Complications of transurethral resection of the prostate

Published on 13/02/2015 by admin

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Complications of transurethral resection of the prostate

Marie L. De Ruyter, MD

Transurethral resection of the prostate (TURP), one of the more common surgical procedures performed in men over age 60, is the standard surgical treatment for benign prostatic hypertrophy (BPH) when symptomatic obstruction of urinary outflow occurs. A variety of factors have led to decreasing mortality and morbidity rates associated with this procedure, including increased awareness of BPH, which has led to earlier treatment, and the availability of new drugs and new surgical techniques, which are associated with lower rates of complications.

In a traditional TURP, resection of the prostate is performed during cystoscopy using a resectoscope with an electrocautery loop. The morbidity rate of 7% to 20% is associated with longer resection times (>90 min), larger gland size (>45 g), acute urinary retention, and age greater than 80 years. One of the most serious complications associated with TURP, TURP syndrome (Box 166-1) occurs in 2% to 15% of patients treated with this approach. Postoperative bleeding with the need for blood transfusion occurs in about 2% to 4.8% of patients who develop TURP syndrome.

Box 166-1

Signs and Symptoms of Transurethral Resection of the Prostate Syndrome

Cardiovascular and Respiratory Central Nervous System Metabolic Other
Hypertension
Bradyarrhythmias/tachyarrhythmias
Congestive heart failure
Pulmonary edema and hypoxemia
Myocardial infarction
Hypertension		 Agitation/confusion
Seizures
Coma
Visual disturbances (blindness)		 Hyponatremia
Hyperglycinemia
Hyperammonemia		 Hypo-osmolality
Hemolysis

image

From Malhotra V, Sudheendra V, O’Hara J, Diwan S. Anesthesia and the renal and genitourinary systems. In: Miller RD, ed. Anesthesia. 7th ed. Vol. 2. Philadelphia: Churchill Livingstone; 2009: Chap. 65.

With newer surgical techniques, however, TURP syndrome occurs in as few as 1.1% of patients, such that anesthesia providers are now unlikely to encounter patients with this complication.

Treatment

Medical options

One of the reasons the incidence of complications of TURP is decreasing is that many men are successfully treated medically, and for those whose symptoms progress, the prostate may not be as large as it might have been without medical treatment; therefore, the operative procedure has a shorter duration and is associated with fewer complications. The medical treatment of BPH includes the oral administration of α-adrenergic antagonists (e.g., tamsulosin) or 5α-reductase inhibitors (e.g., finasteride). If medical treatment is unsuccessful or symptoms progress and the patient is a surgical candidate, a TURP may be performed to treat symptoms.

Surgical options

TURP is performed under direct vision. The most common procedure in the past was performed with a modified cystoscope (resectoscope) with a monopolar electrically energized wire loop. Bleeding was controlled with a coagulating current. Continuous irrigation was used to distend the bladder and remove blood and dissected prostatic tissue. Because the prostate contains large venous sinuses, it was inevitable that irrigating solution would be absorbed into the vascular system. The volume absorbed depended on three factors: the hydrostatic pressure, duration of the resection, and number and size of the opened venous sinuses. The hydrostatic pressure is determined by the height of the irrigating fluid above the patient. Prostate venous sinuses have a pressure of approximately 10 mm Hg. The duration of the TURP was dependent upon the size of the prostate and experience of the surgeon. Approximately 10 to 30 mL of irrigating solution is absorbed per minute of resection time. The choice of irrigation solution is dependent on several factors as discussed later.

Monopolar TURP is still considered by many as the treatment of choice for very enlarged prostates (50-80 g); however, this “gold-standard” is marred by the previously mentioned significant morbidity and mortality rates.

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