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
