Kang, Taek WonChonnam National University Medical School

Changes…

Decreased morbidities/mortality

Increased prostate size needing TURPDevelopment of alternative Tx

TURP Complications Immediate :

TUR syndrome Failure to void Postop hemorrhage Clot retention UTI

Late : Retrograde ejaculation (75%) Impotence (4~10%) Incontinence (<1%) BN contracture

Morbidity / Mortality: 18% / 0.2% → 6%/0.1%

ContentsPatients selection

Preoperative concern

Initiating procedure

Intraoperative concern

Postoperative concern

Take home message

Patient selectionSurgeon experiance

Cormobidities

Counselling

TURP in different eras

Lim KB et al 2004

Postop complications

Lim KB et al 2004

Patient demographics & intraopvariables

Age:

Mean ± SD (range) 69.0 ± 7.7 (46.0–96.0)

No. older than 80 (%) 179 (9.5)

No. older than 90 (%) 12 (0.6)

Mean ± SD wt (kg) 66.5 ± 9.4 (40.5–104.0)

Mean ± SD ht (cm) 166.9 ± 5.9 (145.0–190.0)

No. anesthetic method (%):

General inhalational 244 (13.0)

Spinal 1,634 (87.0)

Mean ± SD operative time (mins) 42.4 ± 26.9

Mean ± SD prostate wt (gm):

Diagnosed 52.6 ± 33.1

Resected 19.2 ± 8.6

Hong JY et al J Urol 2011

No. Pts (%)Comorbidities

Hypertension 865 (46.1)Diabetes 342 (18.2)Cardiac disorder 320 (17.0)Coronary artery obstructive disease 138 (7.3)

Angina 22 (1.2)Atrial fibrillation 60 (3.2)Arrhythmia 79 (4.2)Valve replacement 17 (0.9)Heart failure 4 (0.2)Chronic obstructive pulmonary disease 77 (4.1)

Chronic renal failure 30 (1.6)Central nervous system disorder: 194 (10.3)

Cerebral infarction 117 (6.2)Cerebral hemorrhage 29 (1.5)Parkinson's disease 30 (1.6)Depression 14 (0.7)Dementia 4 (0.2)Malignancy: 41 (2.2)Liver cirrhosis 13 (1.5)Stomach 4 (0.2)Colon 4 (0.2)Rectal 3 (0.2)Lung 5 (0.3)Brain 6 (0.3)Other 7 (0.4)Thyroid disease 34 (1.8)Spine disease 17 (0.9)Other 29 (1.5)

Complications

Persistent hematuria 31 (2.2)

Failure to void 22 (1.2)

Surgical revision: 17 (0.9)

Bleeding 11 (0.6)

Dysuria 5 (0.3)

Renal injury 1 (0.05)

Pulmonary 13 (0.7)

Cardiovascular: 5 (0.3)

Myocardial infarction 1 (0.05)

Angina 3 (0.2)

Arrhythmia 1 (0.05)

Cerebrovascular 3 (0.2)

Infection 4 (0.2)

Sepsis 2 (0.1)

Other 13 (0.7)

Total 109 (5.8)

Hong JY et al J Urol 2011

Postop complications by CCICCI No. Complication/Total No. (%) p Value

0 50/1,127 (4.4)

1 or 2 45/680 (6.6) <0.05 vs 0

3 or Greater 14/71 (19.7) <0.05 vs 0, <0.01 vs 1 or 2

Total 109/1,878 (5.8)

Hong JY et al J Urol 2011

Charlson comorbidity index : predicts the ten-year mortality for a patient who may have a range of co-morbid conditions such as heart disease, AIDS, or cancer (a total of 22 conditions). Each condition is assigned with a score of 1,2,3 or 6 depending on the risk of dying associated with this condition. Then the scores are summed up and given a total score which predicts mortality

Complications by age & comorbiditiesAge (comorbidity) No. Pts/No. Complication (%) p Value

40–49: 5

No 5/0

Yes 0 Nonspecific

50–59: 197

No 134/5 (3.7)

Yes 63/7 (11.1) 0.043

60–69: 800

No 536/23 (4.3)

Yes 264/20 (7.6) 0.028

70–79: 701

No 369/15 (4.1)

Yes 332/26 (7.8) 0.017

80–89: 164

No 78/6 (7.7)

Yes 86/6 (7.0) Nonspecific

90–99: 12

No 4/0

Yes 8/0 Nonspecific

Hong JY et al J Urol 2011

Mechanical difficulties Check all equipment after each use Closely inspect the instruments while assembling

Initiating the procedure Phimosis

Trap periurethral drainage: urethritis, stricture formation

Meatal stenosis Trap periurethral drainage: Prevent passage of resectoscope, instruments

Intraop priapism Forcing instrument in erect

penis result in meatal of urethrla injury Urethral stricture

Circumcision or dorsal slit

Meatotomy or VIU

Amyl nitrate or ephedrine IC inj

Initiating the procedure Urethral stricture

False passage Internal urethrotomy

Perineal urethrostomy

Dilation or VIU

Prevent strictureGentle

technique

Proper preliminary

dilation

Insturmentlubrication

Smallest instrument

Limiting time <1hr

Catheter removal ASAP

Intraoperative concern Bleeding

Prostate size

Resection time

Surgical technique

Preop coagulation profile

Massive fulguration

Sloughing of tissue

Delayed hemorrhage

Careful electrofulgurationof bleeding arteries

BP must be normal at termination

Venous sinus open• Irrigation fluid lowering• Catheter traction• Careful irrigationDo!

• Indiscriminate fulguraion• Continuous irrigation

when occlusion of catheterCaution!

Resection of intravesical ureter

Check both U.O.

Cutting current for bl. neck

Coagulation of U.OStent 4-6wks

IVP, VCUG, cystogram

Extravasation

Spinal, epidural anesthesia• Early detect symptomatic extravasation

General anesthesia• Delay, masking early Sx

Signs & Sx of extravasation Distortion of prostatic urethra

Narrowed lumen Elongated prostatic urethra

Distant bladder neck and trigone Abdominal distention Abdominal discomfort

explorationIf intraperitonealcystogram

Catheter drainDiuretics

Monitoring electrolytes

TUR syndromeconfusion

hypertension

bradycardia

nausea

vomitting

Visual disturbances

Dilutional hyponatremia

Prevent TUR-S Spinal anesthesia

A-line, intraop check of plasm Na

Perforation, venous sinus open

Loop diuretics, IV fluid change to P/S

Severe hyponatremia

Hypertonic saline (3%) may be necessary

Infection

Preopinfection

Prolonged catheter

Postopinfection

Tx of preopUTI

Prophylactic antibiotics

Incontinence Permanent incontinence: 0.5%

Sphincteric injury

Detrusor instability

Forewarn patients

Anticholinergics

UDS

Obstruction, retention

RISK

Poorly controled DM

Chronic U retention

Potential neurogenic

problem

Urethral stricture

BN contracture

Inadequate ts resection

Atonic bladder dysfunction

Bladder neck contractureToo deep

resection of BN

Cutting too much internal sphincter

ring fiber

Small , fibrotic prostate

Excessive catheter traction

Indiscriminate fulguration

Sexual function Retrograde ejaculation

Expected sequela – need forwarn

Normal ejaculation after TURP: suspect BN contracture

Rarely affect potency (4%)

Confuse retrograde ejaculation with impotence

Take home message Medical Tx

Increased prostate size needing TURP

TURP remains GOLD STANDARD

Proper Pt. choice, preop planning, instruments

Communication

Urologist, anesthesiologist, op room staff