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09. HPB (870) > Campbell + AUA BPH/LUTS Surgical Management 2021 > Flashcards

Campbell + AUA BPH/LUTS Surgical Management 2021 Flashcards

1
Q

Minimum coverage for prostate surgery

A

Fluoroquinolone or TMP-SMX

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

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2
Q

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

A

2.5 cm prostate length (normal)

10 g additional weight

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3
Q

Non-ionic irrigants used in M-TURP

A

Glycine

Sorbitol

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4
Q

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

A

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

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5
Q

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

A

Anticoagulants

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6
Q

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: ___

A 
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
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7
Q

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

If unable to find orifice, adjust resection by: ___

A

Indigo carmine, methylene blue

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

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8
Q

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

A

Extraperitoneal

Bladder dome, rule out intraperitoneal rupture

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9
Q

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

A

1-4 weeks

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10
Q

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

A

AUA-SS
QoL score
Qmax
Residual urine

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11
Q

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

A

Prostatic urethral lift (PUL)

** low rates of ED and ejaculatory problems

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12
Q 
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
A

Rezum

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13
Q

Rezum advantages

A

Favorable safety profile
Low retreatment rate
Minimal anesthesia
Preserves sexual function

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14
Q

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

A

TUVP

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15
Q

TUMT MOA and temperatures

A 
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

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16
Q

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

A

TUIP

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17
Q

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

A

HOLEP

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18
Q

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

A

TUNA

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19
Q

532 nm wavelength, absorbed by Hgb

Combined vaporization and coagulation

A

PVP: KTP or LBO laser

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20
Q

2013 nm wavelength, continuous wave

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

A

Thulium laser

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21
Q

AUA 2021:

Indications for surgery

A

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

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22
Q

AUA 2021:

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

A

An asymptomatic bladder diverticulum

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

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23
Q

AUA 2021:

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

A

Simple prostatectomy (open, lap, robotic)
HoLEP
ThuLEP

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24
Q

AUA 2021:

Options for average prostates (30-80cc)

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

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

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25
Q

AUA 2021:

Options for small prostates (<30 cc)

A 
HoLEP
PVP
ThuLEP
TUIP
TUMT 
TURP
TUVP
26
Q

AUA 2021:

Not recommended: (2)

A

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

27
Q

The Baltimore Longitudinal Study examined 1057 men

and found that “prostatism” or BPH voiding dysfunction _____

A

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

28
Q

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 ______.

A

55 and 69 years of age

29
Q

Indications for treatment (TURP): _______

A

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

30
Q

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

A

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

31
Q

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

A

the one best practiced and understood by the urologist.

32
Q

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

A

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

33
Q

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

A

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.

34
Q

In either resection schema, the initial stages of the resection should involve-______.

The produced prostate chips should be ______.

A

long, smooth tissue cuts

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

35
Q

The prostate apex is best resected ______

A

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

36
Q

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

A

24 to 48 hours.

37
Q

PostTURP: Patients should avoid activities that ______ for _______

A

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.

38
Q

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

A

phenazopyridine

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

39
Q

Post-TURP:

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

A

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.

40
Q

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 _____

A

above 75% and can be as high as 93%

41
Q

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

A

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

42
Q

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

A

LASER options

43
Q

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

A

3%

hemorrhage leading to transfusion

44
Q

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 _____.

A

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).

45
Q

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

A

2%

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

46
Q

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 _____.

A

60 cm above the patient

good vision but also not lead to excessive systemic fluid absorption

47
Q

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 ______.

A

hypertonic saline

demyelinating lesion of the brain (central pontine myelinolysis).

48
Q

Intraoperative and Perioperative Complications: _____

A 
TUR Syndrome
Ureteral injury (uncommon)
Hemorrhage: fulgurate arterial bleeding
Perforation
Extravasation: almost always extraperitoneal
Persistent penile erection
49
Q

Postoperative Complications (TURP): _____

A

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

50
Q

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

TUR syndrome occurrence: _____

A

Similar

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

51
Q

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

A

one case

52
Q

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: _____

A

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.

53
Q

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

A

A median lobe

Cystoscopy

54
Q

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 ______.

A

preserving sexual function.

55
Q

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 ______

A

TURP

vaporization (200 W to 240 W)

tissue coagulation (60 W)

some adverse events.

56
Q

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.

A

identical

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

Reintervention

57
Q

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: ___

A

thermoablate

urethral catheter with an antenna that generates radially emitted electromagnetic (EM) waves.

Hyperthermia: <44 C
Thermotherapy: >44.5 C
Thermoablative: >65 C

58
Q

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 ____.

A

vasodilation of local vessels to physiologically dissipate the heat.

“heat shock” or high-intensity TUMT has been utilized to decrease this compensatory vasodilation.

59
Q

Transurethral incision of the prostate (TUIP) is an operative approach to _______.

Can be considered in men with ______.
Ideal patient: _____

Procedure: _____

A

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).

60
Q

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: _____

A

Holmium/thulium: CORNEA

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

61
Q

Wavelengths:

Ho:YAG: ____ nm, absorbed by _____

KTP and LBO: ____ nm, absorbed by _____

A

2140 nm, absorbed by water-rich tissues

62
Q

Wavelengths:

Ho:YAG: ____ nm, absorbed by _____;

KTP and LBO: ____ nm, absorbed by _____

Tm:YAG: ____ nm, absorbed by _____;

A

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

09. HPB (870) (8 decks)

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