Campbell + AUA BPH/LUTS Surgical Management 2021

Question 1

Minimum coverage for prostate surgery

Answer 1

Fluoroquinolone or TMP-SMX

**If patient has STC or IFC, consider extended coverage

Question 2

Cystoscopy: every cm above the normal ___ cm prostate length equates to additional ___ g additional weight.

Answer 2

2.5 cm prostate length (normal)

10 g additional weight

Question 3

Non-ionic irrigants used in M-TURP

Answer 3

Glycine

Sorbitol

Question 4

Postop M-TURP:
Consider fluid absorption: ___ mL
Can remove IFC in ___ hrs
Avoid activities that:

Answer 4

800-1000 mL even in uncomplicated TUR
24-48 hours
Avoid pressure on perineum (horse riding, riding a lawnmower) x 4-6 weeks
Phenazopyridine may help with dysuria

Question 5

TURP vs LASER: LASER is preferred over TURP for patients on ____.

Answer 5

Anticoagulants

Question 6

TUR syndrome things:
Normal prostatic venous pressure: ___ mmHg
Risk factor: Glands larger than ___ g and longer resection times > ___ minutes
Ideal height of fluid: ____
___ cm above ideal height increases fluid absorption x 2 fold
Serum Na < ___ mEq/L - significant dilution, leads to coma or seizures
If CNS symptoms noted, give: ___
Rapid correction of Na may cause: ___

Answer 6

10 mmHg
45 g, 90 minutes
60 cm above patient
10 cm --> 2 fold increase in absorption
< 120 mEq/L
Hypertonic saline
Central pontine myelinolysis

Question 7

If you can’t find the ureteral orifice, use: ___

If unable to find orifice, adjust resection by: ___

Answer 7

Indigo carmine, methylene blue

Start at the midline/median lobe - orifices may become more apparent aftter

Question 8

TURP: Extravasation related to prostatic resection is almost always: ___
Consider cystography if perforation is at the: ___

Answer 8

Extraperitoneal

Bladder dome, rule out intraperitoneal rupture

Question 9

TURP delayed postoperative bleeding noted around ___ postop, accompanied by sloughed tissue or eschar

Answer 9

1-4 weeks

Question 10

BTURP vs. MTURP:
Similar efficacy in terms of (4):
But lower rate of adverse events in B-TURP.

Answer 10

AUA-SS
QoL score
Qmax
Residual urine

Question 11

Handheld device via cystoscope –> mechanically opens the prostatic urethra – compresses prostate parenchyma (lateral lobes) with sutures.

NOT used for patients with a MEDIAN LOBE OR prostates > 80 g

Answer 11

Prostatic urethral lift (PUL)

** low rates of ED and ejaculatory problems

Question 12

Convective radiofrequency water vapor thermal therapy
Convective energy to ablate prostatic tissue
Water vapor (103 C) injected x 9 seconds -- transition zone of prostate -- tissue necrosis 1.5-2.0 cm spherical ablative lesion

Answer 12

Rezum

Question 13

Rezum advantages

Answer 13

Favorable safety profile
Low retreatment rate
Minimal anesthesia
Preserves sexual function

Question 14

Same equipment as TURP, but element has larger surface area
Bipolar current, isosmotic solution
Button electrode or VaporTrode
Higher need for retreatment of LUTS and postop-re-IFC vs. TURP

Answer 14

TUVP

Question 15

TUMT MOA and temperatures

Answer 15

Urethral catheter with antenna emits EM waves
Achieves temp:
< 44 C: hyperthermia
> 44.5 C: thermotherapy
> 65 C: thermoablative

** TUMT is low-risk but also lower-efficacy

Question 16

For prostates < 30 g, young patients concerned about ejaculation or fertility
Uni/bilateral incision through bladder neck to the verumontanum at 5 and 7 oclock positions

Answer 16

TUIP

Question 17

2140 nm
PULSED energy emission
Absorbed by water/water-rich tissues
Steep learning curve: at least 20 procedures required before being able to reliably reproduce quality results
Similar voiding rates vs. open prostatectomy

Answer 17

HOLEP

Question 18

RF energy flows into prostate parenchyma – interacts with water molecules – localized heat – sphere of coagulative necrosis
Local anesthesia
Temperature of needle: 115 C, maintained for 2-3 minutes

Answer 18

TUNA

Question 19

532 nm wavelength, absorbed by Hgb

Combined vaporization and coagulation

Answer 19

PVP: KTP or LBO laser

Question 20

2013 nm wavelength, continuous wave

Equivalent outcomes to HOLEP in terms of AUA-SS, Qmax, PVR, but longer operative time

Answer 20

Thulium laser

Question 21

AUA 2021:

Indications for surgery

Answer 21

Renal insufficiency secondary to BPH
Refractory urinary retention secondary to BPH
Recurrent urinary tract infections (UTIs)
Recurrent bladder stones or gross hematuria due to BPH, and/or with LUTS/BPH refractory to or unwilling to use other therapies

Question 22

AUA 2021:

Clinicians should NOT perform surgery solely for the presence of ___.

Answer 22

An asymptomatic bladder diverticulum

Evaluation for the presence of bladder outlet obstruction (BOO) should be considered

Question 23

AUA 2021:

Options for large (80-150 cc) and very large (>150 cc) prostates

Answer 23

Simple prostatectomy (open, lap, robotic)
HoLEP
ThuLEP

Question 24

AUA 2021:

Options for average prostates (30-80cc)

Answer 24

Robotic waterjet treatment (RWT)
HoLEP
PVP (KTP/LBO)
ThuLEP
TUMT
TURP
TUVP

For patients concerned with ED:
WVTT
PUL (w/o median lobe)

Question 25

AUA 2021:

Options for small prostates (<30 cc)

Answer 25

HoLEP
PVP
ThuLEP
TUIP
TUMT 
TURP
TUVP

Question 26

AUA 2021:

Not recommended: (2)

Answer 26

Prostate artery embolization: not recommended outside clinical trials
TUNA: not recommended