An OR Write-Up On

Operating Room

Presented to

The Faculty of College of Nursing

Baguio Central University

In Partial fulfilment of the

Requirements for the Subject NCM106

by:

Jinky N. Domingo

BSN-4

Mr. Charlie Almeda, RN, MAN

December 2019
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TABLE OF CONTENTS

I. Introduction. . . . . . . . . . . . . . . . . . . 3

II. Patients Profile. . . . . . . . . . . . . . . . . 5

a. Demographic profile

b. Past Medical History

c. Present Medical History

d. Admitting and Final Diagnosis

e. Operation Performed

III. Anatomy and Physiology. . . . . . . . . . . . . . 6

IV. Preparation of the Patient’s . . . . . . . . . . 11

V. Discussion of the Procedure . . . . . . . . . . . 12

VI. Management . . . . . . . . . . . . . . . . . . . 16

VII. Instruments . . . . . . . . . . . . . . . . . . . 19
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CHAPTER I

INTRODUCTION

Our group, were assigned for a 3 day clinical rotation

at Baguio General Hospital and Medical Center in Operating

Room on December 9-11, 2019, under the supervision of our

Clinical Instructor Mr. Charlie Almeda, RN, MAN.

I chose Transurethral resection of the prostate (TURP)

as my case topic because I am keen to learn more about the

operation process and its management. My main objective is

to fully understand the underlying procedure process.

Specifically, my goals are to learn more about the

etiologies, to trace and understand the pathophysiology of

TURP, to learn the basic principle of its management, and

also to provide an appropriate nursing care plan.

Transurethral resection of the prostate (TURP) is a surgery

used to treat urinary problems that are caused by an

enlarged prostate.

An instrument called a resectoscope is inserted through the

tip of your penis and into the tube that carries urine from

your bladder (urethra). The resectoscope helps your doctor

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see and trim away excess prostate tissue that's blocking

urine flow.

TURP is generally considered an option for men who have

moderate to severe urinary problems that haven't responded

to medication. While TURP has been considered the most

effective treatment for an enlarged prostate, a number of

other, minimally invasive procedures are becoming more

effective. These procedures generally cause fewer

complications and have a quicker recovery period than TURP.

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CHAPTER II

Patient Profile

Name: Patient X

Sex: Male

Age:80

Nationality: Filipino

Religion: Roman Catholic

Address: Alapang, La Trinidad Benguet

Operation Performed: Transurethral resection of the

prostate (TURP)

Surgeon: Dr. Dumlao

Anesthesiologist: Dr. Reyes

Anaesthesia: Subarachnoid Block

Anaesthesia started: 1:05 pm

Operation started: 1:20 pm

Operation finished: 2:05 pm

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CHAPTER III

ANATOMY AND PHYSIOLOGY

The prostate is a walnut-sized gland located between the

bladder and the penis. The prostate is just in front of the

rectum. The urethra runs through the center of the prostate,

from the bladder to the penis, letting urine flow out of the

body.

The prostate secretes fluid that nourishes and protects

sperm. During ejaculation, the prostate squeezes this fluid

into the urethra, and it’s expelled with sperm as semen.

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The vasa deferentia (singular: vas deferens) bring sperm from

the testes to the seminal vesicles. The seminal vesicles

contribute fluid to semen during ejaculation.

The prostate is a small muscular gland located inferior to

the urinary bladder in the pelvic body cavity. It is shaped

like a rounded cone or a funnel with its base pointed

superiorly toward the urinary bladder. The prostate surrounds

the urethra as it exits the bladder and merges with the ductus

deferens at the ejaculatory duct.

Several distinct lobes make up the structure of the prostate:

 On the anterior end of the prostate are the two lateral

lobes, which are rounded and shaped like orange slices

when viewed in a transverse section. The lateral lobes are

the largest lobes and meet at the midline of the prostate.

 Posterior and medial to the lateral lobes is the much

smaller anterior lobe, a triangle of fibromuscular tissue

just anterior to the urethra. The fibromuscular tissue of

the anterior lobe contracts to expel semen during

ejaculation.

 The median lobe is found just posterior to the urethra

along the midline of the prostate. The median lobe

contains the ejaculatory ducts of the prostate.

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 The posterior lobe forms a thin layer of tissue

posterior to the median lobe and the lateral lobes.

The prostate contains two main types of tissue: exocrine

glandular tissue and fibromuscular tissue.

 Exocrine glandular tissue in the prostate is epithelial

tissue specialized for the secretion of the components of

semen. Most of the prostate is made of exocrine glandular

tissue, as the prostate’s primary function is the

production of semen.

 Fibromuscular tissue is a mixture of smooth muscle

tissue and dense irregular connective tissue containing

many collagen fibers. The collagen fibers of the tissue

provide strength to the tissue while the smooth muscle

permits the tissue to contract to expel fluids.

Fibromuscular tissue forms the outermost layer of the

prostate and the tissue surrounding the urethra.

Secretion

The prostate produces a secretion that makes up a large portion

of semen volume. The prostatic secretions are a milky white

mixture of simple sugars (such as fructose and glucose),

enzymes, and alkaline chemicals. The sugars secreted by the

prostate function as nutrition for sperm as they pass into the

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female body to fertilize ova. Enzymes work to break down

proteins in semen after ejaculation to free sperm cells from

the viscous semen. The alkaline chemicals in prostatic

secretions neutralize acidic vaginal secretions to promote the

survival of sperm in the female body.

Ejaculation

The prostate contains the ejaculatory duct that releases sperm

during ejaculation. The ejaculatory duct opens to allow semen

to pass from the ductus deferens into the urethra and

eventually out of the body. During orgasm, smooth muscle tissue

in the prostate contracts in order to push semen through the

urethra.

Urination

Urine released from the urinary bladder is carried by the

urethra to the body’s exterior. Under normal conditions, urine

in the urethra passes through the prostate with no

complications whatsoever. The prostate enlarges slowly

throughout a man’s lifetime, potentially leading to the

restriction or blockage of the urethra by the time a man

reaches his fifties or sixties. An enlarged prostate can lead

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to difficulty urinating or eventually even an inability to

urinate. There are many treatments for an enlarged prostate

including medications, lifestyle changes, and prostatectomy,

the surgical removal of the prostate.

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CHAPTER IV

PREPARATION OF THE PATIENT

The room of choice is the “cysto” room with the

“cysto” table.A forcedair warming blanket may be placed.

Antiembolitic hose are applied, Chapter 19 Genitourinary

Surgery 403 19Goldman(F)-19 10/19/07 7:51 PM Page 403

when ordered. Following the administration of regional

(preferred) or general anesthesia, the patient is

positioned in lithotomy using padded knee crutches on the

“cysto” table. Arms may be extended on padded

armboards.All bony prominences and areas vulnerable to

skin and neurovascular pressure or trauma are padded.

Electrosurgical dispersive pad is placed.

Skin Preparation

Cleanse entire pubic area (including scrotum and

perineum), extending from the umbilicus to the mid-

thighs.The anus is prepped last; discard each sponge

after wiping the anus. Draping

Impervious drape sheet under the buttocks, leggings, and

transverse sheet or “cysto” drape

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CHAPTER V

DISCUSSION OF THE PROCEDURE

This procedure is particularly desirable when the patient

is a poor surgical risk, as it eliminates the need for open

prostatectomy. If carcinoma is present following the

histological studies of the resected specimen, open

prostatectomy may be indicated in the good-risk patient.

The goal of prostate surgery for benign prostatic

hypertrophy (BPH) is to remove the obstruction, minimize

the damage to surrounding structures, and cause the patient

as little discomfort as possible.The accessibility of the

obstruction via resectoscope affords the removal of the

obstruction transcystoscopically.This approach also

protects the surrounding organs from injury (by not

spreading cancerous cells inadvertently during laparotomy),

as tissue is removed intralumenally (through the urethra),

not intra-abdominally (through an abdominal incision).

Symptoms of BPH include slow, intermittent, or weak urinary

stream; the sensation of incomplete bladder emptying,

postvoid dribbling; urinary frequency, and nocturia.

Patients may also present with acute or chronic urinary

retention, urinary tract infections, gross hematuria, renal

insufficiency, bladder pain, a palpable abdominal mass, or

overflow incontinence. The absolute indications for primary

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surgical management of BPH are: • Refractory urinary

retention • Recurrent urinary tract infections due to

prostatic hypertrophy • Recurrent gross hematuria • Renal

insufficiency secondary to bladder outlet obstruction •

Bladder calculi • Permanently damaged or weakened bladders

• Large bladder diverticula that do not empty well

secondary to an enlarged prostate TURP is performed less

frequently today because alternative medical and surgical

treatment options are available. TURP is reserved for 402

Chapter 19 Genitourinary Surgery 19Goldman(F)-19 10/19/07

7:51 PM Page 402 patients with symptomatic prostatic

hyperplasia who have acute, recurrent, or chronic urinary

retention.TURP is also appropriate for the sexually active

man in whom the obstruction is not overly large. A major

disadvantage of TURP is that occult tumors in the prostate

may be overlooked. Alternative surgical procedures, as

transurethral microwave therapy (TUMT), in which the tumor

is destroyed by the thermal destruction of

microwaves,transurethral needle ablation (TUNA), in which

radio waves transmitted through needles placed under

telescopic guidance (fluoroscopy) are used to destroy the

tumor, and prostatic laser surgery, which employs a laser

fiber for interstitial coagulation of selected tissue, are

performed more frequently than TURP, although the

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treatments may not be as durable or effective as TURP. An

effective treatment for carcinoma of the prostate,

brachytherapy is performed by radiation oncologists in

specially licensed facilities. In brachytherapy, a template

is made and seeds of radioactive iodine125 or palladium103

(encased in titanium rods) are implanted percutaneously

under ultrasonic guidance; only tumor cells are destroyed

by the radiation, see p. 963. Cryoablation, a nonsurgical

therapy is performed for treating an enlarged prostate,

utilizes liquid nitrogen passed through percutaneously

inserted probes. Should further treatment become necessary,

all of the aforementioned surgical approaches may be

performed.

A. Anesthesia

Subarachnoid block can be used as the sole source of

anesthesia. Alternatively, spinal and epidural

anesthesia can be used jointly, taking advantage of

the qualities of both techniques: the rapid, dense

sensorimotor blockade of a spinal anesthetic and the

opportunity to redose the patient with an epidural

catheter anesthetic.

Spinal anesthesia produces intense sensory and motor

blockade as well as sympathetic blockade. As opposed

to epidural anesthesia, in which medications are

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instilled outside the dura mater, the goal of spinal

anesthesia is to instill the desired medications into

the cerebrospinal fluid (CSF). The sensorimotor block

produced requires smaller doses of local anesthetics

(hence, local anesthetic toxicity is rarely a

concern) and is often more dense in character.

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CHAPTER VI

MANAGEMENT

Nursing Management:

1. Monitor the fluid intake and output during the

bladder irrigation.

2. Palpate the bladder for its character and shape.

Distended bladder may signal that the catheter is

not patent or something is obstructing the flow of

fluid.

3. Use normal saline solution for irrigation. Cold

saline solution is used for the first 24 hours until

the bleeding is controlled.

4. Assess for the proper placement of the bladder

irrigation. Ideally the height of the irrigation

bags can be between 2 to 3 feet above the bladder.

5. Note the following signs of the TURP syndrome:

hypertension, full and bounding pulses, confusion,

agitation, temporary blindness.

Pre-operative Management:

1. Inform the patient about the procedure and the expected

postoperative care, including catheter drainage,

irrigation and monitoring of hematuria.

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2. Discuss the complications of surgery which include:

3. Incontinence or dribbling of urine up to 1 year after

surgery and that Kegel’s exercise will help alleviate

this problem

4. Retrograde ejaculation

5. Bowel preparation is given.

6. Optimal cardiac, respiratory and circulatory status

should be achieved to decrease risk of complications.

7. Prophylactic antibiotics are ordered.

Post-operative Management:

1. Urinary drainage is maintained and observed for signs of

hemorrhage.

2. Maintain patency of urethral catheter.

3. Avoid overdistention of bladder, which could lead to

hemorrhage.

4. Administer anti-cholinergic medications to reduce

bladder spasms.

5. Maintain bed rest for the first 24 hours.

6. Encourage early ambulation, thereafter to prevent

embolism, thrombosis and pneumonia.

7. Wound care is provided to prevent infection.

8. Administer pain medications.

9. Promote comfort through proper positioning.

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10. Administer stool softeners to prevent straining that

can lead to hemorrhage.

11. Reduce anxiety by providing realistic expectations

about postoperative discomfort and overall progress.

12. Encourage patient to express fears related to sexual

dysfunctions and to discuss with partner.

13. Teach measures to regain urinary control.

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CHAPTER VII

ACTUAL INSTRUMENTATION

 Sterile screen unless cystoscopy drape used

 Rigid fiber-optic cystoscope (Brown-Berger) and

panendoscope (McCarthy) or cystourethroscope (Wappler)

for bladder visualization

 Lateral and foroblique fiber-optic telescopes

(interchangeable with all sheaths) and (power) cord

 Resectoscopes (continuous flow), e.g., Iglesias,

Nesbit, Baumrucher, and Stern-McCarthy (sheath,

Timberlake obturator, telescope [composed of

Bakelite], working element, and cutting electrode) to

cut and coagulate tissue

 Bridge (e.g., short, Alberran) required for telescope

to fit into the sheath

 Stopcock, hemostat, and catheter nipples

 Penile clamp (used following local anesthetic

instillation in males)

 Urethral sound

 Resectoscope (for bladder fulguration)

 Catheterizing telescope (for catheterization of the

ureters), add ureteral catheters

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 Sounds (e.g., Van Buren), urethral dilators, hemostat,

Toomey syringe, stopcock

 Bipolar resectoscope (e.g., McCarthy, Nesbit,

Iglesias) with sheath, obturator, and cutting loops

 Adaptors, short bridge, evacuator (e.g., Ellik),

rubber tips, electrosurgical cord, 30-ml glass syringe

 Foroblique and lateral telescopes and (fiber-optic

light) cords with rotating contact

 Note: A flexible fiber-optic cystoscope is employed

for patients unable to tolerate the lithotomy

position.
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