Campbell Endoscopic Management of BPH Flashcards
The Baltimore Longitudinal Study examined 1057 men
and found that “prostatism” or BPH voiding dysfunction _____
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
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 ______.
55 and 69 years of age
Indications for treatment (TURP): _______
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
The patient’s buttocks should be placed near the table edge so that _____.
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
The plan for resection can be varied by any number of patient factors, and in general the best approach is _____
the one best practiced and understood by the urologist.
______ should be noted, and their relationship to the prostatic adenoma confirmed
The bladder neck, trigone, and position of the ureteral orifices, verumontanum, and external sphincter
In situ- ations in which the cutting element does not seem to be function- ing, there is a general algorithm to check: ____-
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.
In either resection schema, the initial stages of the resection should involve-______.
The produced prostate chips should be ______.
long, smooth tissue cuts
long and “canoe-like” in appearance with a length equivalent to the extended resection loop.
The prostate apex is best resected ______
at the end of the procedure in a bloodless field, where resection can be done precisely to avoid injury to the external sphincter.
In the absence of significant capsular perforation or persistent bleeding, the catheter can be removed in _____
24 to 48 hours.
PostTURP: Patients should avoid activities that ______ for _______
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.
Post-TURP:
The long-term use of _____ is discouraged but may help patients overcome this dysuria in the immediate postoperative period.
phenazopyridine
*** Patients should be warned that this medication may make bodily fluids appear red-orange in color and can stain contact lenses.
Post-TURP:
Patients with long-standing obstruction (particularly those with urgency and frequency preoperatively) will often experience _____.
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.
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 _____
above 75% and can be as high as 93%
Post-TURP: Follow-up at 3 months demonstrated that anticoagulated patients had
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
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
LASER options
M-TURP: still at least a chance of intraoperative complication primarily from
3%
hemorrhage leading to transfusion
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 _____.
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).
TUR syndrome was seen in __ of cases in the AUA cooperative study. ___ and ____ were risk factors.
2%
Larger glands (greater than 45 g) and longer resections (greater than 90 minutes)
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 _____.
60 cm above the patient
good vision but also not lead to excessive systemic fluid absorption
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 ______.
hypertonic saline
demyelinating lesion of the brain (central pontine myelinolysis).
Intraoperative and Perioperative Complications: _____
TUR Syndrome Ureteral injury (uncommon) Hemorrhage: fulgurate arterial bleeding Perforation Extravasation: almost always extraperitoneal Persistent penile erection
Postoperative Complications (TURP): _____
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
B-TURP vs M-TURP:
_____ efficacy in regard to AUA-SS, QoL score, Qmax, and residual urine
TUR syndrome occurrence: _____
Similar
No statistical difference in occurrence of TUR syndrome, mostly because of the low incidence of the event overall.
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
one case
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: _____
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.
PUL is contraindicated in men with _____, which is why providers should perform ______ before evaluating urethral anatomy.
A median lobe
Cystoscopy
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 ______.
preserving sexual function.
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 ______
TURP
vaporization (200 W to 240 W)
tissue coagulation (60 W)
some adverse events.
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.
identical
operative duration, catheterization time, hospital stay, blood transfusion, and clot retention.
Reintervention
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: ___
thermoablate
urethral catheter with an antenna that generates radially emitted electromagnetic (EM) waves.
Hyperthermia: <44 C
Thermotherapy: >44.5 C
Thermoablative: >65 C
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 ____.
vasodilation of local vessels to physiologically dissipate the heat.
“heat shock” or high-intensity TUMT has been utilized to decrease this compensatory vasodilation.
Transurethral incision of the prostate (TUIP) is an operative approach to _______.
Can be considered in men with ______.
Ideal patient: _____
Procedure: _____
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).
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: _____
Holmium/thulium: CORNEA
Potassium-titnyl-phosphate (KTP), lithium-triborate (LBO), and neodinium:yttrium-aluminum- garnet (Nd:YAG) LASERs: RETINA
Wavelengths:
Ho:YAG: ____ nm, absorbed by _____
KTP and LBO: ____ nm, absorbed by _____
2140 nm, absorbed by water-rich tissues
Wavelengths:
Ho:YAG: ____ nm, absorbed by _____;
KTP and LBO: ____ nm, absorbed by _____
Tm:YAG: ____ nm, absorbed by _____;
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
