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Anesthetic concerns for patients undergoing a Transurethral Resection of the Prostate (TURP).

Although there are competing alternatives available to treat benign prostatic hyperplasia (BPH), transurethral resection of the prostate (TURP) remains the gold standard using either general or spinal anesthesia. There are advantages and disadvantages related to spinal or general anesthesia. Anesthetic concerns and complications during the preoperative, intraoperative, and postoperative surgical phases are analyzed and summarized. Early detection and prevention play a key role in reducing complications and shortening the recovery period.

Keywords: Anesthesia, transurethral resection of the prostate (TURP), Complication.

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Transurethral resection of the prostate (TURP) is a common surgical procedure to remove the enlarged section of the prostate. In the United States, there are approximately 150,000 TURP procedures performed annually (Urology Care Foundation, 2015). While a TURP is used to treat benign prostatic hyperplasia (BPH), alternative surgical technologies have demonstrated ability in lower surgical-associated morbidity. These technologies, which require anesthesia, include laser-assisted TURP, transurethral vaporization of the prostate (TUVP), transurethral needle ablation of the prostate (TUNA), and transurethral microwave thermotherapy (TUMT) (American Urological Association [AUA], 2015). With the advent of the use of the potassium-titanyl-phosphate (KTP) laser to perform the transurethral prostate resection and vaporization, performing a TURP now requires less than the previously needed 2 to 3 hours, and minimal irrigation fluid is needed (Roehrborn et al, 2015). This allows the anesthesia provider to choose an anesthetic based on patient comorbidities versus a procedure-related approach (American Society of Anesthesiologist [ASA], 2014; AUA, 2015). A TURP is more likely to be converted to an open prostatectomy for patients who have an enlarged prostate with or without an intraoperative slit of capsula prostatic. Therefore, the anesthetic options have to be adjusted accordingly.

Although there are competing alternatives available to treat BPH, TURP remains the gold standard using either general or spinal anesthesia (Urology Care Foundation, 2015). An ASA classification is determined for each patient prior to undergoing TURP. This classification documents the acuity of the patient between normal, healthy, to organ donor (ASA, 2014). Patients with an ASA classification of I or II may have general risks from the procedure, such as blood clots, breathing problems, infection, blood loss, heart attack, or stroke, and reactions to medications (ASA, 2014). However, there are additional complications specific to a TURP procedure, such as TURP syndrome, urinary incontinence, infertility, bladder perforation, and erection disorder (Chen et al., 2010; Favilla et al., 2013; Shen, Lin, & Lin, 2012).

There are advantages and disadvantages related to spinal or general anesthesia. Anesthesia providers and urologists discuss the patient's anesthetic plan preoperatively before proceeding with TURP. The best anesthetic agent, with the appropriate duration of action, is to administer agents that would decrease the chance of complications as much as possible and expedite the patient through the postoperative recovery phase to discharge. The choice of anesthetic is guided by the patient's coexisting diseases and the patient's informed preference.

Currently, there are few studies summarizing the anesthetic concerns between general anesthesia and spinal anesthesia for TURP. The aim of this article is to identify the anesthetic concerns during the preoperative, intraoperative, and postoperative surgical phases of using a general or spinal anesthetic for patients undergoing a TURP.

Preoperative Concerns

Patients scheduled to undergo TURP are generally elderly and may have preexisting and/or coexisting medical conditions, including coronary artery disease (CAD), congestive heart failure (CHF), cerebrovascular disease (CVD), chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and renal impairment. A pre-operative medical history and physical review should be thorough and directed toward the prevention of complications prior to inducing anesthesia. Table 1 summarizes the general concerns during the preoperative evaluations (ASA, 2014; Gill, Chung, & Pearl, 2014).

To prevent TURP syndrome, which is caused by excessive absorption of the irrigating fluid, patients are constantly monitored for hemodynamic changes. Routine monitoring includes electrocardiogram (EGG), noninvasive blood pressure, pulse oximetry, and capnography. In addition, intubation and ventilation should always be ready even if spinal anesthesia is selected. Lastly, preoperative antibiotic prophylaxis may reduce postoperative infection.

Intraoperative Concerns

Anesthetic Options: General Anesthesia (GA) Versus Spinal Anesthesia (SA)

Anesthesia providers select the specific anesthetic agents that will be used for general anesthetic or spinal anesthetic. There are advantages and disadvantages for both general anesthesia and spinal anesthesia (see Table 2). A spinal anesthetic is administrated at the lumbar vertebral level of L2-L3, L3-L4, or L4-L5 to achieve up to a TlO spinal sensory level (Fujiwara, Nakahira, Sawai, Inamoto, & Minami, 2014).

Positioning

Lithotomy position is the most commonly used position for TURP. Lithotomy position is a supine position with bilateral legs placed in stirrups and flexed for access to the perineum location on the patient (Nagelhout & Plans, 2014). Research reports show that patients undergoing a TURP in a lithotomy position exhibited significant hemodynamic changes with blood pressure and cardiac output, especially if the patient is obese (Ciftci, Kepekci, Yavasca, Daskaya, & Inal, 2015). Patients in the lithotomy position are also at high risk for development of deep vein thrombosis (DVT) (Rice, Brassell, & McLeod, 2010). The Trendelenburg position should be avoided because it promotes fluid absorption, which can lead to TUI^ syndrome. Therefore, the lithotomy position is preferred with caution.

Anesthetic Agents

There are several studies that compare the effectiveness of low-dose local anesthetics, such as levobupivacaine, lidocaine and ropivacaine, with or without analgesics (Akcaboy, Akcaboy, & Gogus, 2011; Cuvas, Basar, Yeygel, Turkyilmaz, & Sunay, 2010; Gupta et al., 2013; Kim, So, & Kil, 2012; Li, Li & He, 2015; Wang, Pang, Han, Li, & Wang, 2015). The results of these studies demonstrate effective spinal sensory blockade with less motor blockade in spinal anesthesia if the local anesthetics were combined with fentanyl, and they also provided hemodynamic stability in elderly patients. Wang et al. (2015) discussed how preemptive intravenous oxycodone helped to decrease postoperative pain and reduced the need for tramadol analgesia in the postoperative phase.

Intraoperative Complications

TURP syndrome is a complication characterized as hyponatremia with cardiovascular and/ or neurological manifestations (Hahn, 2001). The syndrome appears to be related to excessive absorption of hypotonic irrigation fluid. Other factors related to an increased risk of TURP syndrome include longer resection time, heavier tissue resection, and use of monopolar diathermy (Aziz & Ather, 2015; Fujiwara et al., 2014; Mamoulakis et al., 2012).

TURP syndrome has become a rare event with advances in surgical technology and was found in only 1% of patients (Suhail, Pirzada, & Khaskheli 2010). There are new modifications leading to a decreased incidence of this complication (for example, the development of continuous flow resectoscopes, utilization of "nonhemolytic" solutions, such as glycine, sorbitol, and mannitol, and use of bipolar circuitry). The clinical manifestation of TURP syndrome was created by Hahn (2001), which listed neurological and cardiovascular abnormalities and severities. Management for TURP syndrome includes stop ping intravenous (IV) fluids, stopping surgery immediately, maintaining osmolality, supporting the patient's airway (intubation and ventilation), and maintaining hemodynamic stability (avoidance of bradycardia and hypotension). Administration of hypertonic saline is ideal; however, reports vary on whether sodium should be corrected slowly because rapid correction could lead to cerebral edema and central pontine myelinolysis (Gupta, 2009; Kuroda et al., 2010).

The goal of therapy is to restore sodium to greater than 120 mmol/L. Meanwhile, mannitol combined with furosemide may be used to treat acute pulmonary edema, and anticonvulsants can be utilized for seizure management (Hahn, 2001). The diagnosis of TURP syndrome is critical, and spinal anesthesia is often considered as the first choice to prevent TURP syndrome. In addition, preparing warmed isotonic solution, lowering the height of irrigating fluid, limiting the surgical duration, and providing invasive monitoring (i.e., arterial blood pressure and central venous pressure) all aid in the prevention and/or early detection of TURP syndrome (Boukatta et al., 2013; Sethi & Kapil, 2014; Singh, Asthana, Sharma, & Lai, 2014).

Bladder and prostatic capsular perforation caused by the TURP procedure and/or TURP syndrome has been reported in previous studies; however, the incidence was only around 0.7% (Park, Cho, & Choi, 2013; Shrestha, & Baidhya, 2010). The diagnosis of bladder and prostatic capsular perforation is usually first detected by abdominal distension and pain, and the patient eventually may experience dyspnea (Park et al., 2013). Other manifestations may occur, such as decreased urine output, increased bladder pressure, and decreased core temperature (Fowler & Owens, 2010; Ladner, Nester, & Cascio, 2010). This issue can be treated by supporting the airway, ruling out TURP syndrome, and performing an alternative technique by an experienced urologist to repair the perforation (Chen, Cheng, Yang, & Chung, 2008; Del Rosso, Masciovecchio, Paradiso Galatioto, & Vicentini, 2013). Prostatic capsular perforation may be associated with excessive bleeding and requires placement of a retroperitoneal drain (Chen et al., 2008).

Coronary artery disease tends to be more prevalent in the patient population who undergo TURP (Marmiroli, Antunes, Reis, Nakano, & Srougi, 2012). Several factors inherent in TURP may impose stress on the cardiovascular system. The incidence of acute myocardial infarction (AMI) in patients undergoing TURP is around 2% (Marmiroli et al., 2012; O'Donnell & Foo, 2009). The fluid excess, which leads to TURP syndrome, can cause extensive stress to the heart during TURP. It has been demonstrated that glycine absorption causes EGG changes, such as T-wave depression or inversion, or prolonged R-R interval and QRS duration. Bleeding and erythrocyte transfusion during TURP may also contribute to intraoperative cardiac ischemia (De Lucia et al., 2013). However, a study reported that cold irrigating fluids lead to hypothermia, which increases myocardial work and oxygen consumption due to vasoconstriction and even shivering (Hahn, 2011).

In contrast, several studies indicated that evaluation of cardiac enzyme levels may or may not provide evidence for cardiac dysfunction during TURP (D'Addessi, Bongiovanni, Volpe, Pinto, & Bassi, 2009; Piscione et al., 2010). To significantly reduce the incidence of an AMI, continuous EGG monitoring is critical for early detection, as well as warming the irrigation fluid, preventing TURP syndrome, managing anesthetic techniques, and monitoring electrolyte imbalances. Huang et al. (2012) provide evidence that the bipolar TURP procedure results in deeper coagulation zones, less bleeding, and less risk for TURP syndrome. However, the hypercoaguable state favors thrombi development, which should be taken into consideration as a risk factor for intraoperative and postoperative AMI. As soon as an AMI is confirmed, the treatment for an AMI should be initiated.

Blood loss during TURP is inevitable and is typically below 500 ml, which can be difficult to quantify due to the use of irrigation solution. Factors associated with excessive bleeding include a large prostate gland, extensive resection, a coexisting infection, prolonged surgery, and the presence of a preoperative urinary catheter. In practice, continuous measurements of the hemoglobin level by using pulse co-oximetry are the most useful for investigation of intraoperative blood loss. Urokinase released from raw prostate tissue may provoke systemic fibrinolysis, which may worsen postoperative hemorrhage (O'Donnell & Foo, 2009). Huang et al. (2012) discussed a technique on how anticoagulation can be used to prevent intraoperative hemorrhage.

Disseminated intravascular coagulation (DIG) is a pathological systemic condition resulting from aberrant activation of the coagulation system. There are few reports indicating that less than 1% of patients develop DIG during the intraoperative or postoperative phase of the TURP, which can be caused by a malignancy or poorly controlled urinary tract infection (UTI) (Alhasan, Aji, Mohammed, & Malami, 2008; Desai, John, Evans, & Eddy, 2015). The preoperative tests and prophylaxis are critical to prevent this condition, as well as assessing the extent of hemorrhage and thrombosis. Management includes platelet and other blood product replacement. Heparin should be provided to those patients who demonstrate extensive fibrin deposition without evidence of substantial hemorrhage; it is usually reserved for cases of chronic DIG (Desai et al., 2015).

Urosepsis is a syndrome resulting from a complicated UTI in a patient with hypoperfusion. The reported rates of urosepsis following TURP range from 1% to 4%, with an associated mortality rate of 13%, which raises up to 20% in men over 64 years of age (Alsaywid & Smith, 2013). Administration of antibiotic prophylaxis is accepted and even a recommended practice. The hypoperfusion needs to be immediately corrected during septic shock.

Intraoperative severe and prolonged erection is a urologic emergency, which is common in patients younger than age 50 years. While a significant proportion of penile erections are idiopathic, they can be induced by spinal anesthesia or general anesthesia with the use of propofol (Staerman et al., 1995). K is difficult to perform a transurethral procedure during a penile erection due to potential complications, such as excessive bleeding and urethral trauma. The accepted techniques for treating this condition are to administer intravenous medications (such as ketamine, glycopyrrolate, and terbutaline), deepen the anesthetic if it is a general anesthetic, and/or perform a dorsal nerve block (Natarajan, Remadevi, Bhaskar Rao, & Ramachandran, 2015).

Postoperative Concerns

Patients are discharged from the recovery room when vital signs are stable, systolic blood pressure and heart rate are 10% within the patients' baseline, and nausea, vomiting, and severe pain are absent (Okojie, Ekwere, & Imarengiaye, 2012). The vast majority of the patients experience either no complications or mild complications ranked from persistent bleeding, UTI, or clot retention. Glot retention is usually caused by inadequate bladder irrigation, which may result in bladder distention, vagal stimulation, and pain. These complications are treated with blood transfusions, necessitating repetitive manual blood clot evacuation via the catheter with or without application of catheter traction, and antibiotics (Mamoulakis et al., 2012).

After TURP, some patients develop overactive bladder and/ or bladder spasms. Some reports elicit safe and effective methods for the prevention and treatment of these conditions by using phloroglucinol or a combination of electroacupuncture with tolterodine (Ghen et al., 2010; Shen et al., 2012). The effect of TURP on erectile function is still controversial, and available evidence is conflicting (Favilla et al., 2013; Loughlin, Morgentaler, & Sansa, 2011; Jaidane et al, 2010).

Venous thromboembolism (VTE) continues to present as a common complication of most surgeries. Due to VTE's rapid onset of symptoms, association with a precipitous clinical course, and high mortality rate, clinical providers should be well versed in appropriate prophylaxis, prompt diagnosis, and therapeutic anticoagulation treatment (Jaffe et al., 2011; Rice et al., 2010).

Postoperative pain is minimized by combining anesthetic agents with a low-dose analgesic, such as fentanyl (Wang et al., 2015). One study also demonstrated a reduction in requests of analgesia and complaints of pain by using intrathecal magnesium sulphate (Okojie et al., 2012). There are incidences of AMIs and TURP syndrome in the postoperative phase, while the prevention and expedited treatment is critical for both conditions (De Lucia et al., 2013; Murray et al., 2014).

Postoperative cognitive impairment in patients who have received a general anesthetic is uncommon following a TURP procedure, and there is no significant difference with other surgeries. One study found that patients with preoperatively impaired cognition had an increased risk of further worsening of their cognitive capabilities postoperatively and should be treated carefully (Wiedemann et al., 2015).

Conclusion

Anesthetic challenges of a patient undergoing TURP include minimization of perioperative risk, which requires thoughtful preoperative assessment of organ function and meticulous intraoperative prevention and management of complications, along with vigilant postoperative monitoring. This article provides an overview of anesthetic concerns for TURP. Nurses and health care providers, by understanding the potential anesthetic and surgical risks to patients undergoing TURP, may be able to assist the patient and family to make an informed decision related to the type of anesthetic preferred and that is specifically tailored to the patient's health status.

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Additional Readings

Das, J., Deuri, A., Roy, RM., & Pant, V. (2010). Priapism during transmethral surgery under spinal anesthesia: Implications and review of management options. Indian Journal of Anesthesiology, 54(6), 576-577. doi:10.4103/0019-5049.72654

Demirel, I., Ozer, A.B., Bayar, M.K., & Erhan, O.L. (2012). TURP syndrome and severe hyponatremia under general anaesthesia. BMJ Case Reports, 19. doi:10.1136/bcr-2012-006899

McVary, K.T., Roehrborn, C.G., Avins, A.L., Barry, M.J., Bruskewitz, R.C., Donnell, R.F, ... Wei, J.T (2015). American urological association guideline: Management of benign prostatic hyperplasia (BPH). Retrieved from https://www.auanet.org/edu cation/guidelines/benign-prostatic-hyperplasia.cfm

Nakahira, J., Sawai, T., Fujiwara, A., & Minami, T. (2014). Transurethral resection syndrome in elderly patients: A retrospective observational study. BMC Anesthesiology, 14(1), 30. doi:10.1186/1471-2253-14-30

Yucel, A, Gulhas, N., Aydogan, M.S., Erdogan, M.A., Be34ur, A., Tasdemir, C., & Ersoy, M.O, (2012). Single intrathecal fentanyl for combined spinal epidural anesthesia confers no advantage over hemodynamic effects in elderly patients. European Review for Medical and Pharmacological Sciences, 16(2), 207-212.

[c] 2016 Society of Urologic Nurses and Associates

Feng, F., Chen, Z., Cromer, J., Doerr, A., Glow A., Horstman-Reser, A., ... Zecy, A. (2016). Anesthetic concerns for patients undergoing a transurethral resection of the prostate (TURP). Urologic Nursing, 36(2), 75-81. doi: 10.7257/1053816X.2016.36.2.75

Feng Feng, MD, PhD, is an Associate Professor of Pathology Clarkson College and Nebraska Methodist College, Omaha, NE.

Zigang Chen is a Supply Chair Analyst, Case Western Reserve University, Cleveland OH.

Jayne Cromer, MS, ORNA, is Director, Nurse Anesthesia Program, Clarkson College, Omaha, NE.

Allyson Doerr, BSN, RN, SRNA, is a Student, Clarkson College, Omaha, NE.

Ann Glow, DNP, CRNA, is Assistant Director, Nurse Anesthesia Program, Clarkson College, Omaha, NE.

April Horstman-Reser, PhD, is an Associate Professor, Arts & Science Division, Nebraska Methodist College, Omaha, NE.

Adrienne Infanger, DNP, CNRA, is the Nurse Anesthesia Program Coordinator, Clarkson College, Omaha, NE.

Eva Lovas, MS, is an Assistant Professor, Nebraska Methodist College, Omaha, NE.

James Ryberg, BA, is a Student, Nebraska Methodist College, Omaha, NE.

Mary Sinclair, MSc, is an Associate Professor, Nebraska Methodist College, Omaha, NE.

Alexis Zecy, BSN, RN, CORN, SRNA, is Senior Registered Nurse Anesthetist, Clarkson College, Omaha, NE.
Table 1.
General Health Concerns for Preoperative Evaluation

System                                Health Concerns

Cardiovascular        Coronary artery disease, atherosclerosis,
                      hypertension, aortic stenosis are common in
                      this population.

Hematology            Hemodynamic imbalance is common in this group,
                      such as dehydration, anemia, and hypovolemia.
                      There is a predication of blood loss during the
                      larger gland removal.

Respiratory           Chronic obstructive pulmonary disease (COPD),
                      pneumonia, and obstructive sleep apnea are
                      common in this group.

Neurological          Assess for cerebrovascular disease,
                      Alzheimer's, dementia, and other neurological
                      diseases in this group.

Urinary               Renal insufficiency may exist due to
                      obstruction caused by benign prostatic
                      hyperplasia (BPH).

Endocrine             There is an increased incidence of type 2
                      diabetes meilitus in the population over age 70
                      years.

Musculoskeletal       Arthritis and decreased range of motion (ROM)
                      are common in this age group, which affects
                      positioning for anesthesia and surgery.

Immune                There is decreased immune response in this
                      population, along with increased susceptibility
                      to nosocomial infections.

Additional tests      Other tests as indicated from history and
                      physical examination.

Premedication         Continually use drugs to prevent
                      cardiovascular/renal failure.

American Society of   ASA I and II patients should not have any
Anesthesiologists     limitations; however, an ASA III patient's
score (ASA) and       coexisting conditions have to be well
possible Goldman      controlled to perform a TURP ASA IV patients
Cardiac risk Index    need to be medically cleared to proceed with
                      this procedure from the patient's doctor and/or
                      specialty doctor, and ASA V patients would not
                      have a TURP procedure done because they are
                      medically unstable to proceed with an elective
                      surgery.

System                Diagnostic Testing that May Be Required

Cardiovascular        Evaluation should be based on
                      history and physical examination,
                      along with ECG, stress test,
                      ECHO and/or other tests as
                      indicated from the examination
                      (Caneado et al., 2009).

Hematology            Obtain labs, such as a CBC,
                      BMP, and coagulation factors.

Respiratory           Evaluations should include the
                      history of smoking and
                      manifestations of dyspnea with
                      moderate exercise. Tests may
                      include pulmonary function tests.
                      chest X-ray, arterial blood gas,
                      and sleep study, among others.

Neurological          Assess mental status, PET/CT
                      scan, or MRI to confirm lesion site
                      and size.

Urinary               Tests include BUN, creatinine.
                      GFR, creatinine clearance,
                      electrolytes, and non-contrast CT.

Endocrine             Check blood glucose level.

Musculoskeletal       Requires complete physical
                      examination on ROM of neck,
                      lumbar vertebrae, and extremities.

Immune                Tests include CBC, but not limited
                      to identifying antibody
                      deficiencies, cellular (T-cell)
                      defects, neutrophil disorders, and
                      complement deficiencies.

Additional tests      Such as MRI, PET scan.

Premedication         Albumin level test.

American Society of   ASA Classification and Goldman
Anesthesiologists     Cardiac Risk Point Scale.
score (ASA) and
possible Goldman
Cardiac risk Index

Notes: ECG = electrocardiogram, TURP = transurethral resection of the
prostate, GFR = glomularfiltration rate, BUN = blood urea nitrogen,
PET = position emission tomography, CT = computerized tomography,
MRI = magnetic resonance imaging, CBC = complete blood count.

Table 2.
Advantages and Disadvantages of General Anesthesia and Spinal
Anesthesia

                               General Anesthesia (GA)

Advantages      Allow for control of ventilation and facilitates
                management of patient discomfort associated
                with neuromuscular diseases, pulmonary
                diseases.

Disadvantages   Lithotomy positioning (see detail in position)
                may cause penile erection. Postoperative
                complications may include pain, postoperative
                nausea and vomiting, possible heavy cough,
                and hematuria.

                                Spinal Anesthesia (SA)

Advantages      Use for patients who have a severe respiratory
                disease. SA would shorten hospital stays and reduce
                overall hospital and anesthesia cost. It also helps
                in early detection of capsular tears and bladder
                perforation, decrease incidence of postoperative
                nausea and vomiting, and fewer hemodynamic changes.

Disadvantages   SA cannot be used in patients with severe
                cardiovascular disease. May also cause penile
                erection, which interferes with surgery.
                Significantly high sensory blocks are required for
                this procedure, which may lead to patient discomfort.

Source: Adapted from Gupta, 2009.
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Title Annotation:General Clinical Practice
Author:Feng, Feng; Chen, Zigang; Cromer, Jayne; Doerr, Allyson; Glow, Ann; Horstman-Reser, April; Infanger,
Publication:Urologic Nursing
Article Type:Report
Date:Mar 1, 2016
Words:5275
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