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ANATOMY OF THE PROSTATE
normal prostate weighs around 18 gm. contains 70% glandular and 30% fibromuscular stroma urethra runs through the length of the prostate Divided into 5 lobes or 2 zones- transitional and peripheral
WHAT IS BPH ?
Non cancerous enlargement of the prostate gland Mainly of the middle lobe or the transitional zone Leads to symptoms of bladder outlet obstruction Disease of the old age, starts at ~ 40 but usually presents between 50 ± 70 years estimated 50% of men have histologic evidence of BPH by age 50 years and 75% by age 80 years In 40-50% of these patients, BPH becomes clinically significant
PROSTATIC HYPERTROPHY .
EFFECTS OF PROSTATIC ENLARGEMENT URETHRAL CHANGES y Enlongation of the prostatic urethra y Exaggeration of the posterior curve y Lateral urethral compression (if unilateral) DIFFICULTY IN MICTURITION AND FOLEYS INSERTION .
BLADDER CHANGES : y Compensatory detrusor hypertrophy (increase atonicity) y Post prostatic pouch (retention) CYSTITIS VESICLES PILES URETER AND KIDNEY y Hydroureter and hydronephrosis (Due to obstruction) y Vesiculo-uretric reflux y Acute pylonephritis y Uremia .
HESITENCY ± (waiting for urination) d/t median lobe pressing the orifice.CLINICAL PRESENTATIONS FREQUENCY y Initially nocturnal y Gradually increases to both at day and night ± cystitis & irritation. .
DYSURIA DRIBBLING URINE ± poor stream . URGENCY ± deranged internal sphincter mechanism.
HEMATURIA ± y rupture of dilated veins y cystitis y prostatic erosion y Calculi formation PAIN ± lower abdomen ACUTE RETENTION .
II III . Enlarged. felt easily and finger can be reached above it. felt easily but the finger is reached with difficulty.GRADING ON P/R I Enlarged. Enlarged. felt easily but finger cannot reach above it.
On USG : y Normal yI y II y III y IV 10-15 gm (weight of prostate) 15-20 gm 20-50 gm 50-150 gm > 150 gm .
0-3.0 cm 3.5 cm (length .5 cm .prostatic urethra) yI y II y III 2.5-3. On URETHROSCOPY y Normal ± 2-2.5 cm > 3.
ADVERSE EFFECTS OF BPH Erodes Quality of Life Complications: y Urinary retention y Recurrent hematuria y Bladder stones y Compromised renal function .
COEXISTING PROBLEMS Patients with symptomatic BPH are frequently elderly with coexistent diseases y abnormal electrocardiogram (ECG) 77% y cardiac disease 67% y chronic obstructive pulmonary disease 29% y diabetes mellitus 8% .
COEXISTING PROBLEMS Occasionally patients are dehydrated and depleted of essential electrolytes ex. y long-term diuretic therapy y restricted fluid intake y CHF Long standing urinary obstruction can lead to y impaired renal function y chronic urinary infection. .
nephrologist. .Patients need to be fully evaluated for the comorbidities and optimized with the help of all investigations and special advices from cardiologist. if required. endocrinologist and physician.
Cardiomeg. MI. PH. -Pulmonary evaluation and Cardiac evaluation. heart Blocks.INVESTIGATIONS INVESTIGATIONS AIM -O2 carrying capacity -Max allowable blood loss -Arrange for compatible blood -Any Infections/Inflamation -Acute/chronic inf. Dysrhythmias. allergies -normal/ / -Screening for DM -Renal Function -Renal Function -Renal Function -Evaluate for IHD. 1 2 3 4 5 6 7 8 9 10 11 Hemoglobin Blood group & Rh type Total Count Diff count ESR RBS Blood Urea Serum Creatinine Urine ECG CXR . Pul Edema.
INVESTIGATIONS Total serum proteins ± more chance of fluid overload if hypoproteinemia seen.Hydroureter with Hydronephrosis .Prostate size Electrolytes : Na. Cl. K.Obstruction / calculi / Cysts/ Organomegaly . PFTs USG Abdomen : . Ca ABG . Mg.
SURGICAL THERAPIES The options available are: TURP Suprapubic (transvesicular) prostatectomy Perineal / retropubic prostatectomy Trans urethral electro vapourization Trans urethral laser ( under LA) Trans urethral incision .
TRANSURETHRAL RESECTION OF THE PROSTATE (TURP) ² considered gold standard by most .
TURP is considered as one of the most difficult procedures that a surgeon can learn and master. Excision and coagulation of the hypertrophied tissue (adenoma) are performed under direct vision through a resectoscope. . It involves removal of the gland upto the level of the capsule.
Wire loop .
Continuous irrigation is necessary to provide y Good visibility by dilating the bladder and the prostate y Maintaining an operative field free of dissected prostatic tissue debris and blood .
5 % y CYTAL (sorbitol 2.IRRIGATING SOLUTIONS Common solutions are y Glycine 1.54%) y Urea 1% .7%+mannitol 0.5% & 4% y Sorbitol 3.5% y Mannitol 3% & 5% y Glucose 2.2% and 1.
The ideal duration of resection is ± 60 min estimated that 10-30 ml of irrigating fluid is absorbed per minute of resection time. Absorption of small amount y spontaneous diuresis Absorption of large amount y over hydration y Increased intravascular pressure y Decreased plasma oncotic pressure y Generalized edema .
. the type of irrigation fluid is important. Also.Absorption of irrigation fluid Takes place via the large prostatic venous sinuses.
70-80% Adult 50-60% Geriatric 45-55% Water requirement= 2500cc/day.NORMALLY«. minimum of 1500 cc/day . Water constitutes over 50% of an individual¶s weight Infant.
y salts or minerals in extracellular or intracellular
body fluids Sodium ± major cation of ECF Potassium ± major cation of ICF Chloride - major anion of ICF
Electrolyte Plasma (mEq/L) ISF ICF Sodium 142 141 10
PARENTERAL FLUID THERAPY
Solution ECF Lactated Ringer¶s 0.9% NaCl 0.45% NaCl D5/0.45% NaCl 3% NaCl 6% Hetastarch
Na+ 142 130 154 77 77 513
K+ 4 4
Ca2+ 5 3
Cl103 109 154 77 77 513 154
mOsm/L 280-310 273 308 154
406 1026 310
5% Albumin 25% Albumin
DISTURBANCES ENCOUNTERED« In case of BPH commonly seen are: Circulatory overload Hypo osmolarity Water intoxication Hyponatremia Hypomagnesemia .
Circulatory overload Hypervolumia ± in acute cases. where cardiac reserve is limited. leads to y Hypo osmolarity ± (increased intravascular volume and hemodilution) y Hypertension ± leading to hypertension anginal pain y fluid shift leading to pulmonary edema esp. y cerebral edema can be precipitated y Hyponatremia ± dilutional y Renal derangements ± amount of irrigation fluid inversely proportional to post op urine output .
.HYPERVOLEMIA Irrigation fluid enters circulation through open prostatic venous sinuses Average rate ± 20ml/min May reach upto 200 ml/min Literature suggests as many as 8 L can be absorbed Average weight gain by end of surgery ± 2 kg.
CALCULATION OF FLUID ABSORBED« Determine serum Na at beginning of the surgery Again at the time of estimation of vol absorbed Volume absorbed = (preop Na / postop Na) ECF ± ECF y ECF = 20% .30% of total body water .
with body wt = 50 kg.ECF =1.Example : In a pt.4 ECF.4 ECF = 0. preop Na 140. volume absorption= 140/100 ECF.4 50 20% = 4 litres .ECF = 0. postop Na 100 Then.
sodium: (N 135-145 meq/L) y Major extracellular cation y Essential for proper functioning of excitatory cells esp.HYPONATREMIA The absorption of large amounts of electrolyte-free irrigating fluid leads to Dilutional hyponatremia. heart and brain y Levels may typically fall by 3-10 meq/L The fall in serum sodium inconsistent with amount of total fluid absorbed but dependent on the rate of absorption of fluid .
may lead to loss of wave activity The CNS derangement is not due to hyponatremia per se but acute hypo osmolarity A slow rate in fall of osmolarity apparently allows the CNS to adapt to the hyponatremia.HYPONATREMIA Acute severe hyponatremia associated with y Abnormal neurological symptoms y Can lead to irreversible brain damage y On EEG. .
A decrease in serum (Na) of 20 to 30 mmol / L implies absorption of 3 to 4 L. less than 120 mmol / L indicates a severe hyponatremia. At levels < 110 meq/L pt can develop respiratory and cardiac arrest .
PREVENTION Pt should be adequately prepared pre op Pts with CHF ± treat vigourosly y diuretics and fluid restriction Conservative surgical approach in critically ill ptsex. simple canalization or balloon dialatation Most imp factor ± preservation of prostatic capsule (surgeon¶s skills) Limit hydrostatic pressure of irrigating solution to <60 cm of H2O Prevent bladder overdistension .
Below 120 meq cellular activity is deranged. Administer intravenous fluids cautiously: y Use a microdrip set. esp. in pts with cardiac or renal derangements y Use vasopressors instead of large boluses of fluid in case of hypotension during regional anesthesia. Hyponatremia also accentuated by pre op deficiency or excessive intra op bleeding. . Surgery should be terminated at levels below this.
TREATMENT Administration of hypertonic saline to treat not always necessary. Not recommended unless pt develops clinical signs of hyponatremia.should be given with serum osmolarity monitoring . Spontaneous or induced diuresis with 20 mg furosemide ± corrects hyponatremia in few hrs Saline administration itself can provoke pulmonary edema ± due to fluid overload Hypertonic saline.
TREATMENT CONTD« Rapid administration of hypertonic saline ± associated with central pontine myelinolysis y Also c/a osmotic demyelination syndrome. Sodium should not be corrected at a rate faster than 1.5 meq/ L/ hour .
Water intoxication .3.
dilated and sluggishly reacting pupil EEG.WATER INTOXICATION: Some patients exhibit neurological signs like: y Decerebrate posture y Clonus y babinski reflex present y Convulsions and eventually coma Eye exam: papilledema.low voltage b/l .
other . BBB essentially impermeable to sodium but freely permeable to water Cerbral oedema raise ICT bradycardia and hypertension neurological symptoms.
WATER INTOXICATION: .
Cell in a hypotonic solution Hemolysis can occur .
TURP SYNDROME The TURP syndrome is an iatrogenic surgical complication but the responsibility for its diagnosis and treatment falls upon the anaesthetist. hence the importance. During TURP. there is opening up of an extensive network of venous sinuses allowing excessive systemic absorption of irrigation fluid. . This extensive absorption of fluid( > 2L) results in a combination of S/S referred to as TURP syndrome. Seen in approx 2% of Pt.
CVS symptoms Fluid overload y CHF y Pulm edema y Hypertension y Bradycardia * If Na+ <120 meq/l negative ionotropic effect manifests as hypotension and tachycardia. * Therapy stop irrigation for 15-20 min Hypoxaemia MI Cardio-pulm arrest .
Hyponatraemia may occur when any of the irrigating fluids is used. but hyperglycinaemia and hyperammonaemia may occur only when glycine is used as the irrigating fluid. and/or y hyperammonaemia. .CNS SYMPTOMS The etiology of these CNS disturbances has been attributed to y hyponatremia. y hyperglycinaemia.
Altered states of consciousness comatose state metabolic encephalopathy. focal or generalized seizures. Mild papilloedema and Decerebrate movements .
What is to be done«. Preop y Correct any fluid / electrolyte imbalance y Correct anemia y T/t cardiac failure Intra op y Blood loss should be carefully replaced y Hydrostatic pressure of the irrigating fluid should not exceed 60 cm of H2O.. ± avoid excessive elevation of the irrigating bag .
at least 300 ml of fluid / min is needed for good visual field. This cannot be achieved at below 60 cm.) y Care that bladder outflow remains unobstructed (watch the Uro-bag volume) y If Ht is changed from 60 to 70 cm ~ 2 fold increase in fluid absorption is seen. DONOT LOWER excessively as this will prolong resection time. y Resection time should not exceed 60 min y However.. . Intra op (cont.
Infusion of clear fluids should be suspended. .TREATMENT Depends on the detection of hyponatremia ± serial sodium measurements must be done whenever unexplained changes in BP or cerebral irritation is seen. Loop diuretic ± furosamide is t/b given Sodium correction is controversial. Blood loss should be replaced by slow blood transfusion.
6 for men and 0.6 * Bd WT (KG) (*use 0.CURRENT [NA]) X 0.5 for women). Na deficit = (DESIRED [NA] .For established cases In case of acute hyponatremia with neurological features. rapid correction till neurological improvement is to be done. .
as manifested by severe confusion.6 ± 1. or evidence of brainstem herniation. Hypertonic saline may be used to rapidly increase serum sodium level in patients with severe acute or chronic hyponatremia. Rate of correction should be 0.0 mEq / L / hr until sodium reaches 125 after that the rate is 1. ½ correction is done in initial 8 hr then the rest over 1-3 days.5 mEq / L / hr. . seizures. coma.
increase of 4-6 mEq/L in serum sodium level is sufficient to arrest progression of symptoms in severe hyponatremia. . Hypertonic (3%) saline ± Contains 514 mEq/L of NaCl.Edema in presence of cardiac failure. Further rapid increase in serum sodium level not indicated. May precipitate P. osmolarity Sh/b acertained before hand and CVP monitored thereby In general.
Normally the blood loss during TURP y 2-5 ml / min of resection time y 20-50 ml / gm of tissue resected Extent of blood loss is determined by y Resection time y Size of gland y Surgical expertise Absorption of irrigating fluid increased intravascular pressure increased bleeding .
coughing during regional anaesthesia Regional anaesthesia is associated with as much bleeding as deep GA as vasodilatation increases venous pooling . Any factor which increases peripheral venous pressure increases bleeding from prostatic bed y Straining during light anaesthesia (GA) y Shivering.
bleeding from skin puncture site. Other possible reasons for excessive bleeding: y Dilutional thrombocytopenia y Local release of fibrinolytic agents : plasminogen and urokinase from mucosa of LUT Sudden loss of blood without clots. sub mucosal h¶ge m/b seen Treated with EPSILON AMINOCAPOIC ACID 4-5 g during the first hour and followed by 1 g /hr for the next 24 hr .
ESTIMATION OF BLOOD LOSS : y Visual estimation is inaccurate d/t mixing y Hypotention & tachycardia are delayed d/t increased circulatory volume y Estimated to be 200-2000 with an average of ~500ml. that enter bloodstream during surgery can trigger DIC. y Serial hematocrit y Hb assessment in suction bottle fluid . Prostatic particles rich in thromboplastin.
Factors increasing mortality Age > 80 yrs Resection time > 150 min Resected tissue > 60 g Presence of azotemia ( 6 times increase) Mortality rate ± 0.8 % .2-0.
.KYOU Thank you«.
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