Prostatectomy

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
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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.
Pulmonary	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
    • Can vary depending on irrigant used:
      • Glycine is metabolized to ammonia and can be associated with encephalopathy. It can also be associated with visual disturbances due to the inhibitory effect of glycine on brainstem neurons.
      • Sorbitol can lead to hyperglycemia
      • Hypotonic fluids can lead fluid overload, HTN, pulmonary edema, hyponatremia and hemolysis
    • 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 (e.g., furosemide) 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