the type of irrigation solution being
used because each solution has different systemic
manifestations when absorbed.
Distilled water causes hemolysis, hemoglobinuria and
dilutional hyponatremia.
Glycine (230 mOsm/L) may cause a post-op visual syndrome
(transient blindness), and metabolism may cause
hyperammonemia and hyperoxaluria.
Sorbitol (165 mOsm/L) is metabolized to fructose and can lead
to hyperglycemia and possibly lactic acidosis.
Mannitol (275 mOsm/L) is an isosmolar solution but can cause
acute intravascular volume expansion and osmotic diuresis.
LR and NS cannot be used in conjunction with electocautery
due to their ionization and ability to conduct electrical currents.
Anesthesia for TURP
Spinal anaesthesia
useful for patients with significant respiratory
disease
good postoperative analgesia and may reduce the
stress response to surgery
easier to detect the early signs of TURP syndrome
Early recognition of capsular tears and bladder
perforation
cont….
A spinal block to T10 is required
The lithotomy position may compensate for sympathetic
block
Treatment of hypotension with vasoconstrictors rather
than rapid fluid administration
General anesthesia
The lithotomy position in combination with a head-
down tilt reduces tidal volume and functional residual
capacity, and increases the likelihood of gastric
regurgitation.
Postoperative analgesia may be provided by a single-
shot caudal epidural injection
Under light planes of general anaesthesia, penile
erection may interfere with surgery. It can usually be
managed by deepening anaesthesia.
Complications of TURP
TURP Syndrome
solution gets absorbed through the large prostatic
venous sinuses
It occurs due to acute changes in:
Intravascular volume
Plasma Na+ concentration
Osmolality
clinical diagnosis based on symptoms and signs
Signs include
Cardiopulmonary (Hypertension, Bradycardia,
Hypotension, Increased CVP, Cardiac dysrhythmias,
Pulmonary edema, Myocardial ischemia, Arterial
hypoxemia and Shock)
Hematologic and Renal(Hyponatremia, Hypo-
osmolality, Metabolic acidosis, Hyperglycemia,
Hemolysis and Acute renal failure)
Central Nervous System(Nausea and Vomiting,
Confusion and Agitation, Seizures, Coma and Blindness)
Factors
Hydrostatic pressure of irrigation
Low peripheral venous pressure (e.g. if patient is
hypovolaemic, or hypotensive)
Duration of surgery
Large blood loss i.e. open prostatic vessels through
which irrigation fluid is absorbed
Capsular or bladder perforation
Management of TURP syndrome
surgery must be abandoned as soon as possible and
i.v fluids stopped
Treatment should involve supporting respiration (if
necessary, with intubation and ventilation) and the
circulation.
Bradycardia and hypotension should be treated with
atropine, adrenergic drugs. I.V.
anticonvulsants (e.g. diazepam or lorazepam)
should be used to control seizures
Diuretic therapy (e.g. i.v furosemide 40 mg) is only
recommended to treat acute pulmonary oedema caused
by the transient hypervolaemia. Furosemide worsens
hyponatraemia, Mannitol (e.g. 100 ml of 20%) causes less
sodium loss
Hypertonic saline (3%) is indicated to correct severe
hyponatraemia, if serum sodium <120 mmol per liter
The rate of correction should be slow. Too rapid a
correction may lead to hypervolaemia and permanente
neurological damage.
Bleeding
It may be difficult to estimate due to dilution with irrigating fluid.
Rough estimates of blood loss include 2-5mL per minute of
resection time, and 20-50mL per gram of prostate resected.
Factors associated with excessive bleeding include
a large gland,
extensive resection (>40–60 g of prostate chippings), coexisting infection,
prolonged surgery (>1 h), and the presence of a preoperative urinary
catheter.
Urokinase released from raw
prostate,POB
Bladder perforation
leads to generalised abdominal pain, which may be
referred from the diaphragm to the chest or shoulder. It
may also be associated with pallor, sweating,
hypotension and nausea and vomiting.
Myocardial ischaemia and hypothermia
Myocardial ischaemia may occur in up to 25% of
patients during TURP; with myocardial infarction
occurring in 1–3%.
Elderly patients are prone to hypothermia,
Open prostectomy
involves the surgical removal of the inner portion of
the prostate via an incision in the lower abdominal
area.
choice for large glands over 80-100ml, large bladder
stones
TURP syndrome is completely avoided. However,
the downsides long hospital stay and more
perioperative bleeding.
Contraindications to open prostatectomy include a
small fibrous gland and previous pelvic surgery that
may obliterate access to the prostate gland.
can be in 3 ways:
1. classical transvesical
2. Millin’s retropubic approaches and
3. Perineal
Suprapubic transvesical prostatectomy
consists of the removal of the hyperplastic prostate through
an extraperitoneal incision of the lower anterior bladder wall.
Retropubic (Millin) prostatectomy
enucleation of the hyperplastic adenoma through a direct
incision of the anterior prostatic capsule
Perineal prostatectomy
With the patient in the lithotomy position, an incision is
made between the rectum and scrotum. The prostate is
approached through the ischio-rectal fossa
Anesthesia for open prostectomy
The type of anesthetic technique and need for
invasive monitoring (arterial and venous centeral
pressure) should be considered if larger blood loss is
expected based on size of the gland, patient
conditions and individual surgeon experience.
The potential of moderate to significant
intraoperative surgical bleeding
Anesthesia for perennial approach can be provided with
either a general or regional (spinal or epidural)
anesthetic technique.
A complication of the perineal approach is lower
extremity nerve injury owning to intraoperative
positioning of extreme lithotomy position.
Epidural anesthesia and analgesia has been favorable on
operative blood loss, Postoperative pain control, and
patient activity level after surgery
epidural anesthesia for RPP have a significant decrease
in operative blood loss compared with general
anesthesia
There is a decreased intraoperative blood loss when a
combined technique of general anesthesia and epidural
anesthesia was compared with a general anesthesia
alone.
Controlled positive pressure ventilation increases
operative blood loss.
We can get improved pain control when epidural
anesthesia is used perioperatively for analgesia.
Vilnius University, Lithuania
Two groups were selected: epidural/general anesthesia group
(study group, 27 patients) received epidural anesthesia in
association with general anesthesia, and general anesthesia group
(control group, 27 patients) received general anesthesia alone
mean blood loss in epidural/general anesthesia group was
(740±210 mL versus 1150±290 mL, with general
blood was transfused in epidural/general anesthesia group: 0.19
blood units transfused versus 0.52 blood units in general
anesthesia group
study proved that induced hypotension with epidural/general
anesthesia reduced intraoperative blood loss and need of blood
transfusions in patient undergoing open prostatectomy.
University of Benin Teaching Hospital
One hundred and twelve patients were recruited in
the study. Their ages ranged between 49–94years
The incidence of intraoperative and recovery room
complications was higher in the spinal group than in
the epidural group, 32 (63%) compared to 19 (37%)
neuraxial block technique for prostatectomy has
gained overwhelming popularity in developing
countries.
Implication of Lithotomy position for
BPH surgery
causes a transient increase in cardiac output and, to a
lesser extent, cerebral venous and intracranial
pressure in otherwise healthy patients.
During spinal anesthesia compensates for venous
blood volume increase due to venous dilation by
increasing venous return.
causes the abdominal viscera to displace the
diaphragm cephalad, reducing lung compliance and
potentially resulting in a decreased tidal volume.
potentially aggravating any previous lower back pain.
Injury to the common peroneal nerve was the most
common lower extremity motor neuropathy,
representing 78% of nerve injuries.
other complication of lithotomy position is lower
extremity compartment syndrome.
Postoperative complications
TURP
discomfort from bladder spasm or from the urinary
catheter
Clot retention may occur after operation
This patient group is at particular risk from deep
venous thrombosis.
Postoperative cognitive impairment
Open prostectomy
Hemorrhage
Infections
Other Complications i.e Rectal injury, suprapubic and
retropubic prostatectomies, urinary fistulas
summary
Benign prostatic hyperplasia is a term used to
describe enlargement of the prostate associated with
lower urinary tract symptoms.
TURP and open prostatectomy are the standard
surgical options
Patients presenting for prostate surgery are often
elderly and may have co-existing morbidities
We can use regional or general anesthesia for TURP
Cont….
Open prostectomy can be classical transvesical ,
Millin’s retropubic or perineal
Their is increased risk of intraoperative bleeding
during open prostectomy
General anesthesia with epidural technique is
superior in preventing intraoperative bleeding
Reference
Kai H. Hammerich, Gustavo E. Ayala, and Thomas M.
Wheeler, Anatomy of the prostate gland, Cambridge
University Press; 2009
American Urological Association (AUA), Algorithm for
the Management of Benign Prostatic Hyperplasia:
Diagnosis and Treatment; May 2010
Aidan M. O'Donnell, Anaesthesia for transurethral
resection of the prostate, Oxford Journals Medicine,
Volume 9, Issue 3 Pp. 92-96; 2014
Miller’s anesthesia, 7th edition
Clinical Anesthesia, 6th Edition; 2009
Hines & Marschall: Stoelting's Anesthesia and Co-
Existing Disease, 5th edition; 2008
Thank you
