TURP

TURP Indications for TURPIndications for TURP What does it involve?What does it involve? What are the complications and how should they be managed?What are the complications and how should they be managed?

Indications for TURP Acute Retention of UrineAcute Retention of Urine Significant symptoms from BOO not responsive to tabletsSignificant symptoms from BOO not responsive to tablets Persistent or recurrent UTIPersistent or recurrent UTI Significant bleeding (if due to Prostate)Significant bleeding (if due to Prostate) Bladder stones secondary to bladder outlet obstructionBladder stones secondary to bladder outlet obstruction

What is a TURP?

Complications of TURP Specific to TURP General Common BleedingBleeding SepsisSepsis Less Common TUR SyndromeTUR Syndrome Erectile DysfunctionErectile Dysfunction Retrograde ejaculationRetrograde ejaculation Stricture formationStricture formation DVTDVT PEPE MIMI

Bleeding Virtually patients will develop some bleedingVirtually patients will develop some bleeding Can range from minor  severeCan range from minor  severe May not be apparent immediately on return to wardMay not be apparent immediately on return to ward Nursing observations vital – pulse, blood pressureNursing observations vital – pulse, blood pressure

Bleeding continued… If bleeding appears more than rosé then use catheter traction +/- speed up irrigation fluidIf bleeding appears more than rosé then use catheter traction +/- speed up irrigation fluid Safe to use with 3 way catheterSafe to use with 3 way catheter Will not cause sphincter damageWill not cause sphincter damage May stop bleeding!May stop bleeding! If bleeding does not settle with above measures, or if patient requires washout  call SpR or ConsultantIf bleeding does not settle with above measures, or if patient requires washout  call SpR or Consultant

Sepsis Occurs when bacteria in urine get into bloodstream during operationOccurs when bacteria in urine get into bloodstream during operation May be associated with fever, rigors etc.. or just with hypotension (shock)May be associated with fever, rigors etc.. or just with hypotension (shock) Patient is usually warm and dry rather than “cool and clammy”Patient is usually warm and dry rather than “cool and clammy” Treatment is with intravenous antibiotics and IV fluids to restore circulating volumeTreatment is with intravenous antibiotics and IV fluids to restore circulating volume

TUR Syndrome Occurs when intraoperative irrigant fluid (glycine) enters bloodstream via veinsOccurs when intraoperative irrigant fluid (glycine) enters bloodstream via veins Glycine metabolised to ammonia and waterGlycine metabolised to ammonia and water Effect is therefore same as giving IV Water  hypotonic transfusion  lowers blood sodiumEffect is therefore same as giving IV Water  hypotonic transfusion  lowers blood sodium

Effects of Absorption on [Na+] absorption of electrolyte +ve irrigating fluid leads to dilutional hyponatraemia (but more than would be expected from absorption of equivalent amount of water)absorption of electrolyte +ve irrigating fluid leads to dilutional hyponatraemia (but more than would be expected from absorption of equivalent amount of water) [Na+] < 120 mmol/l = severe TUR syndrome[Na+] < 120 mmol/l = severe TUR syndrome

Factors affecting absorption Hydrostatic pressure of irrigating fluidHydrostatic pressure of irrigating fluid Number of open venous sinusesNumber of open venous sinuses Peripheral venous pressurePeripheral venous pressure Duration of SurgeryDuration of Surgery Experience of surgeonExperience of surgeon

Presentation CardiovascularCardiovascular CNSCNS MetabolicMetabolic

Cardiovascular signs Increased CVPIncreased CVP BradycardiaBradycardia Increased BP (May be masked by blood loss)Increased BP (May be masked by blood loss) Pulmonary oedemaPulmonary oedema AnginaAngina ECG ChangesECG Changes Cardiovascular collapse (Decreased BP and HR, Cardiac arrest)Cardiovascular collapse (Decreased BP and HR, Cardiac arrest) Falling Hb and HaematocritFalling Hb and Haematocrit

CNS signs ApprehensionApprehension DisorientationDisorientation RestlessnessRestlessness NauseaNausea Visual disturbancesVisual disturbances StuporStupor ComaComa SeizuresSeizures Delayed recovery from GADelayed recovery from GA

Metabolic signs Decreased [Na+]Decreased [Na+]

Treatment of TUR syndrome - Mildly symptomatic =Nausea, vomiting, confusion +/- visual disturbances in the presence of stable CVS=Nausea, vomiting, confusion +/- visual disturbances in the presence of stable CVS Check plasma electrolytes - [Na+] > 120 mmol/lCheck plasma electrolytes - [Na+] > 120 mmol/l Observation onlyObservation only If signs of fluid overload consider loop diureticIf signs of fluid overload consider loop diuretic

Treatment of TUR syndrome - unconscious patient Establish diagnosis - [Na+], [glucose], [urea], osmolality, ammonia level, ABG’s, ECGEstablish diagnosis - [Na+], [glucose], [urea], osmolality, ammonia level, ABG’s, ECG Differential diagnosisDifferential diagnosis Supratentorial massSupratentorial mass Subtentorial massSubtentorial mass Metabolic conditionMetabolic condition PsychiatricPsychiatric Anaesthetic causesAnaesthetic causes Gram -ve septicaemiaGram -ve septicaemia

Treatment of severe TUR syndrome Requires specialist treatment +/- admission to HDU or ITURequires specialist treatment +/- admission to HDU or ITU Hypertonic saline (5%) - give 100 mls over 1 hour and repeat until [Na+] is > 120 mmol/lHypertonic saline (5%) - give 100 mls over 1 hour and repeat until [Na+] is > 120 mmol/l Correction should take place over several hours - acute fluid shifts can lead to greater cerebral irritation and a (permanent) worsening of neurological statusCorrection should take place over several hours - acute fluid shifts can lead to greater cerebral irritation and a (permanent) worsening of neurological status