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

Question 27

The Baltimore Longitudinal Study examined 1057 men | and found that “prostatism” or BPH voiding dysfunction _____

Answer 27

increased progressively from 26% in the fifth decade of life to 79% in the eighth decade of life ** Prevalence of symptoms related to an enlarged prostate increased from 26% of men 40to 49 years of age to 46% of men older than 70 years of age in the Olmstead County Study

Question 28

The most recent guidelines for the detection of prostate cancer recognized that the greatest benefit for prostate-specific antigen (PSA) screening is for men between ______.

Answer 28

55 and 69 years of age

Question 29

Indications for treatment (TURP): _______

Answer 29

Acute urinary retention (AUR) Recurrent and robust gross hematuria Bladder calculi, bladder diverticula, provided medical management has been previously attempted Bilateral hydronephrosis with renal functional impairment

Question 30

The patient’s buttocks should be placed near the table edge so that _____.

Answer 30

the table does not impede the full course of the scope. *** If not positioned far enough down the table, the anterior portions of the prostate may be difficult to reach, particularly in patients with fixed pelvic anatomy from previous pelvic injury, orthopedic history, radiation, or trauma

Question 31

The plan for resection can be varied by any number of patient factors, and in general the best approach is _____

Answer 31

the one best practiced and understood by the urologist.

Question 32

______ should be noted, and their relationship to the prostatic adenoma confirmed

Answer 32

The bladder neck, trigone, and position of the ureteral orifices, verumontanum, and external sphincter

Question 33

In situ- ations in which the cutting element does not seem to be function- ing, there is a general algorithm to check: ____-

Answer 33

Check the connection to the scope and generator; inspect the irrigating fluid to verify that it is commensurate with the generator technology being used; and, if a monopolar technology is being used, check that the patient is properly grounded.

Question 34

In either resection schema, the initial stages of the resection should involve-______. The produced prostate chips should be ______.

Answer 34

long, smooth tissue cuts long and “canoe-like” in appearance with a length equivalent to the extended resection loop.

Question 35

The prostate apex is best resected ______

Answer 35

at the end of the procedure in a bloodless field, where resection can be done precisely to avoid injury to the external sphincter.

Question 36

In the absence of significant capsular perforation or persistent bleeding, the catheter can be removed in _____

Answer 36

24 to 48 hours.

Question 37

PostTURP: Patients should avoid activities that ______ for _______

Answer 37

place excessive or uneven pressure on the perineum (e.g., horse riding, use of a riding lawnmower) for 4 to 6 weeks to avoid inciting any postoperative bleeding while the freshly resected prosthetic bed re-epithelializes.

Question 38

Post-TURP: The long-term use of _____ is discouraged but may help patients overcome this dysuria in the immediate postoperative period.

Answer 38

phenazopyridine *** Patients should be warned that this medication may make bodily fluids appear red-orange in color and can stain contact lenses.

Question 39

Post-TURP: Patients with long-standing obstruction (particularly those with urgency and frequency preoperatively) will often experience _____.

Answer 39

a continuation or exacerbation of these symptoms in the postopera- tive period. If proper bladder emptying can be verified, an anticho- linergic or beta-3 agonist medication during this time may help the patient feel more comfortable.

Question 40

Post-TURP: The number of patients who judge their voiding symptoms to be “better” or “much better” depends partly on the initial severity of symptoms and duration of follow-up but is generally _____

Answer 40

above 75% and can be as high as 93%

Question 41

Post-TURP: Follow-up at 3 months demonstrated that anticoagulated patients had

Answer 41

a higher rate of transfusion (1.9% vs. 1.0%, P = .026), bladder clots (13% vs 4.7%, P < .001) and thromboembolic events (2.4% vs. 0.7%, P = .02). *** Follow-up studies have found differing results

Question 42

In summation, the risk associated with TURP in the antico- agulated patient is significant, and authors have postulated that ____ may be preferable in patients who are unable to come off of anticoagulation for surgery

Answer 42

LASER options

Question 43

M-TURP: still at least a chance of intraoperative complication primarily from

Answer 43

3% hemorrhage leading to transfusion

Question 44

The prostatic venous system has a pressure of approximately ______, and fluid at a pressure exceeding this will lead to _____. The absorption of the hypo-osmolar irrigating fluid leads to an _____ with resulting _____.

Answer 44

10 mm Hg to fluid absorption when these vessels are exposed during resection. acute dilutional hyponatremia neurologic changes (confusion, nausea, vomiting, visual changes, hypertension, tachypnea, and bradycardia).

Question 45

TUR syndrome was seen in __ of cases in the AUA cooperative study. ___ and ____ were risk factors.

Answer 45

2% Larger glands (greater than 45 g) and longer resections (greater than 90 minutes)

Question 46

The height of the irrigating fluid above the patient should be carefully chosen. Madsen and Naber (1973) demonstrated that the ideal height of the fluid was _______. From their work, this appears to be the minimal height to maintain _____.

Answer 46

60 cm above the patient good vision but also not lead to excessive systemic fluid absorption

Question 47

TUR syndrome: If profound CNS symptoms are noted, judicious administration of ______ should be instituted, and formulas exist to help guide this resuscitation as overly rapid correction of hyponatremia may lead to a ______.

Answer 47

hypertonic saline demyelinating lesion of the brain (central pontine myelinolysis).

Question 48

Intraoperative and Perioperative Complications: _____

Answer 48

``` TUR Syndrome Ureteral injury (uncommon) Hemorrhage: fulgurate arterial bleeding Perforation Extravasation: almost always extraperitoneal Persistent penile erection ```

Question 49

Postoperative Complications (TURP): _____

Answer 49

Bladder neck contracture: prompt office cystoscopy to verify diagnosis --> gentle dilation with sounds or balloon --> then endoscopic incision if needed Urethral stricture: prevent with calibration and gentle dilation of meatus; well-lubricated cystoscope SUI: preserve ext. sphincter Delayed postoperative bleeding: 1-4 weeks, sloughed tissue or eschar POUR Incomplete resection Urinary storage symptoms Ejaculatory problems

Question 50

B-TURP vs M-TURP: _____ efficacy in regard to AUA-SS, QoL score, Qmax, and residual urine TUR syndrome occurrence: _____

Answer 50

Similar No statistical difference in occurrence of TUR syndrome, mostly because of the low incidence of the event overall.

Question 51

In the meta-analysis of patients undergoing bipolar TURP, no patient suffered from TUR syndrome. The authors concluded that by treating _____ patients with B-TURP, _____ of TUR syndrome could be prevented

Answer 51

one case

Question 52

PUL: altering prostatic anatomy without ablating tissue. Permanent transprostatic implants - sutures that are delivered by a handheld device through a cystoscope to mechanically open the prostatic urethra by compressing the prostate parenchyma. NOT suitable for: _____ Advantage: _____

Answer 52

not appropriate for patients with a median lobe Low rates of local symptoms along with minimization of impact on sexual factors like ED and ejaculatory problems.

Question 53

PUL is contraindicated in men with _____, which is why providers should perform ______ before evaluating urethral anatomy.

Answer 53

A median lobe Cystoscopy

Question 54

REZUM: Water vapor thermal ablation therapy boasts a favorable safety profile and a low retreatment rate, and it can be used in the office or outpatient setting using minimal anesthesia, making it an attractive option for both provid- ers and patients, particularly those concerned with ______.

Answer 54

preserving sexual function.

Question 55

TUVP: same set of equipment as ____ at that time with the exchange of the resecting loop for an element with a larger surface area The “cutting” current is used for ____ with the “fulguration” current leading to . Common monopolar power settings are _____ for cutting current and ____ for coagulation. The bipolar technology uses settings of 280 W and 140 W. Overall, initial results of monopolar TUVP were similar to those for TURP with a decrease in ______

Answer 55

TURP vaporization (200 W to 240 W) tissue coagulation (60 W) some adverse events.

Question 56

MTURP vs TUVP: They were able to analyze over 200 patients in each group and found essentially_______ changes in AUA-SS (–73% in both groups) and Qmax (216% in TUVP, 191% in TURP) between the different techniques. The authors found that TUVP had an improved profile compared with TURP with respect to _____ _______ for LUTS/BPH and postoperative urinary retention was less likely to occur in the TURP group.

Answer 56

identical operative duration, catheterization time, hospital stay, blood transfusion, and clot retention. Reintervention

Question 57

The objective of TUMT is to locally ____ prostate tissue while maintaining normal temperatures in the surrounding, nontargeted tissue. This concept uses a specialized _____ Temps: Hyperthermia: ___ Thermotherapy: ___ Thermoablative: ___

Answer 57

thermoablate urethral catheter with an antenna that generates radially emitted electromagnetic (EM) waves. Hyperthermia: <44 C Thermotherapy: >44.5 C Thermoablative: >65 C

Question 58

High-energy (HE) TUMT: When heat is applied to the prostatic parenchyma, there is a natural response with _____. Although it makes the procedure more tolerable, this slow increase of energy increased procedure times and decreased efficacy. The use of ____.

Answer 58

vasodilation of local vessels to physiologically dissipate the heat. “heat shock” or high-intensity TUMT has been utilized to decrease this compensatory vasodilation.

Question 59

Transurethral incision of the prostate (TUIP) is an operative approach to _______. Can be considered in men with ______. Ideal patient: _____ Procedure: _____

Answer 59

disrupt the prostatic capsule to alleviate voiding symptoms. small prostate glands (<30 g) ideal patient for this procedure is a young man with a small prostate who is concerned about either a loss of ejaculation or future fertility. Generally, a unilateral or bilateral incision is made through the bladder neck and can be extended all the way distally to the verumontanum. This incision is usually made posterolaterally (in the region of the 5 o’clock and 7 o’clock positions).

Question 60

LASER: The portion of the eye that is injured depends on the wavelength used. Holmium/thulium (large wavelength): _____ KTP, lithium-triborate (LBO), and neodinium:yttrium-aluminum- garnet (Nd:YAG) LASERs: _____

Answer 60

Holmium/thulium: CORNEA Potassium-titnyl-phosphate (KTP), lithium-triborate (LBO), and neodinium:yttrium-aluminum- garnet (Nd:YAG) LASERs: RETINA

Question 61

Wavelengths: Ho:YAG: ____ nm, absorbed by _____ KTP and LBO: ____ nm, absorbed by _____

Answer 61

2140 nm, absorbed by water-rich tissues

Question 62

Wavelengths: Ho:YAG: ____ nm, absorbed by _____; KTP and LBO: ____ nm, absorbed by _____ Tm:YAG: ____ nm, absorbed by _____;

Answer 62

Ho:YAG: 2140 nm, absorbed by water-rich tissues; PULSED KTP and LBO: 532 nm, absorbed by hemoglobin (better hemostasis) Tm:YAG: 2013 nm, absorbed by water-rich tissues; CONTINUOUS