m
 





   

  

p


  

m

‡ normal prostate weighs around 18 gm.
‡ contains 70% glandular and 30% fibromuscular stroma
‡ urethra runs through the length of the prostate
‡ Divided into 5 lobes or 2 zones- transitional and peripheral
Ô
( ?on cancerous enlargement of the prostate gland
( Mainly of the middle lobe or the transitional zone
( Leads to symptoms of bladder outlet obstruction
( Disease of the old age, starts at ~ 40 but usually
presents between 50 ± 70 years
( estimated 50% of men have histologic evidence of
Bp by age 50 years and 75% by age 80 years
( n 40-50% of these patients, Bp becomes clinically
significant

 

mm
m
   

( 6
 L C?

º
nlongation of the prostatic urethra
º
aggeration of the posterior curve
º Lateral urethral compression (if unilateral)
Dë

  
 ë
 

 
( BLDD
C?
 :
º Compensatory detrusor hypertrophy (increase atonicity)
º post prostatic pouch (retention)

( CY

( 
CL
 pL


( 6

?D KD?
Y

º ydroureter and hydronephrosis (Due to obstruction)
º esiculo-uretric reflu
º cute pylonephritis
º 6remia
     

( m
6
?CY
º nitially nocturnal
º radually increases to both at day and night ±
cystitis & irritation.

( 

?CY ± (waiting for urination) d/t median lobe

pressing the orifice.
( 6
?CY ± deranged internal sphincter
mechanism.

( DY6 

( D BBL? 6 ?
± poor stream

( 
M6  ±
º rupture of dilated veins
º cystitis
º prostatic erosion
º Calculi formation

( p? ± lower abdomen

( C6


?
?
  
(
? p/

 D
nlarged, felt easily and finger can be reached

above it.

 D
nlarged, felt easily but the finger is reached with

difficulty.

 D
nlarged, felt easily but finger cannot reach above it.
(
n 6 :
º ?ormal D 10-15 gm (weight of prostate)
º D 15-20 gm
º  D 20-50 gm
º  D 50-150 gm
º  D · 150 gm
(
n 6

C
pY

º ?ormal ± 2-2.5 cm (length - prostatic urethra)

º D 2.5-3.0 cm
º  D 3.0-3.5 cm
º  D · 3.5 cm
 mm
m
(
rodes uality of Life
( Complications:
º 6rinary retention
º ecurrent hematuria
º Bladder stones
º Compromised renal function

 
 
( patients with symptomatic Bp are frequently
elderly with coeistent diseases

º abnormal electrocardiogram (
C ) 77%

º cardiac disease 67%
º chronic obstructive pulmonary disease 29%
º diabetes mellitus 8%

 
 
(
ccasionally patients are dehydrated and
depleted of essential electrolytes e.
º long-term diuretic therapy
º restricted fluid intake
º Cm

( Long standing urinary obstruction can lead to

º impaired renal function
º chronic urinary infection.
   ! "#$$% &$# " ' ( ) *
+ '!  ,+- .( ( ($, " $$
&/   ,)$ &) "' +
)' $ /0 ,(' $ /0  )' $ / 
,(%)0 " '1#'2
  

M
MM  M

1 à
 
 
 





2 
 


  


 


3  
 
M  M
 

4 
   

  

5  
o

6    



7 
   
 

8  

    
 

9    
 

10  

Mà
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11  
 
 

 

   

 

à
 

( otal serum proteins ± more chance of fluid
overload if hypoproteinemia seen.
( pms
( 6 bdomen :
-
bstruction / calculi / Cysts/
rganomegaly
- ydroureter with ydronephrosis
- prostate size
(
lectrolytes : ?a, K, Cl, Mg, Ca
( B

  
he options available are:
( 6 p
( uprapubic (transvesicular) prostatectomy
( perineal / retropubic prostatectomy
( rans urethral electro vapourization
( rans urethral laser ( under L)
( rans urethral incision
  
   

m


3
) '/ $'!%+ 
( 6 p is considered as one of the most difficult
procedures that a surgeon can learn and master.

( t involves removal of the gland upto the level of the

capsule.

(
cision and coagulation of the hypertrophied tissue

(adenoma) are performed under direct vision through
a resectoscope.
Ô'$ ,
( Continuous irrigation is necessary to provide

º ood visibility by dilating the bladder and the

prostate
º Maintaining an operative field free of
dissected prostatic tissue debris and blood
  




( Common solutions are

º lycine 1.2% and 1.5%
º Mannitol 3% & 5%
º lucose 2.5% & 4%
º orbitol 3.5 %
º CYL (sorbitol 2.7%+mannitol 0.54%)
º 6rea 1%
( he ideal duration of resection is ± 60 min
( estimated that 10-30 ml of irrigating fluid is
absorbed per minute of resection time.
( bsorption of small amount
º spontaneous diuresis
( bsorption of large amount
º over hydration
º ncreased intravascular pressure
º Decreased plasma oncotic pressure
º eneralized edema
! ',  "''/ "$#
( akes place via the large prostatic venous
sinuses.

( lso, the type of irrigation fluid is important.


 42

Ôater constitutes over 50% of an individual¶s weight

nfant- ï
 
dult 
 
eriatric 

Ôater requirement= 2500cc/day; minimum of 1500 cc/day
Õ Õ
 Õ
º salts or minerals in etracellular or intracellular
body fluids

ż odium ± major cation of
Cm

ż potassium ± major cation of Cm

ż Chloride - major anion of Cm

  
4
   


odium 142 141 10

potassium 5 4.1 150

Calcium 5 4.1 -

Magnesium 3 3 40

chloride 103 115 15

  
 -
   

      

Cm r
 r

r

Lactated
inger¶s
r  r



0.9% ?aCl r r 

0.45% ?aCl   r

D5/0.45%
?aCl
   

3% ?aCl r r r

6%
etastarch
 r r r

5% lbumin

 rr  
 rr  

25%
lbumin



r rr  
 rr  

  

 4
n case of Bp commonly seen are:
( Circulatory overload
( ypo osmolarity
( Ôater intoication
( yponatremia
( ypomagnesemia
 ')#$ '% &'$ 
( ypervolumia ± in acute cases, leads to

º ypo osmolarity ± (increased intravascular

volume and hemodilution)
º ypertension ± leading to hypertension anginal
pain
º fluid shift leading to pulmonary edema esp. where
cardiac reserve is limited.
º cerebral edema can be precipitated
º yponatremia ± dilutional
º enal derangements ± amount of irrigation fluid
inversely proportional to post op urine output
 

( rrigation fluid enters circulation through
open prostatic venous sinuses
( verage rate ± 20ml/min
( May reach upto 200 ml/min
( Literature suggests as many as 8 L can
be absorbed
( verage weight gain by end of surgery ±
2 kg.
 


mm

4
( Determine serum ?a at beginning of the
surgery
( gain at the time of estimation of vol absorbed
( olume absorbed =
(preop ?a / postop ?a) ȋ
Cm ±
Cm
º
Cm = 20% - 30% of total body water
(
ample :
n a pt. with body wt = 50 kg, preop ?a 140,
postop ?a 100
hen, volume absorption=
140/100 ȋ
Cm-
Cm =1.4
Cm-
Cm
= 0.4
Cm
= 0.4 ȋ 50 ȋ 20%
= 4 litres
 
 
( he absorption of large amounts of electrolyte-free
irrigating fluid leads to Dilutional hyponatremia.
( sodium: (? 135-145 meq/L)
º Major etracellular cation
º
ssential for proper functioning of ecitatory cells esp.
heart and brain
º Levels may typically fall by 3-10 meq/L
( he fall in serum sodium inconsistent with amount of
total fluid absorbed but dependent on the rate of
absorption of fluid

 
( cute severe hyponatremia associated with
º bnormal neurological symptoms
º Can lead to irreversible brain damage
º
n

- may lead to loss of Į wave activity
( he C? derangement is not due to
hyponatremia R
 but acute hypo osmolarity
(  slow rate in fall of osmolarity apparently allows
the C? to adapt to the hyponatremia.
( less than 120 mmol / L indicates a severe
hyponatremia.  decrease in serum (?a) of 20 to
30 mmol / L implies absorption of 3 to 4 L.
( t levels < 110 meq/L pt can develop respiratory
and cardiac arrest
   

( pt should be adequately prepared pre op
( pts with Cm ± treat vigourosly
º diuretics and fluid restriction
( Conservative surgical approach in critically ill pts-
e. simple canalization or balloon dialatation
( Most imp factor ± preservation of prostatic
capsule (surgeon¶s skills)
( Limit hydrostatic pressure of irrigating solution to
<60 cm of 2

( prevent bladder overdistension

( yponatremia also accentuated by pre op
deficiency or ecessive intra op bleeding.
( Below 120 meq cellular activity is deranged.
urgery should be terminated at levels below this.
( dminister intravenous fluids cautiously:
º 6se a microdrip set, esp. in pts with cardiac or
renal derangements
º 6se vasopressors instead of large boluses of
fluid in case of hypotension during regional
anesthesia.
  
( dministration of hypertonic saline to treat -
not always necessary.
( ?ot recommended unless pt develops clinical
signs of hyponatremia.
( pontaneous or induced diuresis with 20 mg
furosemide ± corrects hyponatremia in few hrs
( aline administration itself can provoke
pulmonary edema ± due to fluid overload
( ypertonic saline- should be given with serum
osmolarity monitoring
  
4
( apid administration of hypertonic saline ±
associated with central pontine myelinolysis
º lso c/a osmotic demyelination syndrome.
( odium should not be corrected at a rate faster
than 1.5 meq/ L/ hour
¢2Ô' 5) 
Ô  

6
( ome patients ehibit neurological signs
like:
º Decerebrate posture
º Clonus
º babinski refle present
º Convulsions and eventually coma
(
ye eam: papilledema, dilated and
sluggishly reacting pupil
(

- low voltage b/l
( BBB essentially impermeable to sodium
but freely permeable to water

( Cerbral oedema ĺ raise C ĺ

bradycardia and hypertension ĺ other
neurological symptoms.
Ô  

6
 
!" 

‡ #
 
 
 

( he 6 p syndrome is an iatrogenic surgical
complication but the responsibility for its diagnosis
and treatment falls upon the anaesthetist, hence
the importance.

( During 6 p, there is opening up of an etensive

network of venous sinuses allowing ecessive
systemic absorption of irrigation fluid.
( his etensive absorption of fluid( · 2L) results in
a combination of / referred to as 6 p
syndrome.
( een in appro 2% of pt.
%+, +
( mluid overload
º Cm
º pulm edema
º ypertension
º Bradycardia
* f ?a+ <120 meq/l negative ionotropic effect
manifests as hypotension and tachycardia.
* herapy D stop irrigation for 15-20 min
( ypoaemia
( M
( Cardio-pulm arrest
  

( he etiology of these C? disturbances has been
attributed to
º hyponatremia,
º hyperglycinaemia, and/or
º hyperammonaemia.

( yponatraemia may occur when any of the irrigating

fluids is used, but hyperglycinaemia and
hyperammonaemia may occur only when glycine is
used as the irrigating fluid.
$' ") ) #

( comatose state
( metabolic encephalopathy.
( focal or generalized seizures.
( Mild papilloedema and
( Decerebrate movements
Ô( ! 422

( preop D
º Correct any fluid / electrolyte imbalance
º Correct anemia
º /t cardiac failure

( ntra op D
º Blood loss should be carefully replaced
º ydrostatic pressure of the irrigating fluid should
not eceed 60 cm of 2
. ± avoid ecessive
elevation of the irrigating bag
( ntra op (cont..)
º Care that bladder outflow remains unobstructed
(watch the 6ro-bag volume)
º f t is changed from 60 to 70 cm ~ 2 fold
increase in fluid absorption is seen.
º esection time should not eceed 60 min
º owever, at least 300 ml of fluid / min is needed
for good visual field. his cannot be achieved at
below 60 cm. D
?
 L
Ô
ecessively as this
will prolong resection time.
  
( Depends on the detection of hyponatremia ± serial
sodium measurements must be done whenever
uneplained changes in Bp or cerebral irritation is
seen.
( nfusion of clear fluids should be suspended.
( Blood loss should be replaced by slow blood
transfusion.
( Loop diuretic ± furosamide is t/b given
( odium correction is controversial.
 m '!$()D
( n case of acute hyponatremia with neurological
features, rapid correction till neurological
improvement is to be done.

( $%&

ë 
ë'(


'() *+$,-.

* %  $ %/ 
( ate of correction should be 0.6 ± 1.0 m
q / L / hr
until sodium reaches 125 after that the rate is 1.5
m
q / L / hr.

( ½ correction is done in initial 8 hr then the rest over

1-3 days.
( ypertonic saline may be used to rapidly increase
serum sodium level in patients with severe acute or
chronic hyponatremia, as manifested by severe
confusion, coma, seizures, or evidence of
brainstem herniation.
( ypertonic (3%) saline ± Contains 514 m
q/L
of ?aCl. May precipitate p.
dema in presence
of cardiac failure.

( osmolarity h/b acertained before hand and

Cp monitored thereby

( n general, increase of 4-6 m
q/L in serum

sodium level is sufficient to arrest progression
of symptoms in severe hyponatremia. murther
rapid increase in serum sodium level not
indicated.
  
( ?ormally the blood loss during 6 p
º 2-5 ml / min of resection time
º 20-50 ml / gm of tissue resected

(
tent of blood loss is determined by

º esection time
º ize of gland
º urgical epertise

( bsorption of irrigating fluid D increased intravascular

pressure D increased bleeding
( ny factor which increases peripheral venous
pressure increases bleeding from prostatic bed
º training during light anaesthesia ( )
º hivering, coughing during regional
anaesthesia

( egional anaesthesia is associated with as

much bleeding as deep  as vasodilatation
increases venous pooling
(
ther possible reasons for ecessive bleeding:

º Dilutional thrombocytopenia

º Local release of fibrinolytic agents : plasminogen

and urokinase from mucosa of L6

ż udden loss of blood without clots, bleeding from

skin puncture site, sub mucosal h¶ge m/b seen
ż reated with
pL
? M?
Cp
C CD 4-5
g during the first hour and followed by 1 g /hr for
the net 24 hr
( prostatic particles rich in thromboplastin, that
enter bloodstream during surgery can trigger DC.

(
M
?
m BL

D L
 :
º isual estimation is inaccurate d/t miing
º ypotention & tachycardia are delayed d/t
increased circulatory volume
º
stimated to be 200-2000 with an average of
~500ml.
º erial hematocrit
º b assessment in suction bottle fluid
m) ')'/+ '$%
( ge · 80 yrs
( esection time · 150 min
( esected tissue · 60 g
( presence of azotemia ( 6 times increase)
( Mortality rate ± 0.2-0.8 %
KYOU
(7% #42