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Kang, TaekWon Chonnam National University Medical School · 2011-09-05 · TURP Complications...
Transcript of Kang, TaekWon Chonnam National University Medical School · 2011-09-05 · TURP Complications...
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