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{{Infobox surgical case reference
{{Infobox surgical case reference
| anesthesia_type =  
| anesthesia_type = Regional or GA
| airway =  
| airway = ETT
| lines_access =  
| lines_access = 1-2PIV
| monitors =  
| monitors = Standard, 5-lead EKG
| considerations_preoperative =  
| considerations_preoperative = Pts are usually elderly, may have renal impairment from chronic retention
| considerations_intraoperative =  
| considerations_intraoperative = Risk for TURP syndrome, bladder perf
| considerations_postoperative =  
| considerations_postoperative = Pain varies based on type of procedure, TURP is relatively mild pain, open procedures are associated with more significant pain
}}
}}


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=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
Patients are usually elderly, and are more likely to have pre-existing medical conditions
{| class="wikitable"
{| class="wikitable"
|+
|+
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|-
|-
|Neurologic
|Neurologic
|
|Cerebrovascular disease and Alzheimer's common in this age group. Assess AMS preop to guide evaluation of postop changes.
|-
|-
|Cardiovascular
|Cardiovascular
|
|HTN, CAD common in this age group. Assess exercise tolerance.
|-
|-
|Respiratory
|Respiratory
|
|COPD is more common in this age group, consider preop testing as guided by H&P including smoking history and symptoms.
|-
|Gastrointestinal
|
|-
|-
|Hematologic
|Hematologic
|
|Moderate blood loss expected with large glands, if <80g, no T&C necessary. Preop Hb.
|-
|-
|Renal
|Renal
|
|Anticipate renal impairment due to chronic obstruction, consider BUN, Cr, electrolytes. If elevated BUN or Cr, check CrCl
|-
|-
|Endocrine
|Endocrine
|
|Increased incidence of DM
|-
|-
|Other
|Other
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=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===


=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
* As guided by H&P
* Preop Hb
* T&C for glands >80g


=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===


=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
* Regional may be used, and may hold some advantage due to earlier detection of TURP syndrome with mental status changes.
** other advantages include lower intraop blood loss, possible lower incidence of postop DVT, faster return of bowel function
* Postdural puncture headache is very low in this age group.
* T9 level is optimal (T8-10 depending on incision site)
* Spinal anesthetic is usually favored over continuous lumbar epidural for TURP as the procedure is relatively short
** Spinal with 0.75% bupi, 12mg in 7.5% dextrose (1.6mL)
* For open or laparoscopic procedures, continuous epidural may also be used


== Intraoperative management ==
== Intraoperative management ==


=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
* Standard ASA monitors


=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
* Standard induction for GA cases
* Regional may also be used


=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
* Lithotomy


=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
* Standard maintenance


=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
* Postop pain usually not significant.
* BP may decrease when legs are repositioned to supine from lithotomy. Legs should be simultaneously returned to supine position to avoid stress on L-spine


== Postoperative management ==
== Postoperative management ==


=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
* PACU


=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
* In TURP, pain is usually minimal, may use opiates PRN


=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
* TURP syndrome
** Symptoms: N/V, visual disturbances, AMS, coma, seizures, HTN, cardiovascular collapse
*** Sodium <120 is associated with more severe symptoms
** Pathophysiology: Intravascular volume overload due to absorption of irrigant  resulting in hyponatremia and hypotonicity
** Risks: increased hydrostatic pressure of irrigant, number of venous sinuses opened, duration of surgery, experience of surgeon, peripheral venous pressure
*** resections should be optimally limited to <1h
** Treat: may use diuresis (lasix) and hypertonic saline
* Risks of lithotomy position:
** Peroneal nerve compression at lateral fibular head > foot drop
* Bladder perforation:
** may produce shoulder pain in awake patient
** In asleep patient, increased BP and HR


== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
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|+
|+
!
!
!Variant 1
!TURP
!Variant 2
!Open/Robotic/Laparoscopic
|-
|-
|Unique considerations
|Unique considerations
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|-
|-
|Position
|Position
|
|Lithotomy
|
|Supine or Lithotomy
|-
|-
|Surgical time
|Surgical time
|
|1h
|
|1h for simple, 3h for radical
|-
|-
|EBL
|EBL
|
|Blood loss can be large if venous sinuses entered
|
May be difficult to quantify due to irrigant use
|May be significant (1500cc) in radical retropubic resections
|-
|-
|Postoperative disposition
|Postoperative disposition
|
|PACU
|
|PACU
Catheter irrigation completed in PACU to clear blood clots and prevent obstruction
|-
|-
|Pain management
|Pain management
|
|Pain score 1
|
|Pain score 8, consider PCA or PRN opiates
|-
|-
|Potential complications
|Potential complications
|
|TURP sundrome
|
Foot drop from lithotomy position
|DVT
Foot drop from lithotomy position
 
Indigo carmine reaction
|}
|}


Revision as of 19:34, 26 June 2021

Prostatectomy
Anesthesia type

Regional or GA

Airway

ETT

Lines and access

1-2PIV

Monitors

Standard, 5-lead EKG

Primary anesthetic considerations
Preoperative

Pts are usually elderly, may have renal impairment from chronic retention

Intraoperative

Risk for TURP syndrome, bladder perf

Postoperative

Pain varies based on type of procedure, TURP is relatively mild pain, open procedures are associated with more significant pain

Article quality
Editor rating
In development
User likes
0

Prostate resection can be performed for benign conditions, such as urinary retention, as well as prostate cancer or other cancers of the pelvis. The procedure can be performed open, laparoscopically, robotically, or through the urethra (TURP).

Preoperative management

Patient evaluation

Patients are usually elderly, and are more likely to have pre-existing medical conditions

System Considerations
Neurologic Cerebrovascular disease and Alzheimer's common in this age group. Assess AMS preop to guide evaluation of postop changes.
Cardiovascular HTN, CAD common in this age group. Assess exercise tolerance.
Respiratory COPD is more common in this age group, consider preop testing as guided by H&P including smoking history and symptoms.
Hematologic Moderate blood loss expected with large glands, if <80g, no T&C necessary. Preop Hb.
Renal Anticipate renal impairment due to chronic obstruction, consider BUN, Cr, electrolytes. If elevated BUN or Cr, check CrCl
Endocrine Increased incidence of DM
Other

Labs and studies

  • As guided by H&P
  • Preop Hb
  • T&C for glands >80g

Regional and neuraxial techniques

  • Regional may be used, and may hold some advantage due to earlier detection of TURP syndrome with mental status changes.
    • other advantages include lower intraop blood loss, possible lower incidence of postop DVT, faster return of bowel function
  • Postdural puncture headache is very low in this age group.
  • T9 level is optimal (T8-10 depending on incision site)
  • Spinal anesthetic is usually favored over continuous lumbar epidural for TURP as the procedure is relatively short
    • Spinal with 0.75% bupi, 12mg in 7.5% dextrose (1.6mL)
  • For open or laparoscopic procedures, continuous epidural may also be used

Intraoperative management

Monitoring and access

  • Standard ASA monitors

Induction and airway management

  • Standard induction for GA cases
  • Regional may also be used

Positioning

  • Lithotomy

Maintenance and surgical considerations

  • Standard maintenance

Emergence

  • Postop pain usually not significant.
  • BP may decrease when legs are repositioned to supine from lithotomy. Legs should be simultaneously returned to supine position to avoid stress on L-spine

Postoperative management

Disposition

  • PACU

Pain management

  • In TURP, pain is usually minimal, may use opiates PRN

Potential complications

  • TURP syndrome
    • Symptoms: N/V, visual disturbances, AMS, coma, seizures, HTN, cardiovascular collapse
      • Sodium <120 is associated with more severe symptoms
    • Pathophysiology: Intravascular volume overload due to absorption of irrigant resulting in hyponatremia and hypotonicity
    • Risks: increased hydrostatic pressure of irrigant, number of venous sinuses opened, duration of surgery, experience of surgeon, peripheral venous pressure
      • resections should be optimally limited to <1h
    • Treat: may use diuresis (lasix) and hypertonic saline
  • Risks of lithotomy position:
    • Peroneal nerve compression at lateral fibular head > foot drop
  • Bladder perforation:
    • may produce shoulder pain in awake patient
    • In asleep patient, increased BP and HR

Procedure variants

TURP Open/Robotic/Laparoscopic
Unique considerations
Position Lithotomy Supine or Lithotomy
Surgical time 1h 1h for simple, 3h for radical
EBL Blood loss can be large if venous sinuses entered

May be difficult to quantify due to irrigant use

May be significant (1500cc) in radical retropubic resections
Postoperative disposition PACU PACU

Catheter irrigation completed in PACU to clear blood clots and prevent obstruction

Pain management Pain score 1 Pain score 8, consider PCA or PRN opiates
Potential complications TURP sundrome

Foot drop from lithotomy position

DVT

Foot drop from lithotomy position

Indigo carmine reaction

References

Top contributors: Olivia Sutton, Scott Alan Blaine and Chris Rishel

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