Divertikel Indikasi operasi

1. Ukuran divertikel >1/3 buli

2. Leher sempit

3. Batu di divertikel

4. ISK kronis

5. Keganasan

6. Perburukan traktus urinarius bagian atas, baik karena obstruksi /refluk

Tehnik operasi

1. Extravesica eksisi

2. intravesica inversi

3. Laparoskopik divertikulektomi

- Indikasi open prostat

1. Akses transuretra tdk memungkinkan

2. Volume untuk open: unpad 60 ,campbel 75, rscm 90, iaui 80

3. Bph dengan batu buli besar (sekalian operasinya)

💢Penyebab Kenaikan PSA: patologis dan fisiologis

- Infeksi

- Post coitus

- Ca prostat

- Urology maneuver (FC, Endourologi)

💢TUR SYNDROME
Resiko meningkat jika volume >45 cc waktu>90"

Jika pake electrocauter monopolar--> irrigation fluid MUST NOT contain electrolyte!

Accidental resorption of irrigation fluid can cause tur syndrome

Symptoms:

1. Chest pain

2. Bradycardia

3. Hypertension

4. Hypotension

5. Poor urine output

6. Blurred vision, transient blindness

7. Nausea - vomitting

8. Confusion gelisah

9. Tiredness

10. Unconsciousness

11. Headache

❌Yang harus diperhatikan saat TURP

1. Resection time < 45 menit

2. Limiting height of bag containing the irrigating fluid, to the maximum of 1 m above the patient, inserting
suprapubic catheter

3. Usage of Bipolar resection

Hypotonic hyperhydration,

Hemolysis,

Hyponatremia,
✔ "Acute dilutional hyponatremia"

Hemodilusi cairan extravaskuler ke intravaskuler, sehingga perubahan neurologis:

-bradikardia dari brain swelling --> gelisah

-overload cairan (HT) --> penurunan kesadaran

-confusion, nausea, visual disturbance, vomitting

1. indikasi operasi bph

Surgical treatment is usually required when patients have experienced recurrent or refractory urinary retention,
overflow incontinence, recurrent UTIs, bladder stones or diverticula, treatment-resistant macroscopic haematuria
due to BPH/BPE, or dilatation of the upper urinary tract due to BPO, with or without renal insufficiency (absolute
operation indications, need for surgery).

Additionally, surgery is usually needed when patients have not obtained adequate relief from LUTS or PVR using
conservative or medical treatments (relative operation indications).

Indikasi absolut:

• Gangguan fungsi ginjal krna prostat

• ISK berulang

• Retensi berulang

• Batu akibat stasis urine krna prostat

• Divertikel di bladder

• Gagal medikamentosa / akut retensi

• Makroskopik hematuria berulang

Indikasi relatif :

• Keinginan pasien

• Status sosial pasien (pilot atau traveler)

• Kelainan penyerta, hernia atau hemorrhoid

Sumber : EAU Guidline 2020

 2. definisi gagal twoc

definition: trial without catheter (TWOC) is when a catheter (the tube inserted into your bladder to

drain urine) is removed from the bladder for a trial period to determine whether you are

able to pass urine spontaneously. You will also have an ultrasound scan of your bladder as

part of the trial.

http://www.swbh.nhs.uk/wp-content/uploads/2012/06/Trial-without-catheter-ML3617.pdf

3. lama dilakukan twoc dan cara menilainya

Cara menilai TWOC:

TWOC adalah cara untuk mengevaluasi apakah pasien dapat berkemih secara spontan setelah terjadi retensi. Setelah
kateter dilepaskan, pasien kemudian diminta dilakukan pemeriksaan pancaran urin dan sisa urin. TWOC baru dapat
dilakukan bersamaan dengan pemberian α1-blocker selama minimal 3-7 hari. TWOC umumnya dilakukan pada
pasien yang mengalami retensi urine akut yang pertama kali dan belum ditegakkan diagnosis pasti.

Sumber : IAUI Guidlines

4. Definisi gagal medika: mentosa pada bph .

patient should be reviewed at six months and then annually, provided there is no deterioration of symptoms
or development of absolute indications for surgical treatment
Sumber: Eau guideline 2020
5. klasifikasi luts dan pilihan pengobatannya
Storage: frequency, urgency, nocturia, incontinence
Voiding: Slow stream, splitting or spraying, intermittency, hesitancy, straining, terminal dribble
Post-micturition: post-micturition dribble, feeling of incomplete emptying
Sumber: Eau guideline
6. Scores untuk menilai luts dan bph defenisi protusi prostat dan gradenya defenisi
Symptom score questionnaires
All published guidelines for male LUTS/BPH recommend using validated symptom score questionnaires .
Several questionnaires have been developed which are sensitive to symptom changes and can be used to
monitor treatment. Symptom scores are helpful in quantifying LUTS and in identifying which type of
symptoms are predominant; however, they are not disease-, or age-specific. A systematic review (SR)
evaluating the diagnostic accuracy of individual symptoms and questionnaires, compared with urodynamic
 studies (the reference standard), for the diagnosis of BOO in males with LUTS found that individual
symptoms and questionnaires for diagnosing BOO were not significantly associated with one another.

The International Prostate Symptom Score (IPSS)

The IPSS is an eight-item questionnaire, consisting of seven symptom questions and one QoL question.
The IPSS score is categorised as ‘asymptomatic’ (0 points), ‘mildly symptomatic’ (1-7 points), ‘moderately
symptomatic’ (8-19 points), and ‘severely symptomatic’ (20-35 points). Limitations include lack of
assessment of incontinence, post-micturition symptoms, and bother caused by each separate symptom.

The International Consultation on Incontinence Questionnaire (ICIQ-MLUTS)

The ICIQ-MLUTS was created from the International Continence Society (ICS) Male questionnaire. It is a
widely used and validated patient completed questionnaire. It contains thirteen items, with subscales for
nocturia and OAB, and is available in seventeen languages.

Danish Prostate Symptom Score (DAN-PSS)

The DAN-PSS is a symptom score used mainly in Denmark and Finland. The ICIQ-MLUTS and DAN-
PSS measure the bother of each individual LUTS

Sumber : EAU Guidline 2020

7. Transisional zone index

The transitional zone index (TZI) was calculated as being the transitional zone volume/whole gland volume
ratio of the prostate. Many formulas can be used to assess the prostate and transition zone volume.
8. indikasi biopsi prostate:

Indication of Prostate Biopsy :

1. DRE: palpable nodule, asymmetrical

2. LAB: PSA> 10 or between 4-10 with PSAD> 0.15 -> PSAD = PSA / VOLUME PROSTATE
3. TRUS-P: hyper / hypoechoic lesions appear

9. Teknik biopsi prostat

10. alogaritma penatalaksanaan bph

Lifestyle modifications with watchful waiting

Standard of Care:
Patients on watchful waiting should have periodic physician-monitored visits.

Optional:
Physicians can use baseline age, LUTS severity, prostate volume and/or serum PSA to advise patients of their
individual risk of symptom progression, acute urinary retention or future need for BPH-related surgery (these risk
factors identify patients at risk for progression).

Optional:
A variety of lifestyle changes may be suggested for patients with nonbothersome symptoms. These can include the
following:

 Fluid restriction particularly prior to bedtime

 Avoidance of caffeinated beverages, spicy foods

 Avoidance/monitoring of some drugs (e.g., diuretics, decongestants, antihistamines, antidepressants)

 Timed or organized voiding (bladder retraining)

 Pelvic floor exercises

 Avoidance or treatment of constipation

 11. teknik teknik operasi turp

12. jenis jenis biopsi prostatat (transrectal dll)& Kelebihan dan kekuranan TRUSP biopsi dibanding
perineum

13. indikasi biopsi dari nilai PSAV

PSAV measurement has benn shown to be very helpful, as clinically significant prostate cancer is more
likely to be found in men with a rapidly rising PSA. Studies suggest that for men with a total PSA higher
than 4ng/mL
14. Defenisi PSADT

PSA doubling time (PSADT) is an attractive intermediate end point for assessing novel therapies in
biochemically recurrent prostate cancer (BRPC). it would be useful to include these parameters in the decision-
making process. For instance, a relationship was found between increased PSA velocity (>2 ng/mL/year) before
initiation of oncological treatment and increased (12-fold) risk of death. A number of well-documented retrospective
analyses show that PSADT is one of the most important parameters to describe the disease aggressiveness. It has to
be stressed that single determination of PSA levels is much less precise in terms of describing the biological
aggressiveness of prostate cancer than PSADT. 

Sumbert: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3921716/

15. Definisi Free PSA / binding PSA dan kegunaan nya

The measurement of bound and free PSA can help to differentiate mildly elevated PSA levels caused by
cancer from elevated levels resulting from benign prostatic hyperplasia. The lower the ratio of free to total
PSA, the higher the likelihood of cancer (Free PSA is reported as a percentage) for example, among men
with greater 25 % psa, only 98% are found to have cancer at the prostate biopsy.
PSA makes the semen more liquid. semen that’s more liquid can more easily move sperm to a women’s
fallopian tubees during the reproductive process

16. Komplikasi TURP ( intra, early, delayed) dan mana yang paling sering
Intraop:
- Pendarahan
- TUR syndrome
- Bladder injury (perforation)
- Urethral injury (perforation)
 Early post op:
- Acute urinary retention due to blood clot
- UTI
- Sepsis
- Pain
 Late post Op:
- Retrograde ejaculation 62-72%
- Urgency 0-38%
- Erectile dysfunction 30%
- Dysuria 0-22%
- Urethral stricture 4.1%
- Bladder neck contracture 2%
- SUI 0.6-5%

17. Tanda tanda TURP syndrome

Transurethral resection of prostate (TURP) syndrome is a systemic complication of transurethral resection
of the prostate or bladder tumours, caused by excessive absorption of electrolyte-free irrigation fluids. This
syndrome may potentially cause neurologic disturbance (gangguan kesadaran) , pulmonary edema,
 cardiovascular compromise, and death. Normal saline cannot be used as irrigation solution with
conventional monopolar resection Glycine solution is almost universally used as an irrigation solution in
traditional therapeutic endoscopic urologic procedures. The incidence of this complication is between
0.78% and 1.4%. The surgeon should be informed immediately, the intervention stopped as quick as
possible and the treatment should start without delay.

Kumay V, et al. TUR syndrome - A report.Urol Case Rep. 2019 Sep; 26: 100982.
Published online 2019 Jul 26

18. Cara menghindari TURP syndrome

The most important point in the treatment of TURP syndrome is early diagnosis.
- First, the absorbed water must be eliminated and hypoxaemia and hypoperfusion must be prevented.
- Loop diuretics such as furosemide can be used to eliminate excess fluid.
- If severe symptomatic hyponatremia is present with impaired consciousness and convulsions,
hypertonic saline solutions can be administered.
- The amount and rate of the hypertonic saline solution (3% or 5%) to treat hyponatremia is adjusted
according to the patient's serum sodium concentration.
- It is recommended that the rate of the hypertonic saline solution infusion must not be higher than 100 
ml/h if serum sodium concentration is above 120 mmol/l to avoid circulatory overload.
- The hyponatremia must be treated aggressively to avoid intravascular haemolysis if serum sodium
concentration is below 100 mmol/l

Demirel I, et al. TURP syndrome and severe hyponatremia under general anaesthesia.BMJ Case Rep. 2012;
2012: bcr-2012-006899. Published online 2012 Nov 19.

19. Age adjusted PSA adalah

20. Cara kerja obat obatan bph, a blocker, 5 ari dll

Pengobatan dengan a1 blocker bertujuan menghambat kontraksi otot polos prostat sehingga mengurangi
resitensi tonus leher kandung kemih dan uretra

5a reductase inhibitor
 Bekerja dengn mneginduksi proses apoptosis sel epitel prostat yang kemudian mengecilkan volume prostat
hingga 20-3-%

Antagonis respetor muskarinik

Bekerja dengan menghambat atau mengurangi stimulasi respetor muskarinik sehingga akan mengurangi
kontraksi sel otot polos kandung kemih

Phospodiesterase 5 inhibitor
Pde 5 meningkatkan konsentrasi dan memperpanjang aktivitas dari cyclic guanosine monophosphate
(cGmp) intraseluler, sehingga dapat mengurangu tonus otot polos detrusor, prostat da urethra
21. indikasi pemilihan operasi TURP, TUIP TUNA, TUMT

22. Indikasi operasi Open prostat dan jenis operasinya beserta keuntungan dan kerugian
surgery is recommended if the patient has refractory urinary retention (at least on failed attempt at catheter
removal) or any of the following conditions, clearly secondary to BPH: recurrent urinary tract infection,
recurrent gross hematuria, bladder stones, renal insufficiency, or large bladder diverticula
 Frayer (transvesika): direct visual to the bladder neck and ureteral orifice  untuk: pembesaran
lobus median prostat, ada bladder diverticulum simtomatik, ada batu buli besar, obesitas (sulit
untuk retropubik)
 Milin (Retropubic): lapang padang lebih besar, langsung menuju adenoma saat enukleasi 
memastikan compute removal, optimal preservasi kontinensia urin, direct visual: ke prostatic fossa
setelah enukleasi -> kontrol perdarahan, minimal trauma ke bladder
 Dejong (transperineal) : dapat mengobati abses prostat & kista prostat, post operative pain rendah,
dapat dilakukan pada pasien dengan riwayat operasi retropubic

23. Vaskularisasi prostat

A. Arterial
 The arterial supply to the prostate is derived from the inferior vesical, internal pudendal, and middle rectal
(hemorrhoidal) arteries.
B. Venous
The veins from the prostate drain into the periprostatic plexus, which has connections with the deep dorsal
vein of the penis and the internal iliac (hypogastric) veins.

24. Zona prostat berdasarkan mc neal dan lowsley

Pembagian Zona prostat menurut mcmeal losley
According to the classification of Lowsley, the prostate consists of five lobes: anterior, posterior, median,
right lateral, and left lateral. This classification is often used in cystourethroscopic examinations.McNeal
(1981) divides the prostate into four zones: peripheral zone, central zone (surrounds the ejaculatory ducts),
transitional zone (surrounds the urethra), and anterior fibromuscular zone.
Sumber : Tanagho-Smith ed 18th. Anatomy of Genitorinary Tract.Page 8-13

1. Teknik TURP
Some patients with bladder outlet obstruction due to BPH have substantial median lobe enlargement, so the median
lobe requires early resection to permit irrigation of prostatic chips out of the operative field. Typically, the median
lobe is resected down to the point where circular bladder neck fibers are encountered. At this point, the bladder neck
and prostatic fossa are flat with the bladder floor that extends from the trigone. Overresection of this area may
undermine the bladder neck and should be avoided. After the median lobe has been resected appropriately, the resec-
tion continues in the floor of the prostate to the proximal aspect (bladder side) of the verumontanum. The
verumontanum is the key landmark used during resection of the prostate and should not be resected.

After the bladder neck and prostatic floor have been resected, then attention can be turned to the anterior prostate.
Many indi- viduals have only a small amount of anterior tissue. Resection begins just inside the bladder neck and
continues to a point near the verumontanum. The scope is positioned at the verumonta- num, rotated 180 degrees
without any in or out movement, and anterior tissue is resected. Accidental movement of the scope distal (outward)
can lead removal of tissue distal to the verumontanum. One is best served by waiting until the end of the procedure
to complete the most distal (apical) resection. Often only one or two loop depths are required in the anterior portion
of the prostate.

After the prostate has been opened by the initial resection at the 6 and 12 o’clock positions, one can begin taking
down the lateral lobes. The resectionist should perform the procedure the same way every time in order to develop a
style that is thorough and repetitive. One typically begins at the 6 or 12 o’clock position and resects from the bladder
neck for one loop length. An expe- rienced resectionist will rotate the scope slightly to position for the next loop
pass without advancing or withdrawing the scope after each pass. On small prostates, this may be the entirety of the
prostate. Larger prostates, however, may require multiple loop lengths. In that case, one should resect the first loop
length all the way around 360 degrees. After this is done to near the appropriate depth, one can progress more dis-
tally. It should be noted that if the prostate is extremely large, care should be given not to resect too deeply and to
open venous sinuses early in the case

One then progresses distally until the distal aspect of the loop length reaches the proximal verumontanum. Short
scal- loping resection “bites” are to be avoided. Long loop lengths of appropriate depth leave a smooth prostatic
fossa. Avoid coagulat- ing small bleeding vessels in tissue that will be soon resected. At this point, one should
complete the resection of the lateral lobe tissue and develop thorough hemostasis.

The final aspect of the procedure is trimming the apical tissue. Many urologists find it helpful to gently withdraw the
resecto- scope distal to the verumontanum to visualize exactly the edge of the existing resected tissue. One can then
place the resectoscope at the proximal aspect of the veru and then without moving the resectoscope in or out, resect
the lateral lobe apical tissue by sequentially rotating the scope. It is helpful to visualize the verumontanum several
times during this procedure to prevent resecting too distally. How much tissue to resect from the prostatic apex is up
to one’s own training and experience. When adequately resected, the apex should appear open when viewed from
the distal aspect of the verumontanum even in the very large prostate. After the more typical 20- to 30-g resection,
the prostatic fossa should appear wide open when viewed from the distal verumontanum. Nevertheless, substantial
resec- tion distal to the veru often leads to either transient or permanent incontinence due to intrinsic sphincter
dysfunction and is to be avoided.

After the bulk of tissue resection, the bladder is irrigated with an Ellik evacuator, which produces a Venturi effect,
allowing chips of prostate tissue to settle to the bottom of the bulb

After chips and clots are evacuated from the bladder, the prostate and bladder must be reexamined

HINMAN'S 4th edition

2. Apa saja yang dinilai dari usg untuk menilai resiko retensi?
It is well known that the prostate's anatomic conformation together with intravesical prostatic protrusion (IPP)
may affect normal voiding demonstrated the possibility of using the IPP measurements for diagnosing BOO, which
was also a predictor of the capacity for spontaneous voiding after acute urinary retention in Tan et al. study (10).

Other authors have suggested determining bladder weight, bladder wall width or prostate conformation through
abdominal or rectal ultrasound (11-14). Kojima et al. demonstrated, studying 104 patients, that the bladder weight
more than 35 g performed thought transabdominal ultrasound is strongly associated with bladder outlet obstruction
on pressure-flow studies (15).

A bladder wall thickness of 5 mm appeared to be the best cutoff point to diagnose bladder outlet obstruction,
since 63.3% of patients with bladder wall thickness less than 5 mm were unobstructed while 87.5% of those with a
bladder wall thickness 5 mm or greater were obstructed in a study including 174 patients of Manieri et al. at 150 mL
bladder filling (16).

Hakenberg et al. (17) found that mean bladder wall thickness was 3.33 mm in healthy men and 3.67 mm in men
with LUTS and BPE, measuring all patients at different bladder fillings. BOO was found in 95.5% of men with a
detrusor wall thickness greater than or equal to 2 mm in Oelke et al. study, at 250 mL or more bladder filling.

Sumber:https://www.scielo.br/scielo.php?script=sci_arttext&pid=S1677-55382008000500012

3. Jenis jenis biopsi prostat (sextant biopsy, mri dll)

a. Transrectal ultrasound and ultrasound-based techniques: 12-core prostate biopsy, double-sextant prostate
biopsy
 b. Magnetic resonance imaging-targeted biopsies

EAU Guideline 2020

4. Berapa persen retrograde ejakulasi post turp

Penyulit dini yang dapat terjadi pada saat TURP bisa berupa perdarahan yang memerlukan transfusi ( 0-
9%), sindrom TUR (0-5%), AUR (0-13,3%), retensi bekuan darah (0-39%), dan infeksi saluran kemih (0-
22%).Sementara itu, angka mortalitas perioperatif (30 hari pertama) adalah 0,1. Selain itu, komplikasi jangka
panjang yang dapat terjadi meliputi inkontinensia urin (2,2%), stenosis leher kandung kemih (4,7%), striktur urethra
(3,8%), ejakulasi retrograde (65,4%), disfungsi ereksi (6,5-14%), dan retensi urin dan UTI.

sumber : IAUI Guidelines

5. Pasa trusp biopsi, anastesi lokal dengan blok pada nervus apa

The prostatic neurovascular bundle is located at the 5 and 7 o’clock positions on the prostate. In the sagittal view,
orient the TRUS probe to the lateralmost aspect of the prostate at the junc- tion of the prostate and seminal vesicle.
Using a 7–10-inch 22-guage spinal needle, inject a total of 10 mL of 50 : 50 mixture of 1% lidocaine and 0.25%
Marcaine into the space between the seminal vesicle and prostate bilaterally (Fig. 73.6). Additional injections at the
lateral aspect of the apex with up to 5 mL of blocking agents have also been described.

Sumber: Hinman’s Atlas Surgery

6. Antibiotik pada trusp biopsi

For transrectal biopsy, quinolones are the drugs of choice, with ciprofloxacin being superior to ofloxacin.
For transperineal biopsy, which avoids rectal flora, a single dose of intravenous cephazolin only is sufficient

EAU Guideline 2020

7. Nilai normal dari uroflowmetry

Normal peak flow ranges between 12 and 30 mL/sec, depending on the voided volume. Average flow rates
vary from 6 to 25 mL/sec, with a substantial overlap between normal and abnormal individuals.40 

Voiding time varies, from 10 to 20 seconds for a volume of 100 mL to 25 to 35 seconds for a volume of
400 mL. The first half of the urinary volume is rapidly evacuated in the first one third of the total voiding time, and
the rest in the remaining two thirds of the voiding period

The diagnostic accuracy of uroflowmetry for detecting BOO varies considerably and is substantially
influenced by threshold values. A threshold Q max of 10 mL/s has a specificity of 70%, a PPV of 70% and a
sensitivity of 47% for BOO. The specificity using a threshold Q max of 15 mL/s was 38%, the PPV 67% and the
sensitivity 82% [81]. If Qmax is > 15 mL/s, physiological compensatory processes mean that BOO cannot be
excluded

EAU Guideline 2020

 8. Pada kondisi apa uroflow tidak dapat di lakukan
Uroflowmetry parameters should preferably be evaluated with voided volume > 150 mL. As Qmax is prone
to within-subject variation [79, 80], it is useful to repeat uroflowmetry measurements, especially if the voided
volume is < 150 mL, or Qmax or flow pattern is abnormal.

EAU Guideline 2020

9. Alpha blocker selektif, uro selektif dan superselektif beserta contoh obat nya

a. Selective alpha-1 blockers

Selective alpha-1 blocker ends with the suffix "-osin." These medications include alfuzosin, doxazosin,
terazosin, tamsulosin, and prazosin. These medications are FDA approved to treat benign prostatic hyperplasia
(BPH). These medications may also be options to treat essential hypertension. However, they are not typically first-
line agents for the management of hypertension.

b. Selective alpha-2 blockers

Selective alpha-2 blockers include the medications yohimbine and idazoxan. Yohimbine has been used to treat
male sexual dysfunction, although the effectiveness has not yet been established and is not currently FDA approved
for this use or any other uses.

c. Super selektif alpha 1A blockers

Selectivity Silodosin is a highly sensitive alpha-1A receptor antagonist with little or nocardiovascular side-
effects. It has been shown to have negligible effects on blood pressure and no effect on cardiac repolarization.3 In
particular, silodosin has been shown to be more effective than tamulosin in relieving nocturia, incomplete bladder
emptying and frequency.3

Sumber:

https://www.ncbi.nlm.nih.gov/books/NBK556066/

Sumber: Karen Koch. Silodosin a safer alpha – blocker targeting benign prostatic hyperplasia. South African Family
Practice, 57:5, 291-292. 2015.

10. Patofisiologi TUR sindrome

Circulatory overload: Due to circulatory overload, the blood volume increases, systolic and diastolic pressures
increase and the heart may fail. The absorbed fluid dilutes the serum proteins and decreases the oncotic pressure of
blood. This, concurrent with the elevated blood pressure, drives fluid from the vascular to interstitial compartment
causing pulmonary and cerebral edema. In addition to direct absorption into the circulation, a significant volume
(upto 70%) of the irrigation solution has been found to accumulate interstitially, in the periprostatic and
retroperitoneal spaces

Water intoxication: a neurological disorder caused by increased water content of the brain. The patient becomes first
somnolent and then incoherent and restless. Seizures may also develop leading on to coma in decerebrate position.
There will be clonus and positive Babinski responses. Papilloedema, with dilated, sluggishly reacting pupils can
occur. The EEG will show low voltage, bilaterally. The symptoms of water intoxication appear when serum so dium
level falls 15 - 20 meq/l below normal level.

Hyponatremia: Dilution of serum sodium through excessive absorption of irrigation solution.Loss of sodium into the
stream of the irrigation fluid from the prostatic resection site, accumulated in the periprostatic and retroperitoneal
spaces. The symptoms of hyponatremia are restlessness, confusion, incoherence, coma and seizures.

Glycine toxity: Excess of glycine absorbed into circulation is toxic to heart and retina and may lead to
hyperammonemia. Experimentally glycine has been found to reduce the vitality and survival of isolated
cardiomyocytes. 

Ammonia toxicity: Hyperammonemia implies that the body cannot fully metabolize glycine through the glycine
cleavage system, [29] citric acid cycle [30] and conversion to glycolic acid and glyoxylic acid. [31] Another possible ex-
planation is arginine deficiency. Ammonia is normally converted to urea in the liver via the ornithine cycle

Hypovolemia , hypotension:  when glycine is used as irrigating fluid, consist of a transient arterial hypertension, that
may be absent if the bleeding is profuse, followed by more prolonged hypotension

Visual Disturbances: One of the most alarming complications of TURP syndrome is transient blindness, foggy
vision and seeing halos around objects.  [33],[37],[38] The pupils may be dilated and unresponsive. The optic disc appears
normal. The symptom can coexist with other features of TURP syndrome or can be an isolated symptom. The vision
returns to normal in 8-48 hours after surgery. TURP blindness is caused by retinal dysfunction probably due to
glycine toxicity. 

Perforation: An early sign of perforation, which often goes unnoticed, is a decreased return of irrigating fluid from
the bladder. Abdominal pain, distension, nausea and distress follow. Bradycardia and arterial hypotension are
profound. There is also a high risk of failure to diurese spontaneously. In intraperitoneal perforation, symptoms
develop faster

Sumber: Moorthy H K, Phiip S. TURP syndrome – current concepts in the pathophysiology and management.
Indian J Urol 2001: 17:97-102
 11. Patofisiologi hipertropi, sakulasi dan divertikel buli

The term bladder diverticulum is usually reserved for a subjectively large herniation of the bladder
urothelium through the muscularis propria of the bladder wall. This results in a thin-walled, urine-filled structure
adjacent to and connecting with the bladder lumen through a variably sized neck, or ostium. Histologically the
diverticulum wall is composed of mucosa, subepithelial connective tissue or lamina propria, some scattered thin
muscle fibers, and an adventitial layer. The outside wall of the bladder diverticulum often contains some residual
scattered strands or bundles of smooth muscle; however, these are disorganized and nonfunctional. Therefore
bladder diverticula generally empty poorly during micturition, leaving a large postvoid residual urine volume that
results in the characteristic findings on presentation and imaging.

Sumber: Campbell 12th edition. Bladder and Female Diverticula