Anesthesia for TURP

Maimouna Bah and Michael Stuart Green

M. Bah, M.S., M.D.
Department of Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, Hahnemann University Hospital,
Philadelphia, PA, USA M. S. Green, D.O., M.B.A. (*)
Department of Anesthesiology and Perioperative Medicine, Drexel University College of Medicine, Philadelphia, PA, USA
e-mail: Michael.Green@Drexelmed.edu

Introduction
Transurethral Resection of the prostate (TURP) is a common urological procedure that is considered the “gold
standard” for the treatments of patients with symptomatic urinary obstruction related to benign prostatic
hypertrophy (BPH). The prostate consists of four integrated zones that is divided and named based on their
location; the anterior, peripheral, central, and preprostatic zones. Each zone consists of secretory, smooth muscle,
and fibrotic tissues that are enclosed in one capsule rich in blood supply. In BPH the smooth muscle and epithelial
cells proliferate within the transition zone of the prostate, in which the middle and posterior lobes are the ones
commonly involved [1]. The result of this proliferation is a bladder outlet obstruction due to increased muscle
tone. TURP is still considered the main treatment modality for BPH, however due to the significant side effect
that can occur with the procedure, the development of other treatment options have resulted in the steady decline
of it use. Other options include transurethral needle ablation of the prostate (TUNA) and transurethral microwave
thermotherapy (TUMT) [2].

Surgical Technique
Transurethral resection of the prostate (TURP) is performed by inserting a resectoscope through the urethra into
the prostate to resect layers of the prostate tissue while preserving the prostatic capsule. If the capsule is penetrated
a significant risk of large amounts of irrigation solution being absorbed into the circulation is realized [3]. The
resectoscope uses either an electrically powered cutting coagulating metal loop or a laser vaporizer. The
coagulation can be accomplished with either a monopolar TURP (M-TURP) technique, which transmits a high
energy electrocautery current from a single electrode or bipolar TURP (B-TURP) technique, which utilized
electrodes with continuous bidirectional flow of current [3]. There been several studies that have shown lower
rates of complications with bipolar techniques compared to monopolar. In contrast to either of these techniques
the laser vaporization resectoscope allows the sealing of prostatic veins during the resection [4]. The laser can
vaporize tissue in millimeter cuts, therefore compared to electrocautery, laser significantly reduces surgical
complication, procedure time, and overall hospital length of stay [4].
TURP requires continuous use of fluid for visualization, distention, and irrigation of the bladder and prostate.
Ideally, the irrigation solution should be a transparent isotonic and nontoxic solute that is inexpensive. However,
that solution does not exist. When the available solution is examined, distilled water for example, it is inexpensive
but is hypotonic and when large contents is absorbed into the circulation it result into hemolysis, shock, and renal
failure. Crystalloids, including Lactate ringer’s and normal saline, are highly ionized which could result in
disbursement of electric current to the surrounding tissue. Commonly used solutions are glycine 1.2 and 1.5%,
mannitol 3–5%, glucose 2.5–4%, sorbitol 3.5%, Cytal (a mixture of sorbitol 2.7%, and mannitol 0.54%), and urea
1% [5]. These solutions are moderately hypotonic to preserve their transparency and do not result in hemolysis
and excessive absorption. However, if significant amounts of these solutes are absorbs, the patient will experience
specific adverse effects. For example, glycine can cause cardiac and retinal toxic effects, mannitol will rapidly
expands the blood volume resulting in pulmonary edema with worsening CHF in cardiac patients, and glucose
causes severe hyperglycemia specifically in diabetic patients [5].

Anesthetic Concerns
The patient population that undergo TURP are generally older and have significant coexisting medical conditions
such as coronary artery disease, congestive heart failure, cerebrovascular disease, chronic obstructive pulmonary
diseases, obstructive sleep apnea, and renal impairment. The development of deep vein thrombosis is a significant
risk due advanced age, presence of malignancy, varicose veins, and obesity. Therefore, a comprehensive
preoperative medical evaluation with history and physical exam is required with the goal of optimizing patients
to minimize and prevent complications. Due to the complications associated with the procedure these patients
must be constantly monitored for hemodynamic changes. Routine monitoring includes electrocardiogram,
noninvasive blood pressure, pulse oximetry, and capnography. In addition, emergency drugs and intubation
equipment should remain ready available.

General Anesthesia Versus Regional Anesthesia

Anesthesia for TURP can be accomplished via either general or neuraxial techniques. Sensation from the prostate
and bladder is transmitted by afferent parasympathetic nerve fibers from the second and third sacral roots and by
sympathetic nerves of the hypogastric plexus which is derived from nerve roots extending inferiorly from T11 to
L2 [6]. In order to obtain satisfactory regional anesthesia for TURP, a block level that interrupts sensory
transmission from the prostate and bladder neck is required therefore anesthesia about T10 is ideal. Sensory levels
block above T9 is undesirable due to the pain resulting from the prostatic capsule perforation which would then
not be apparent to the patient.
Spinal anesthesia has been the most frequently used anesthetic for TURP in the United States. Spinal provides
adequate anesthesia for the patient with good relaxation of the pelvic floor and perineum, and allows the early
recognition of symptoms of water intoxication and fluid overload since the patient is awake. A change in the
patient’s mental status is an early indicator of excess absorption of irrigation fluid and complications may ensue.
Other advantages of regional anesthesia over general anesthesia is that regional has been shown to be associated
with a decreased in incidence of deep vein thrombosis and operative blood loss due to decrease in systemic blood
pressure secondary to the sympathetic blockade resulting in decrease in peripheral and central venous pressure
and therefore blood loss during prostate surgery. Regional anesthesia also decreased analgesics requirement in the
immediate postoperative period compared with general anesthesia. A study by Wang et al. showed low dose
bupivacaine spinal anesthesia with intrathecal sufentanil resulted in an effective spinal sensory blockade with less
motor blockade and provided hemodynamic stability in elderly patients. It also helped decrease postoperative pain
and reduced the need for other analgesic medication [7].
Spinal is preferred over a continuous epidural for several reasons. Compared to epidural spinal is technically easier
to perform in elderly patients, incomplete block of sacral nerve roots is avoided, and the short duration of the
procedure. Bladder perforation is also recognized more frequently if the spinal level is limited to T10. General
anesthesia however may be necessary in patients who require ventilatory or hemodynamic support, have a
contraindication to regional anesthesia, or refuse regional anesthesia.

Positioning
TURP is performed in the lithotomy position with the patient placed in slight trendelenburg. Trendelenburg
positioning result in numerous physiological changes. Increase in cardiac preload due to increase in venous return,
decrease in pulmonary blood volume and pulmonary compliance due to cephalad shift of the diaphragm, and a
decrease in lung volume parameters including residual volume, functional residual volume, tidal volume, and vital
capacity all occur. Nerve injuries to the common peroneal, sciatic, and femoral nerves can occur. Patients in the
lithotomy position are also at high risk for development of deep vein thrombosis (DVT) due to polling and stagnant
nature of the blood in the lower extremities [8].

Ammonia and Glycine Toxicity

Visual disturbances have been associated with TURP. This has been found to be related to the systemic absorption
of glycine. Visual symptoms can include halos, loss of light perception, blurred vision, and transient blindness.
The pupils are usually dilated and unresponsive to stimulation, but the fundoscopic examination and intraocular
pressure are normal. Symptoms can last several hours after the resection. Glycine is an amino acid that is an
inhibitory neurotransmitter within the central nervous system. Normal plasma glycine levels are 13–17 mg/L. A
case report showed that glycine levels of 1029 mg/L were measured during one episode of blindness. Twelve
hours later, the glycine level in this case had declined to 143 mg/L, by which time vision had returned to
preoperative status. However, an overall correlation between plasma glycine levels and CNS toxicity has not been
established [9]. Glycine can also become oxidized into ammonia, leading to CNS toxicity. The ammonia causes
suppression of norepinephrine and dopamine in the CNS resulting in encephalopathy. Ammonia toxicity usually
presents within the first hour with nausea and vomiting, and progress rapidly to coma. Glycine has also has been
implicated in myocardial depression and hemodynamic changes associated with TURP syndrome.

Perforations
Another common complication of TURP is perforation of the bladder. This may occur due to difficult placing
instruments and bladder over distension with irrigation fluid. Perforations usually occur during difficult resections
in which the cutting loop or knife electrode comes in contact with the bladder wall. Most perforations are extra-
peritoneal, and in a conscious patient result in pain in the periumbilical, inguinal, or suprapubic regions. The
surgeon may also note an irregular return of irrigating fluid. If the perforation extends into the peritoneum the
patient may experience pain in the generalized upper part of the abdomen or it may be referred to the diaphragm,
precordial region, and/or shoulders. Other signs and symptoms include pallor, bradycardia, hypotension,
restlessness, diaphoresis, nausea, vomiting, abdominal pain, abdominal rigidity, dyspnea, shoulder pain, and
hiccups. The severity of symptoms depends on the location, size of the perforation, and the type of irrigating fluid.

Coagulopathies
The prostate is highly vascular and has an extensive plexus of venous sinuses that can be opened during the
procedure. As a result there is a significant risk of bleeding both during the procedure and in the postoperative
time period. It is difficult to adequately estimate blood loss due to the blood being mixed with ample quantities of
irrigation fluid. Therefore patient’s vital signs and serial hematocrit values should be monitored to assess the blood
loss and need for transfusion. Factors that influence blood loss are the vascularity, size of the gland, the duration
of surgery, and sinuses opened during resection. The resection of prostate causes release of urokinase and
plasminogen activator tissue causing local fibrinolysis and bleeding of the surrounding tissue [10].
Thromboplastin is also released and can enter the circulation resulting in disseminated intravascular coagulation
(DIC) and systemic coagulopathy [10]. If bleeding becomes uncontrollable, the procedure should be terminated
and a Foley catheter placed into the bladder with traction applied allowing for the exertion of pressure on the
prostatic bed reducing bleeding. Bleeding requiring transfusion occurs in approximately 2.5% of TURP
procedures [11]. Fibrinolysis can be treated with aminocaproic acid.

Hypothermia
Irrigation fluids are usually stored at room temperature and during the TURP procedure a patient can receive
several liters; this may result in a loss of a significant amount of heat. The absorption of this fluid also leads to a
decrease in the patient’s body temperature causing shivering. About 1 °C per hour is estimated to be lost with the
irrigation fluid. The use of warmed irrigating solutions has been shown to be efficacious in reducing heat loss,
however this practice is not widely followed due to concerns regarding warmed fluids yielding increased bleeding
due to the vasodilation effects, which have not been proven.

TURP Syndrome
TURP syndrome is a clinical diagnosis that presents with concerning cardiovascular and/or neurological
symptoms caused by excessive absorption of the irrigating fluid. This syndrome can be diagnosed through the
first postoperative day and should remain on the differential if changes are noted. TURP syndrome results in
severe CNS derangements associated with extreme hyponatremia, such as convulsions and coma. Due to the
degree of vascularity of the prostate gland a significant amount of irrigation solution can potentially be absorbed.
Factors that significantly affect the amount absorb are hydrostatic pressures of the irrigant and the time length of
the resection. On average, 20 mL/min of fluid is absorbed with a total of greater than 6 L absorbed in procedures
lasting up to 2 h [12]. Additional factors include heavier tissue resection and use of monopolar resectoscope.
Violation of the prostate capsule during the resection can lead to solution entering peritoneal and retroperitoneal
spaces and therefore the circulation. The type of absorbed fluid determines the sequela the patient presents with.
Currently, the two most commonly used fluids are glycine and Cytal. Therefore, previously common
complications such as hemolysis or hyponatremia have been significantly reduced [13]. Fluid overload/over
hydration does still remain a challenge. About 20–30% of absorbed solution remains in the intravascular space
with the remaining entering the interstitial space. These result in increased capillary leak, pulmonary edema,
cardiovascular overload, cerebral edema, and possibly death (see Table 82.1).
Extracellular sodium concentration must be in the physiologic range for depolarization of excitable cells and
production of the action potential to occur, which is 135–145 mEq/L. Hyponatremia is serum sodium below 135
mEq/L. Symptoms ranges from nausea, malaise, irritability, apprehension, confusion, and headache. These may
present early even with mild to moderate hyponatremia. Neurological symptoms are most often observed with
levels <115 mEq/L. This includes seizures and coma [13]. Cardiovascular symptoms are a result of negative
inotropy with causes dysrhythmias, electrocardiogram changes including QRS widening, U waves, ST-segment
elevation. Cardiovascular symptoms are usually seen around the same sodium levels (less than 115 mEq/L) [13].

Treatment of Transurethral Resection of the Prostate Syndrome

Management of TURP syndrome is initiated with supportive care. It is very important to ensure appropriate
oxygenation, ventilation, and circulatory assistance if needed. It should include fluid restriction and possible
diuretic administration such as furosemide if indicated to promote excretion of free water. Seizures are treated
with anticonvulsants such as benzodiazepines. Patients with severe hyponatremia 3% hypertonic saline can be
initiated slowly (less than 100 mL/h) to avoid worsening cerebral edema and central pontine myelinolysis.

Conclusion
TURP is associated with significant risk that can cause a short procedure to become life threatening. Patents are
in a dynamic state and need careful monitoring. General and neuraxial anesthesia have advantages and
disadvantages related to each. Spinal or epidural anesthesia allows the patient’s subjective judgment to contribute
to assessment of their condition during surgery. Bleeding is very common during TURP which can be easily
controlled, however when large venous sinuses are opened hemostasis can be difficult to obtain [14]. Mortality
rates are similar in patients receiving regional anesthesia or general anesthesia.