Surgery Flashcards
TURP BAUS consent
almost all burning bleeding frequency 75% retograde ejaculation 10-50% not resolve all symptoms 2-10% bleeding stricture cancer retreatment infection retention erections incontinence
less 1%
TUR
anaesthetic
death
TURP efficacy
%qmax 150%
IPSS 70%
pvr 77%
qol 70%
retreatment annual 2%, 4% 1 year, 10% 5 years
TURP complications transfusion death TUR sepsis AUR clot retention incontinence BN stricture ED
Transfusion 3% death 0.1% TUR 0.8% AUR 4.5% clot retention 5% UTI 4% sepsis 3% incontinence <1% ED 10% BN stricture 3-5%
Reynard paper outcome TURP
1999
failure to void after turp dependent on previous bladder volume
379 patients
12% failed to void after turp on initial twoc, only in those with retention prev
10% AUR
38% with chronic retention >500mls pvr and 44% acute on chronic retention failed to void
only 1% of patients required long term catheter
persistance of DO after BOO relieved paper
Abrams
1979
DO persists in 20-40% of patients
DO present in % of men with BOO
45-50% of men with BOO
TUR syndrome glycine osmolality absorption rate average absorped glycine metabolismg
1.5% 220 mosmol 20ml per min 1.5l on average liver metabolism oxidative deamination in liver 90% and kidney 25% to GLYOXYLIC ACID and ammonia NH3 which is then broken down to GABA and NH3 this depresses cerebrum and can cause hyperammonia encephalopathy
ideal irrigant solution
Ideally the irrigation solution should be
isotonic,
non hemolytic,
electrically inert (so that diathermy can be used), non toxic,
transparent,
easy to sterilize and inexpensive
Electrolyte solutions such as normal saline or Ringer Lactate do least harm when absorbed into the circulation.
However they cause dispersion of high frequency current from the resectoscope and hence abandoned.
water as irrigant
Sterile water: Though sterile water has many qualities of an ideal irrigating fluid, the disadvantage is its extreme hypotonicity, causing hemolysis, dilutional hyponatremia, shock and renal failure.
glycine concentration vs serum osmol
The os¬molality of 1.5% glycine is 230 mosm/1 compared to se¬rum osmolality of 290 mosm/l and hence cardiovascular and renal toxicities can occur at this concentration also.
absorption of glycine rate
20ml per minute
or around 1.5l for an average case
The uptake of I litre of fluid within one hour, which corresponds to an acute decrease in the serum sodium concentration of 5-8 mmols/l, is the volume above which the risk of absorption related symptoms is statistically in¬creased
TUR syndrome main components
glycine toxicity neurotransmitters
fluid overload
dilutional hyponatraemia
glycine also acting on ANP release and natriuresis
glycine toxicity myocardium
hyperammonia due to glycine metabolism and encephalopathy
hypertension followed by hypotension, rapid equilibrium of hypotonic fluid with EC fluid compartment
lab findings TUR syndrome
hyponatramiea iso osmolar or mildly hypoosmolar increased osmolar gap hyperglycinaemia hyperammonaemia due to deamination of glycine met acidosis haemodilution
when does visual disturbance resolve
in 2-12 hours
can be to light perception only
fundoscopy later normal
ethanol test TUR syndrome
1% ethanol in irrigant
detect on breathalyser
can detect 75ml absorption per 10 mins of surgery
management TUR 9
- Stop operation
- Catheter inflate and pressure
- Check extravasation – retropubic drain
- Send bloods
- Give dose 40mg IV furosemide
- ITU
- Serum sodium restored slowed
- Judicious use of fluid restriction
- Diuretics
- Rarely hypertonic saline
restoration sodium
avoid central pontine demyelination
aim to raise no more than 10-12 per 24 hours or 1 mmol per hour
3% hypertonic saline only indicated neurological manisfestations
do not restor to normal, only to symptom resolving
through central line as sclerosis peripheral veins
bradycardia and hypotension - atropine, adrengeric drugs, IV calcium
anti convulsants seizures
summary TUR answer
Emergency station or BPH station
Definition – absorption of irrigant during the procedure. Causes dilutional hyponatraemia and fluid overload and effects of glycine toxicity.
Manifests as tachycardia or bradycardia, hypotension, headache, confusion, convulsions, cardiac dysrhythmia
How to reduce chances of TUR – minimize resection time especially if capsular perforation/venous bleeding++ (<1hr), reduce height of irrigant to maintain good vision, continuous flow resection.
How to treat – send bloods, keep irrigation to minimum, put catheter on traction, 40mg IV furosemide, ITU monitoring. Serum sodium should be slowly restored with fluid restriction, diuretics and rarely hypertonic saline.
advantages Bipolar TURP on systmatic review
69 RCT no long term follow up shorter catheterisation shorter hospital time less complications no TUR syndrome no different UTI rate or efficacy can be used with pacemakers blood transfusion 1% can be day case
TUIP reoperation rate vs TURP
15% vs 2% at 2 years meta analsysis TURP vs TUIP
Millins name operation procedure complication transfusion comparison TURP
terence millin 1945 lower midline or pfannenstiel defat prostate divide superficial DVC expose prostate transverse incision capsule 1cm distal bladder neck adenoma visible and plane between it and capsule developed urethra cut distally with scissors haemostasis capsule closed 22Fr catheter and drain
vs TURP transfusion 10%
incontinence, stricture reop 1%
meta analysis
operating time and weight superior to holep
longer hospital stay, cathete rtime, transfusion rate and reduced sexual function
TUMT
TUMT - TransUrethral Microwave Thermotherapy
Microwave energy delivered via catheter with a cooling system designed to protect the urethra. Causes coagulative necrosis and shrinkage of the tissue. Damage to adrenergic nerves also relieves symptoms. Improvement in 55%. Sexual side effects less common than after TURP. Irritative symptoms, period of catheterization and UTI more common than after TURP.
TUNA
TUNA – TransUrethral Needle Ablation of prostate
Low level radiofrequency delivered via a transurethral needle. The resultant heat causes localized necrosis. LA procedure. Provides a modest improvement in symptoms. Risks incl. bleeding, UTI and stricture. Sexual function preserved. ?Long-term benefit.
REZUM
radiofrequency generator single use transurethral device standard 30 degree cystoscopy lens lithotomy RF current applied to inductive coild heater thermal energy water vapour delivered prostate 9sec in TZ via convection diffuses evenly depth of needle 10mm upon contact body temp tissue, water vapour condenses, phase shift to liquid state dispenses concentrated energy onto the cell membranes instant cell necrosis 1-3 injections average each lobe 28% reduction prostate volume 6 months
complications rezum
33% dysuria 25% bleeding 16-20% pelvic pain 6-7% UTI 4% not relieve symtpoms and retreat within 4 ywars
2% reduced ejcaultory volume
complications urolift
33% burning stinging 25% bleeding 20% pain discomfort pelvic area 13% not relieve symptoms 3% UTI 3-5% retention 4% temporary urge inconcinence 7% urgency <1% encrustation
urolift components
Nitinol capsular tab, stainless steel urethral tab and polyethylene suture holding them together.
LIFT study
Multicenter,
AUA Symptom Index >13, Qmax <12 and prostate volume 30-80cc.
Primary end point was AUASI reduction at 3 months
206 men randomized to UroLift or sham
Result: UroLift reliably performed with patient under LA provides a rapid and sustained improvement in symptoms and flow whilst preserving sexual function
urolift and mri
Controversial
Creates artefact
Company information states that ‘the patient can be safely scanned under specific MR conditions’
ROPE study TURP PAE how many centres follow up period drop in IPSS
register started in 2015 BJUI 2018 90 TURP 216 PAE 17 centres TURP 15 point improvement PAE 10 point
risk penile ischaemia ROPE study
1%
percentage not suitable for PAE
30%
prostatic artery from
internal pudendal artery, anterior common-gluteal pudendal trunk
superior vesicle
or obturator artery
single vs dual prostatic artery supply
60% single prostatic artery supply 40% dual prostatic artery supply
NICE PAE
adequate to support use
selection should be done by uro and int radiologist
complications PAE
groin haematoma arterial dissection 2% sepsis tranfusion 0.5% penile ulceration 1% technical failure 10% retention 9% 1% bladder wall ischaemia seminal vesicle ischaemia - non target embolisation
LIFT study
vs sham
5 yr follow up RCT
qmax improvement 3 ml.sec
14% need surgery
BPH 6 study
TURP vs urolift 2 year follow up 80 patients 10 centres Qmax and IPSS better with TURP Urolift quicker recovery less retrograde ejaculation
Urolift NICE
considered as alternative for use in day case setting BPH aged to and older prostate less than 100mls without obstructing median lobe
NICe review REZUM
longest follow up
4 studies 1 blinded control trial 4 year study update 188 men IPSS change 52% change 21 to 10 sustained at 48 months qmax 10 to 15, 49% improvement baseline at 4 years 4.4% retreatment rate
NICE greenlight
in high risk patients
defined those as increased risk bleeding
or porstate larger than 100
or with urinary retention
IPSS fall with urolift
50% fall from 22 to 11 at 3 months
sustained 1 year
36% reduction at five years
ROPE overnight stay mena procedure time reop rate qmax vs turp
qmax 3 vs 7.5 for TURP
IPSS 10 vs 15 improvement TURP
29% overnight vs 80% TURP
reop rate 5% > 1 year, 15% <1 year
