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Key points
Spinal anaesthesia is Approximately 40 000 transurethral resections The nerve supply to the prostate arises from
considered to be the of the prostate (TURP) are performed annually the prostatic plexus, which originates from the
technique of choice for TURP. in the UK. TURP remains the surgical gold stan- inferior hypogastric plexus, and carries both
TURP syndrome comprises dard for the treatment of benign prostatic hyper- sympathetic fibres from T11 to L2 and para-
the effects produced by rapid plasia (BPH), which causes urinary obstruction sympathetic fibres from S2 to S4. Pain fibres
changes in osmolality and and increases the risk of urinary tract infection. from the prostate, prostatic urethra, and bladder
circulating volume, together Perioperative morbidity from this procedure mucosa originate primarily from sacral nerves
with respect to plasma (280 –300 mosmol kg21). Other solutions operation and afterwards is recommended. If required, sedation
available include mannitol 5% and sorbitol 3.5%.3 may be provided with 1–2 mg of midazolam i.v., although this
may cause confusion, disinhibition, and restlessness. Propofol infu-
Patient group sion may be more successful.
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Anaesthesia for TURP
Table 1 Potential problems during TURP techniques. Visual assessment of the colour of the discarded irriga-
Intraoperative tion fluid is unreliable.
TURP syndrome Factors associated with excessive bleeding include a large
Haemorrhage gland, extensive resection (.40– 60 g of prostate chippings), coex-
Myocardial ischaemia
Hypothermia isting infection, prolonged surgery (.1 h), and the presence of a
Prostatic capsular perforation preoperative urinary catheter. The histology of the gland is not
Bladder or urethral perforation associated with differences in bleeding.9 In practice, frequent
Penile erection
Postoperative measurement of the haemoglobin is the most useful investigation.
TURP syndrome Urokinase released from raw prostate tissue may provoke sys-
Bladder spasm temic fibrinolysis which may worsen postoperative haemorrhage.
Ongoing bleeding
Clot retention Where blood loss is extensive, a bolus of tranexamic acid, e.g.
Deep venous thrombosis 15 –25 mg kg21, may reduce the volume of haemorrhage.
Myocardial ischaemia/infarction For patients with a normal preoperative haemoglobin, who
Postoperative cognitive impairment
undergo a small resection (,30 g), it is very unusual to require
blood transfusion after operation.9
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Anaesthesia for TURP
the difference between the amount of irrigating fluid used and patient is asymptomatic.10 Rapid correction of hyponatraemia may
volume recovered).3 lead to central pontine myelinolysis (CPM). The presence of symp-
A higher rate of absorption is produced by several factors. toms has been described as the most important factor determining
morbidity and mortality from hyponatraemia.10 An acute decrease
1. The pressure of the irrigation fluid. The height of the bag
to ,120 mmol litre21 is invariably symptomatic and should be
should be kept as low as possible to achieve adequate flow of
treated with hypertonic saline.11
fluid. Seventy centimetres are usually satisfactory. However, the
Dilutional hyponatraemia may prolong the action of non-
surgeon will frequently stop and drain the bladder to remove
depolarizing neuromuscular blocking agents, and may cause broad-
chippings; during this time, the hydrostatic pressure within the
ening of the QRS complex or T-wave inversion.
bladder is low.
2. Low venous pressure, e.g. if the patient is hypovolaemic or
hypotensive. Glycine and its metabolites
3. Prolonged surgery, especially .1 h, although this is now
Glycine is a major inhibitory neurotransmitter in the CNS and
uncommon.
retina. Glycine toxicity may cause nausea, headache, malaise, and
4. Large blood loss, implying a large number of open veins.
weakness, and also visual disturbances including transient blind-
5. Capsular perforation, or bladder perforation, allowing a large
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Anaesthesia for TURP
96 Continuing Education in Anaesthesia, Critical Care & Pain j Volume 9 Number 3 2009