Campbell + AUA BPH/LUTS Surgical Management 2021 Flashcards
Minimum coverage for prostate surgery
Fluoroquinolone or TMP-SMX
**If patient has STC or IFC, consider extended coverage
Cystoscopy: every cm above the normal ___ cm prostate length equates to additional ___ g additional weight.
2.5 cm prostate length (normal)
10 g additional weight
Non-ionic irrigants used in M-TURP
Glycine
Sorbitol
Postop M-TURP:
Consider fluid absorption: ___ mL
Can remove IFC in ___ hrs
Avoid activities that:
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
TURP vs LASER: LASER is preferred over TURP for patients on ____.
Anticoagulants
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: ___
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
If you can’t find the ureteral orifice, use: ___
If unable to find orifice, adjust resection by: ___
Indigo carmine, methylene blue
Start at the midline/median lobe - orifices may become more apparent aftter
TURP: Extravasation related to prostatic resection is almost always: ___
Consider cystography if perforation is at the: ___
Extraperitoneal
Bladder dome, rule out intraperitoneal rupture
TURP delayed postoperative bleeding noted around ___ postop, accompanied by sloughed tissue or eschar
1-4 weeks
BTURP vs. MTURP:
Similar efficacy in terms of (4):
But lower rate of adverse events in B-TURP.
AUA-SS
QoL score
Qmax
Residual urine
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
Prostatic urethral lift (PUL)
** low rates of ED and ejaculatory problems
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
Rezum
Rezum advantages
Favorable safety profile
Low retreatment rate
Minimal anesthesia
Preserves sexual function
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
TUVP
TUMT MOA and temperatures
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
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
TUIP
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
HOLEP
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
TUNA
532 nm wavelength, absorbed by Hgb
Combined vaporization and coagulation
PVP: KTP or LBO laser
2013 nm wavelength, continuous wave
Equivalent outcomes to HOLEP in terms of AUA-SS, Qmax, PVR, but longer operative time
Thulium laser
AUA 2021:
Indications for surgery
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
AUA 2021:
Clinicians should NOT perform surgery solely for the presence of ___.
An asymptomatic bladder diverticulum
Evaluation for the presence of bladder outlet obstruction (BOO) should be considered
AUA 2021:
Options for large (80-150 cc) and very large (>150 cc) prostates
Simple prostatectomy (open, lap, robotic)
HoLEP
ThuLEP
AUA 2021:
Options for average prostates (30-80cc)
Robotic waterjet treatment (RWT) HoLEP PVP (KTP/LBO) ThuLEP TUMT TURP TUVP
For patients concerned with ED:
WVTT
PUL (w/o median lobe)