TURP Complications and BPH Pathophysiology
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What condition is most commonly associated with the need for transurethral resection of the prostate (TURP)?

  • Interstitial cystitis
  • Urinary tract infection
  • Prostate cancer
  • Benign prostatic hyperplasia (BPH) (correct)

    • Which factor does NOT influence the volume of irrigating fluid absorbed during TURP?

  • Type of anesthesia used (correct)
  • Hydrostatic pressure of the solution
  • Duration of resection
  • Peripheral venous pressure

    • What serious complication can arise from systemic absorption of irrigation fluid during TURP?

  • Deep vein thrombosis
  • Pulmonary embolism
  • Metabolic acidosis (correct)
  • Aortic dissection

    • What is the primary cause of urethral obstruction in patients requiring TURP?

    <p>Prostatic enlargement</p> Signup and view all the answers

    Which perioperative complication is NOT typically associated with TURP?

    <p>Anaphylactic shock</p> Signup and view all the answers

    What anatomical feature significantly affects fluid absorption during TURP?

    <p>The complex venous network surrounding the prostatic capsule</p> Signup and view all the answers

    Which statement best describes the dynamic obstruction caused by prostatic enlargement?

    <p>It results from smooth muscle tension at the bladder neck and prostate.</p> Signup and view all the answers

    What can severe dilutional hyponatremia lead to during or after TURP?

    <p>Neurologic and cardiac compromise</p> Signup and view all the answers

    What might be a result of significant bleeding during TURP?

    <p>Severe anemia and metabolic acidosis</p> Signup and view all the answers

    What is the primary physiological effect of terazosin hydrochloride on the prostate gland?

    <p>Decreases smooth muscle contraction</p> Signup and view all the answers

    What is the proposed result of alpha-1 adrenergic overstimulation in the prostate gland?

    <p>Prostatic hyperplasia</p> Signup and view all the answers

    Which spinal cord levels are primarily responsible for the majority of sensory innervation from the prostate gland?

    <p>T12-L2 and L5-L6</p> Signup and view all the answers

    Why is prescribing antibiotics to all patients before TURP considered controversial?

    <p>Bacteriuria incidence is relatively low</p> Signup and view all the answers

    What metabolic by-product synthesized by 5-alpha reductase accelerates cellular proliferation in the prostate gland?

    <p>Dihydrotestosterone (DHT)</p> Signup and view all the answers

    What type of drugs do SAR inhibitors like finasteride target?

    <p>5-alpha reductase</p> Signup and view all the answers

    What has been shown to reduce postoperative bacteriuria after TURP by nearly twofold?

    <p>Preoperative antibiotic administration</p> Signup and view all the answers

    What is the role of the energized wire loop during transurethral resection of the prostate?

    <p>To control bleeding by applying a coagulating current</p> Signup and view all the answers

    Which of the following factors is linked to the development of Benign Prostatic Hyperplasia (BPH)?

    <p>Metabolic syndrome components such as hypertension and obesity</p> Signup and view all the answers

    How does the sympathetic nervous system relate to BPH progression?

    <p>It causes vascular insufficiency leading to impaired blood flow</p> Signup and view all the answers

    What is the significance of C-reactive protein levels in patients with BPH?

    <p>Elevated levels suggest a risk for developing BPH due to inflammation</p> Signup and view all the answers

    What does the average age of male patients at significant urinary obstruction due to BPH typically indicate?

    <p>Progressive nature of BPH in older populations</p> Signup and view all the answers

    Which preexisting medical condition is commonly found in patients presenting for TURP?

    <p>Diabetes and hypertension</p> Signup and view all the answers

    What is the purpose of continuously infusing an irrigating solution during TURP?

    <p>To maintain visibility and reduce the risk of blood loss</p> Signup and view all the answers

    What possible relationship exists between cardiovascular dysfunction and BPH?

    <p>Hypertension may be a contributing factor to BPH progression</p> Signup and view all the answers

    What is a possible physiologic consequence of the lithotomy position during TURP for patients with chronic obstructive pulmonary disease?

    <p>Increased myocardial workload</p> Signup and view all the answers

    Which irrigating solution is most commonly used in North America for TURP procedures?

    <p>Glycine 1.5%</p> Signup and view all the answers

    What is a risk associated with hyperflexion of the thighs in the lithotomy position?

    <p>Compressions of the peroneal nerve</p> Signup and view all the answers

    What cellular effect occurs if the extracellular fluid during TURP is hypotonic compared to the intracellular fluid?

    <p>Cell swelling and lysis</p> Signup and view all the answers

    What is the primary consequence of hyperglycinemia on vision?

    <p>It leads to transient visual disturbances.</p> Signup and view all the answers

    What metabolic issue may arise from the use of sorbitol in irrigation solutions?

    <p>Lactic acidosis.</p> Signup and view all the answers

    Which of the following characteristics of glycine may impact surgical outcomes during TURP?

    <p>It is a metabolic depressant leading to decreased consciousness</p> Signup and view all the answers

    Which factor would most likely decrease the systemic absorption of irrigating fluid during TURP?

    <p>Intermittent coagulation of bleeding vessels.</p> Signup and view all the answers

    What adaptation occurs in the lumbar region as a consequence of the lithotomy position?

    <p>Decreased lumbar curve</p> Signup and view all the answers

    What is a physiological characteristic of normal osmolarity relevant to TURP?

    <p>Approximately 280 mOsm/L</p> Signup and view all the answers

    What is a significant consideration regarding the use of distilled water as an irrigating solution?

    <p>It poses a risk of causing cell lysis.</p> Signup and view all the answers

    What complication can result from the absorption of hypo-osmolar irrigating solution during TURP?

    <p>Dilutional hyponatremia</p> Signup and view all the answers

    Which of the following statements about glycine is accurate?

    <p>It is cardiotoxic and can lead to cardiac hypokinesis.</p> Signup and view all the answers

    What role does the height of the irrigation solution container play during TURP?

    <p>It influences the hydrostatic pressure and visibility during the surgery.</p> Signup and view all the answers

    Why is normal saline/lactated Ringer's solution problematic during TURP?

    <p>It contains electrolytes affecting current dispersion.</p> Signup and view all the answers

    What is a common sign of intraperitoneal bladder perforation during general anesthesia?

    <p>Bradycardia</p> Signup and view all the answers

    What is the average estimated blood loss during a TURP procedure?

    <p>300 to 400 mL</p> Signup and view all the answers

    Which factor does NOT contribute to increased blood loss during TURP?

    <p>Duration of anesthesia</p> Signup and view all the answers

    Which treatment is appropriate for managing postoperative DIC in TURP patients?

    <p>Administering blood products</p> Signup and view all the answers

    What factor can make estimating blood loss during TURP challenging?

    <p>Dilution of blood by irrigation</p> Signup and view all the answers

    What primarily causes dilutional hyponatremia during the absorption of irrigating fluid in TURP?

    <p>Loss of sodium to the intravascular space</p> Signup and view all the answers

    Which of the following is a potential cardiac effect of hypervolemia during TURP?

    <p>Congestive heart failure</p> Signup and view all the answers

    How is the estimated blood loss during TURP calculated?

    <p>(Hct % of irrigant X Total volume of irrigant) / Preoperative Hct %</p> Signup and view all the answers

    What surgical approach is commonly used for managing large bladder perforations?

    <p>Direct surgical closure</p> Signup and view all the answers

    What is a characteristic of TURP syndrome that can vary between patients?

    <p>Cardiovascular response to hyponatremia</p> Signup and view all the answers

    Which factor is NOT mentioned as increasing the likelihood of developing TURP syndrome?

    <p>Reoperation on a larger prostate</p> Signup and view all the answers

    What condition might arise due to metabolic acidosis associated with TURP syndrome?

    <p>Cerebral edema</p> Signup and view all the answers

    What assay might show an increase of 15% to 25% as a result of cellular changes during TURP?

    <p>Serum potassium</p> Signup and view all the answers

    What is a critical aspect to ensure adequate treatment of TURP syndrome?

    <p>Understanding the variability of symptoms in different patients</p> Signup and view all the answers

    Which of the following statements about serum sodium levels and TURP syndrome is true?

    <p>Symptoms can occur without distinctly low serum sodium</p> Signup and view all the answers

    Which symptom indicates a potential hypothermic condition in a postoperative TURP patient?

    <p>Body temperature of 35.4°C</p> Signup and view all the answers

    What could be a complication if the irrigating fluid is not warmed during TURP?

    <p>Hypothermia</p> Signup and view all the answers

    What is a common sign indicating potential bladder perforation following TURP?

    <p>Limited urine output from the catheter</p> Signup and view all the answers

    Which intervention is critical for diagnosing myocardial ischemia in a TURP patient postoperatively?

    <p>Obtain a 12-lead ECG</p> Signup and view all the answers

    Which parameter is primarily assessed to identify signs of hypervolemia in a TURP patient?

    <p>Lung sounds</p> Signup and view all the answers

    What potential group of complications may arise from fluid absorption during TURP?

    <p>Dilutional hyponatremia</p> Signup and view all the answers

    Which condition could result from insufficient warming measures post-TURP?

    <p>Hypothermia</p> Signup and view all the answers

    Which diagnostic evaluation is necessary for managing suspected myocardial ischemia during the postoperative period?

    <p>12-lead ECG</p> Signup and view all the answers

    What is a critical response when a TURP patient exhibits sinus tachycardia and confusion?

    <p>Initiate forced-air warming</p> Signup and view all the answers

    Which of the following is NOT a treatment consideration in managing postoperative complications after TURP?

    <p>Diuretics for hypernatremia</p> Signup and view all the answers

    What is the recommended treatment for seizure activity in a patient experiencing TURP syndrome?

    <p>Use benzodiazepine and control the airway</p> Signup and view all the answers

    Which of the following complications is specifically associated with severe systemic absorption of irrigation fluid during TURP?

    <p>Dilutional hyponatremia</p> Signup and view all the answers

    During TURP, how often should serum sodium values be checked to monitor for TURP syndrome?

    <p>Every 20 minutes</p> Signup and view all the answers

    Which of the following is an appropriate initial response if TURP syndrome is suspected?

    <p>Stop surgery and initiate ACLS/BLS protocols as needed</p> Signup and view all the answers

    What complication is characterized by a clinical scenario involving monitor requirements and symptom emergence post-TURP?

    <p>TURP syndrome</p> Signup and view all the answers

    Study Notes

    Transurethral Resection of the Prostate (TURP)

    • Majority of patients presenting for TURP have pre-existing medical conditions.
    • TURP irrigation fluid absorption can cause fluid overload, low sodium levels (hyponatremia), and metabolic acidosis.
    • Factors influencing irrigation fluid absorption during TURP:
      • Hydrostatic pressure of the irrigation solution
      • Number and size of open venous sinuses
      • Peripheral venous pressure
      • Duration of resection
    • Severe dilutional hyponatremia can lead to rapid neurological and cardiac complications.
    • TURP-related complications include:
      • TURP syndrome
      • Hemorrhage
      • Hypothermia
      • Sepsis
      • Bladder perforation
      • Myocardial dysfunction

    Pathophysiology of BPH and TURP

    • Benign prostatic hyperplasia (BPH) affects approximately 90% of men during their lifetime.
    • TURP is the second most common surgical procedure in men over 65 years old.
    • Urethral obstruction in BPH is caused by:
      • Static component: Mechanical obstruction by enlarged prostate lobes narrowing the urethral lumen leading to urinary retention.
      • Dynamic component: Smooth muscle tension in the prostate and bladder neck further impeding urine flow.
    • Varying degrees of obstruction cause discomfort and hydronephrosis.
    • Prostatic capsule is surrounded by a complex venous network.
    • Venous ligation during resection allows irrigation fluid entry into systemic circulation.
    • Complications related to fluid absorption and blood loss include:
      • Severe anemia
      • Dilutional hyponatremia and hypervolemia
      • Metabolic acidosis

    Transurethral Resection of the Prostate (TURP)

    • Procedure: Removal of excess prostatic tissue via a resectoscope inserted into the urethra.
    • Technique: Cutting or coagulating current applied to prostate tissue.
    • Hemostasis: Frequent coagulation helps reduce blood loss.
    • Anesthesia: General anesthesia is typically used.

    Preoperative Considerations**

    • High Prevalence of Coexisting Diseases: Patients undergoing TURP often have significant systemic conditions due to the age range affected (average 70 years).
    • Cardiovascular Dysfunction: BPH may be linked to metabolic syndrome (hypertension, diabetes, obesity, insulin resistance, dyslipidemia), and increased inflammatory mediators (C-reactive protein).
    • Autonomic and Sensory Innervation:
      • Autonomic: Sympathetic (T10-L2) and parasympathetic (S2-S4) innervation modulates prostate growth and function.
      • Sensory: Sensory information relayed to spinal cord segments T12-L2 and L5-L6.
    • Medications:
      • Terazosin Hydrochloride (alpha-adrenergic antagonist): Decreases smooth muscle contraction in the prostate capsule and bladder neck, reducing urinary obstruction symptoms. Does not slow BPH progression.
      • Finasteride (5-alpha reductase inhibitor (SARI)): Reduces dihydrotestosterone (DHT) levels, slowing prostate growth and decreasing urinary obstruction.
    • Antibiotic Prophylaxis: Controversial practice, but antibiotic prophylaxis may decrease bacteriuria and UTI risk.
    • Septicemia: Significant concern, particularly in older patients, with mortality rates as high as 20%.

    ### Lithotomy Position

    •  The lithotomy position, commonly used for TURP, involves positioning the patient on their back with their legs raised and abducted.
    •  This position leads to a reduced functional residual capacity in the lungs, potentially causing breathing difficulties, particularly in patients with chronic obstructive pulmonary disease (COPD).
    •  The elevation of the legs increases central venous blood volume by approximately 500 mL, resulting in an increased myocardial workload.
    •  Venous stasis and peripheral ischemia are more likely in patients with pre-existing vascular insufficiency due to the lithotomy position.
    •  Ligaments in the lower legs and lumbar region are stretched, leading to a decreased lumbar curve. This can cause spinal anesthesia to spread cephalad, potentially resulting in a high spinal, especially within minutes after the spinal anesthetic is administered.
    •  It's crucial to pad the lower legs to prevent injury to nerves, including the common peroneal (lateral knee), saphenous (inner knee), obturator, femoral, and lateral femoral cutaneous nerves.

    ### Irrigating Solutions for TURP

    • Continuous irrigation through the resectoscope is essential during TURP to dilate the prostatic urethra, provide visibility for the surgeon, and remove blood and resected prostatic tissue.
    • The osmolarity of irrigating solutions is crucial. Absorption of solutions that are significantly hyperosmolar or hypoosmolar can have serious physiological effects.
    •  The definition of osmosis involves water moving across a semipermeable membrane from an area of higher concentration (lower solute concentration) to an area of lower concentration (higher solute concentration).
    •  Extracellular fluid hypotonia relative to intracellular fluid causes cellular swelling and lysis, while hypertonicity leads to cell crenation (shrinkage).
    •  Glycine (1.5%) is the most common irrigating solution in North America. It's an essential amino acid and inhibitory neurotransmitter naturally found in the body.
    •  Glycine's metabolic byproduct, ammonia, is a potent depressant of the brain and heart, leading to decreased consciousness and cardiac output. Glycine is cardiotoxic, potentially causing cardiac hypokinesis and elevated troponin I levels.
    •  Ammonia decreases the production and release of norepinephrine from postsynaptic nerve terminals, resulting in hypotension.
    •  Hyperglycinemia can cause transient visual disturbances, ranging from blurred vision to blindness, lasting 24-48 hours. It is theorized that glycine's inhibitory effects disrupt retinal synaptic transmission.
    •  Cytal (2.7% sorbitol/0.54% mannitol) contains mannitol, a sugar alcohol that is not metabolized and is rapidly excreted by the kidneys. However, sorbitol is metabolized to fructose, potentially causing hyperglycemia.
    •  Theoretically, fructose metabolism during glycolysis takes precedence over glucose metabolism, leading to the release of pyruvate and lactate, resulting in lactic acidosis.
    •  Distilled water, due to its hypoosmolarity and risk of cellular lysis, is rarely used in TURP procedures.
    •  Normal saline/lactated Ringer's, while seemingly ideal due to isoosmolarity and lack of metabolic byproducts, are not preferred because the electrolytes interfere with electrical current focusing during the procedure.

    ### Factors Affecting Irrigating Fluid Absorption

    • The hydrostatic pressure of the irrigating solution: This is determined by the height of the irrigating solution container. An ideal height of 60 cm is recommended to ensure good surgical visibility.
    • The number and size of open venous sinuses during resection: A larger prostate gland has a greater surface area, exposing more venous sinuses during resection, leading to increased irrigant absorption. Intermittent coagulation of bleeding vessels can minimize absorption.
    • The peripheral venous pressure: Absorption is maximized when venous pressure is lowest.
    • The duration of resection: Approximately 10-50 mL of irrigant can be absorbed into systemic circulation per minute of resection. Ideally, TURP procedures should not exceed 60 minutes.

    TURP Syndrome

    • Fluid absorption during transurethral resection of the prostate (TURP) can cause several physiological changes, including dilutional hyponatremia, hypocalcemia, and hyperkalemia.
    • These cellular changes can lead to severe metabolic acidosis, known as TURP acidosis.
    • Hypervolemia during TURP can cause cerebral edema, myocardial ischemia, and congestive heart failure.
    • Factors that increase the likelihood of TURP syndrome include a resection time exceeding 60 minutes, a prostatic weight greater than 30 grams, an inexperienced surgeon, and a total irrigation volume exceeding 30 liters.
    • While serum sodium levels can be indicative of TURP syndrome, the severity of signs and symptoms can vary between patients.
    • The best way to prevent TURP syndrome is to avoid the situation from occurring.
    • Careful monitoring and prompt intervention are crucial for managing TURP syndrome.

    Bladder Perforation

    • Bladder perforation can occur during TURP due to increased pressure from the irrigating solution or the cutting current of the energized wire loop.
    • The location of the perforation can be either intraperitoneal or extraperitoneal.
    • The signs and symptoms of bladder perforation include abdominal pain, tenderness, and distention.
    • Bradycardia during general anesthesia may indicate an intraperitoneal bladder perforation due to the leakage of irrigation fluid into the peritoneal cavity.
    • Most small, extraperitoneal bladder perforations resolve spontaneously, while larger perforations require direct surgical closure.

    Blood Loss

    • The average estimated blood loss during TURP is 300 to 400 mL, with variability based on prostate size and resection duration.
    • Blood loss is increased when the prostate size exceeds 45 grams or the resection time exceeds 90 minutes.
    • Diluting effects of irrigation fluid make accurate estimation of blood loss challenging.
    • Medications like tranexamic acid can be administered to minimize blood loss during TURP.
    • Postoperative disseminated intravascular coagulation (DIC) syndrome is a rare complication of TURP and can be managed with fibrinogen, platelets, and cryoprecipitate.

    Postoperative Complications after Transurethral Resection of the Prostate (TURP)

    • Potential postoperative complications:

      • Bladder perforation
        • Symptoms: Discomfort in the abdominal and/or inguinal regions, no urine output from the urethral catheter
        • Treatment: Urology consultation
      • Hyponatremia
        • Diagnosis: Serum sodium value
        • Treatment: Treat as discussed in previous medical resources
      • Hypervolemia
        • Diagnosis: Listen to bilateral lung fields, obtain chest x-ray
        • Treatment: Consider diuretics
      • Hemorrhage
        • Diagnosis: Obtain hemoglobin/hematocrit value
        • Treatment: Administer blood if necessary
      • Hypothermia
        • Diagnosis: Confirm temperature value, forced-air warming
        • Treatment: Consider meperidine to decrease shivering when oxygen saturation improves
      • Myocardial ischemia/infarction
        • Diagnosis: Obtain chest x-ray, obtain 12-lead ECG
        • Treatment: Administer volume if no signs of congestive heart failure, administer phenylephrine, check calcium levels (potential cause of hypotension), cardiologist consultation

    • Hypothermia:

      • Average temperature loss after TURP: 1° to 1.5°C
      • Cause: Not warming bladder irrigation
      • Contributing factor: Can inhibit coagulation and increase myocardial oxygen demand

    • Post-anesthesia care unit (PACU) symptoms in this scenario:

      • Restlessness
      • Confusion
      • Shivering
      • Blood pressure: 80/46
      • Respiratory rate: 32
      • Sinus tachycardia with intermittent unifocal premature ventricular contractions (PVCs) rate: 102
      • Room air oxygen saturation: 93%
      • Temperature: 35.4°C

    • Treatment in this scenario:

      • Provide high-flow oxygen
      • Warming measures
      • Diagnose specific cause(s) of the scenario before definitive treatment

    Postoperative Complications of Transurethral Resection of the Prostate (TURP)

    • TURP syndrome is a rare but serious complication. It can occur during or after TURP. It is a syndrome of fluid overload, hyponatremia, and neurological dysfunction.
    • Hemorrhage is a common complication of TURP. It can occur during or after the procedure.
    • Hypothermia is a risk during TURP. The procedure can cause a drop in body temperature.
    • Sepsis is a rare but serious complication of TURP. It is an infection of the blood.
    • Bladder perforation can occur during TURP. It is a tear in the bladder wall.
    • Postoperative hemorrhage is a serious complication of TURP. It occurs when bleeding continues after the procedure has been completed.
    • Subclinical disseminated intravascular coagulation is a condition that can occur after TURP. It is a disorder of blood clotting.
    • Myocardial infarction is a rare but serious complication of TURP. It is a heart attack.
    • Transient myocardial ischemia is a temporary reduction in blood flow to the heart. It can occur after TURP.

    Treatment for TURP Syndrome

    • Stop the surgery immediately.
    • Initiate Advanced Cardiac Life Support (ACLS) or Basic Life Support (BLS) protocols as needed.
    • Check electrolytes, particularly serum sodium values, every 20 minutes.
    • Administer diuretics like furosemide.
    • Treat seizure activity with benzodiazepines, propofol, and airway management.
    • Administer hypertonic saline (3% or 5%) with an infusion rate not exceeding 100 mL per hour.
    • Perform invasive hemodynamic monitoring.

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    Description

    This quiz covers the critical aspects of Transurethral Resection of the Prostate (TURP) and the pathophysiology of Benign Prostatic Hyperplasia (BPH). Focus areas include irrigation fluid absorption, TURP-related complications, and the impact of BPH on men's health. Test your knowledge on these common issues faced by older male patients.

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