Transurethral Resection of the Prostate



Transurethral Resection of the Prostate


Anuj Malhotra

Vinod Malhotra

Fun-Sun F. Yao





A. Medical Disease and Differential Diagnosis



  • Are there differences in morbidity and mortality rates between TURP and suprapubic or retropubic prostatectomy?


  • What comorbidities are common in patients undergoing TURP?


  • Does a history of prior MI increase the patient’s risk of perioperative reinfarction?


  • In patients with a history of recent MI, would you recommend that the surgery be postponed for a certain period? If so, why? If not, why not?


B. Preoperative Evaluation and Preparation



  • How would you evaluate the patient’s cardiac condition? What additional tests would you have liked to order? Would you recommend that the patient undergo coronary angiography before surgery? Explain.


  • Are patients with a Q-wave infarction at greater risk of reinfarction than those with a non-Q-wave infarction? If so, why? If not, why not?


  • Would you discontinue any antihypertensives or any medications for angina? Why or why not?


  • For a patient with an ICD, what information should you know? What precautions should be taken?


  • What types of coronary stents are available? What is their perioperative relevance?


  • What is the conventional recommendation for antiplatelet therapy in a patient with previous percutaneous coronary intervention (PCI) undergoing noncardiac surgery?


  • What risk is associated with perioperative antiplatelet therapy?


  • How should patients with coronary stents undergoing noncardiac surgery be approached?



C. Intraoperative Management



  • What monitors would you use for this patient?


  • What anesthetic technique is preferable for patients undergoing TURP, and why?


  • Does regional anesthesia result in a lower incidence of perioperative mortality than general anesthesia? Whether yes or no, explain why or why not.


  • What intravenous fluid would you use during TURP?


  • Forty minutes after a sensory level of T10 was established with intrathecal anesthesia, and monopolar TURP resection was initiated with the use of glycine as the bladder irrigating solution, the patient becomes agitated and complains of nausea. Further sedation along with an antiemetic is administered. However, shortly thereafter, the patient becomes very restless, blood pressure rises, and heart rate decreases. The patient becomes cyanotic and obtunded, blood pressure precipitously falls, and pupils are dilated and unresponsive to light. What is the most likely cause of these signs and symptoms, and would these occur during bipolar or laser TURP resection?


  • What are the important characteristics of irrigation solutions used during TURP?


  • Why is plain distilled water rarely used for irrigation during TURP? What types of irrigation solutions are available?


  • What is the effect on body temperature of continuous bladder irrigation during TURP?


  • What is the definition of TURP syndrome? What are the signs and symptoms of the syndrome?


  • How can hyponatremia occur if the bladder irrigating fluid is not absorbed via the prostatic vessels?


  • How does the patient absorb irrigation solution during TURP? How much irrigation solution is typically absorbed?


  • How can one estimate the volume of irrigation solution absorbed during TURP?


  • What is the relation between the duration of surgery and the incidence of TURP syndrome?


  • What factors increase the incidence of TURP syndrome?


  • What is the effect on cardiopulmonary, renal, and central nervous system (CNS) functions of excessive absorption of irrigation solution during TURP?


  • What causes CNS dysfunction in patients who have undergone TURP?


  • What is the physiologic role of sodium ions in the body? What is the effect of excessive absorption of irrigation solution on serum sodium level?


  • What is the relation between serum sodium level and the incidence of neurologic symptoms in patients who have undergone TURP?


  • How does acute hyponatremia affect the cardiovascular system?


  • What prophylactic measures may reduce the incidence of TURP syndrome?


  • What therapeutic measures are recommended for patients with TURP syndrome?


  • Is normal saline administration always necessary to correct hyponatremia? Explain. What are the risks of rapidly correcting hyponatremia?


  • What are the toxic effects of glycine? Is there an antidote to glycine toxicity? What are the metabolic by-products of glycine?


  • What are the symptoms and clinical course of TURP-induced hyperammonemia?


  • Why do some patients who have undergone TURP develop hyperammonemia and others do not? Is there a preventive treatment for hyperammonemia in these patients?


  • What are the clinical characteristics, causes, and prognosis of TURP-related blindness?


  • What gynecologic procedure has been associated with a syndrome similar to TURP syndrome?



  • What are the causes of excessive bleeding during TURP?


  • What triggers disseminated intravascular coagulopathy in patients undergoing TURP? How would you treat it?


  • What are the causes, signs, symptoms, and treatment of bladder perforation during TURP?


  • What are the causes, signs, symptoms, and preventive measures for bladder explosion during TURP?


  • What are the causes of hypotension during TURP?


D. Postoperative Management



  • What is the source of postoperative bacteremia in patients who have undergone TURP? What factors increase the incidence of bacteremia?


  • What are the signs of post-TURP septicemia? What preventive measures are generally recommended?


  • What bacteria-related cause may possibly lead to sudden postoperative shock in patients who have undergone TURP?


  • Is postoperative hypothermia a risk factor for myocardial ischemia?


  • How would you diagnose perioperative MI?


E. Comparing Monopolar, Bipolar, and Laser TURP



  • What differentiates monopolar from bipolar TURP?


  • Are decreased morbidity and mortality associated more closely with monopolar TURP or with bipolar TURP?


  • What differentiates the technologies for laser TURP?


F. Are There Preferred Anesthetic and Preferred Surgical TURP Techniques for This Patient?



A. Medical Disease and Differential Diagnosis


A.1. Are there differences in morbidity and mortality rates between TURP and suprapubic or retropubic prostatectomy?

Many anesthesiologists and urologists consider TURP to be a simpler and safer procedure than open prostatectomy; however, no differences have been reported in mortality rates between patients who have undergone monopolar TURP and those who have undergone retropubic or suprapubic prostatectomy. With recent advances in TURP, including bipolar and laser, the overall mortality has declined to 0.10%.



Malhotra V. Transurethral resection of prostate. Anesthesiol Clin North America. 2000;18:883-897. Reich O, Gratzke C, Bachmann A, et al. Morbidity, mortality, and early outcome of transurethral resection of the prostrate: a prospective multicenter evaluation of 10,654 patients. J Urol. 2008;180:246-249.

Roos NP, Wennberg JE, Malenka DJ, et al. Mortality and reoperation after open and transurethral resection of the prostate for benign prostatic hyperplasia. N Engl J Med. 1989;320:1120-1124.


A.2. What comorbidities are common in patients undergoing TURP?

TURP patients often are elderly and suffer from cardiac, pulmonary, vascular, and endocrine disorders. The incidence of cardiac disease is 67%; cardiovascular disease, 50%; abnormal electrocardiogram (ECG), 77%; chronic obstructive pulmonary disease, 29%; and diabetes mellitus, 8%. Occasionally, these patients are dehydrated and depleted of essential electrolytes because of long-term diuretic therapy and restricted fluid intake.



Gravenstein D. Transurethral resection of the prostate (TURP) syndrome: a review of the pathophysiology and management. Anesth Analg. 1997;84:438-446.

Malhotra V. Transurethral resection of prostate. Anesthesiol Clin North America. 2000;18:883-897.

Miller RD, Cohen NH, Eriksson LI, et al, eds. Miller’s Anesthesia. 8th ed. Philadelphia, PA: Elsevier Saunders; 2015:2217-2243.



A.3. Does a history of prior MI increase the patient’s risk of perioperative reinfarction?

Yes, a history of prior MI or ischemic heart disease is considered an intermediate predictor of perioperative cardiac morbidity. Unstable coronary syndrome, severe angina, or recent MI indicates major clinical risks. Also see Chapter 14, section A.1.


A.4. In patients with a history of recent MI, would you recommend that the surgery be postponed for a certain period? If so, why? If not, why not?

An acute MI (7 days or less), or a recent MI (more than 7 days but less than or equal to 1 month), is considered an event requiring evaluation to determine if there is residual myocardium at risk. The stratification is based on the presentation of the disease; patients with active ischemia are at highest risk. Therefore, it is advocated to wait at least 6 weeks after an MI before elective surgery is performed, although no evidence supports this precaution. Also see Chapter 14, section A.7.



Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e278-e333.


B. Preoperative Evaluation and Preparation


B.1. How would you evaluate the patient’s cardiac condition? What additional tests would you have liked to order? Would you recommend that the patient undergo coronary angiography before surgery? Explain.

The American College of Cardiology/American Heart Association guidelines suggest a stepwise approach that takes into account the clinical markers of cardiac risk, functional capacity, and surgery risk. The patient’s medical history should focus on information about previous cardiac evaluations and interventions (coronary stent and automatic implantable cardioverter-defibrillator [AICD] placement). During physical examination of all organ systems, attention should be paid to the circulatory functions, especially in the presence of active cardiac conditions such as unstable coronary syndromes, decompensated congestive heart failure (CHF), significant arrhythmias, or severe valvular disease. The functional capacity of the patient is best evaluated by the activity history. Minimally, a routine ECG and chest radiograph should be obtained. If the patient presents signs and symptoms of CHF, angina, syncope, or arrhythmia, further cardiac testing should be considered if the results would impact the patient’s management. Traditional indications for coronary angiography apply regardless of future surgical interventions. Also see Chapter 14, section B.1.



Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e278-e333.


B.2. Are patients with a Q-wave infarction at greater risk of reinfarction than those with a non-Q-wave infarction? If so, why? If not, why not?

Studies suggest that patients who survive a non-Q-wave infarction are at greater risk of reinfarction than those who survive a Q-wave infarction.



Landesberg G. The pathophysiology of perioperative myocardial infarction: facts and perspectives. J Cardiothorac Vasc Anesth. 2003;17:90-100.

Mann DL, Zipes DP, Libby P, et al, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 10th ed. Philadelphia, PA: WB Saunders; 2015:1227-1252.

Priebe HJ. Perioperative myocardial infarction—aetiology and prevention. Br J Anaesth. 2005;95:3-19.



B.3. Would you discontinue any antihypertensives or any medications for angina? Why or why not?

Antianginal agents and β-blockers should be continued until the day of the surgery to prevent rebound hypertension and tachycardia that may result from sudden withdrawal of these drugs. Patients taking ACE inhibitors or angiotensin II receptor antagonists might present intraoperative hypotension due to a decrease of intravascular volume. It has been suggested that ACE inhibitors or angiotensin II receptor antagonists be withheld on the day before surgery and restarted after adequate intravascular volume has been established in order to avoid renal dysfunction.



Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:e278-e333.


B.4. For a patient with an ICD, what information should you know? What precautions should be taken?

Patients undergoing surgery with an ICD need to have the device interrogated prior to surgery. Recent and accurate information should be collected about the device’s features, the date of insertion, and the indication for placement. On the day of surgery, the device should be assessed for settings, pacer dependency, baseline rhythm and rate, tachyarrhythmia history, effect of magnet, and battery status.

In the event of potential electromagnetic interference, the antitachycardia algorithm of the ICD should be turned off and external cardioversion paddles should be placed until the device is reset to its initial functions after the procedure. Also see Chapter 8, sections B and C.



American Society of Anesthesiologists. Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: pace makers and implantable cardioverter-defibrillators: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Cardiac Implantable Electronic Devices. Anesthesiology. 2011;114:247-261.


B.5. What types of coronary stents are available? What is their perioperative relevance?

PCI is a common procedure in the United States. Coronary stent placement was introduced in order to reduce the risk of thrombosis, dissection, and restenosis after angioplasty. Two types of coronary stents have been used: bare metal stents (BMS) and drug-eluting stents (DES). Two types of DES—sirolimus and paclitaxel-eluting stents—have been used extensively to reduce the neointimal hyperplasic reaction seen with the use of BMS, which is the main cause of restenosis. Evidence suggests that DES delay the endothelialization of coronary stent struts. Patients with DES are at risk for late thrombosis if the antiplatelet therapy is prematurely interrupted.



Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014;130:2215-2245.


B.6. What is the conventional recommendation for antiplatelet therapy in a patient with previous percutaneous coronary intervention (PCI) undergoing noncardiac surgery?

Therapy with thienopyridines (ticlopidine or clopidogrel) and aspirin is recommended for 2 to 4 weeks after dilatation without stenting; elective surgery should be postponed for 2 to 4 weeks. After BMS, antiplatelet therapy for 4 to 6 weeks is recommended; elective surgery should be postponed for 4 to 6 weeks. After the implantation of DES, at least 12 months of antiplatelet therapy is required; elective surgery should be delayed for 12 months. Of note, newer DES may not require the same duration of dual therapy, and in these cases, consultation with the patient’s cardiologist can help guide the timing of discontinuation. In patients with an indication for PCI and a projected need for surgery within the next 12 months, a balloon angioplasty or BMS may be considered. Daily aspirin should be continued during the
perioperative period. Continuation of aspirin is not a contraindication to neuraxial anesthesia. For more details, see Chapter 10, section A.5 and Figure 10.1 and Chapter 14, section A.8.



Abualsaud AO, Eisenberg MJ. Perioperative management of patients with drug-eluting stents. JACC Cardiovasc Interv. 2010;3:131-142.

Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2215-2245.

Narouze S, Benzon HT, Provenzano DA, et al. Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med. 2015;40:182-212.


B.7. What risk is associated with perioperative antiplatelet therapy?

The results of studies on the risk of surgical bleeding with aspirin are inconsistent. In Burger’s review and meta-analysis (aspirin withdrawal vs. low-dose aspirin), the low-dose group’s relative risk of bleeding increased by a factor of 1.5, but there was no increase in bleeding complications or in perioperative mortality, with the possible exceptions of intracranial surgery and prostatectomy. Studies with ticlopidine or clopidogrel are also contradictory. Although some data support increased risk of major perioperative bleeding with dual-antiplatelet therapy (0.4% to 1%), there is no consensus regarding withholding thienopyridines. The risk of perioperative bleeding must be balanced against protection from a coronary event.



Burger W, Chemnitius JM, Kneissl GD, et al. Low-dose aspirin for secondary cardiovascular prevention— cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation—review and meta-analysis. J Intern Med. 2005;257(5):399-414.

Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2215-2245.


B.8. How should patients with coronary stents undergoing noncardiac surgery be approached?

The preoperative evaluation of patients with coronary stents should include information regarding the date of stent placement, the coronary anatomy before the intervention, the type of coronary stent, the localization of the intervention, complications (if any) during the procedure, the residual anatomy after the intervention (e.g., possibility of incomplete revascularization), and the antiplatelet strategy. Multidisciplinary discussions regarding how the risk of bleeding compares with the risk of coronary stent thrombosis are strongly encouraged. The most recently published Practice Alert indicates, “Elective surgery with a significant risk of bleeding should be postponed until the recommended course of thienopyridine therapy has been completed.” If surgery must be performed and if thienopyridine therapy must be interrupted (surgery with high risk of perioperative bleeding), aspirin should be continued and thienopyridine should be readministered as soon as possible after the procedure. Bridge therapies have been proposed for patients who undergo surgical procedures, but this practice has not been shown to reduce the risk of thrombosis. Currently, continuing double antiplatelet therapy is recommended in patients with DES for surgery with minor or intermediate risk of perioperative bleeding. A careful “case-by-case” consideration is advisable. Discussion between the anesthesiologist, the surgeon, and the treating cardiologist is recommended. For more details, see Chapter 10, section A.5 and Figure 10.1.



Abualsaud AO, Eisenberg MJ. Perioperative management of patients with drug-eluting stents. JACC Cardiovasc Interv. 2010;3:131-142.

Caplan RA, Connis RT, Nickinovich DG, et al. Practice alert for the perioperative management of patients with coronary artery stents: A report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2009;100(1):22-23.

Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130:2215-2245.



C. Intraoperative Management


C.1. What monitors would you use for this patient?

The following monitors would be used for this patient:



  • American Society of Anesthesiologists standard monitors, including multiple-lead ST-segment analysis


  • Temperature


  • Consider direct arterial blood pressure.


  • Consider transthoracic echocardiography, if necessary.


C.2. What anesthetic technique is preferable for patients undergoing TURP, and why?

Regional anesthesia has advantages for patients undergoing monopolar electrode TURP for the following reasons:



  • It allows monitoring of the patient’s mentation, thereby facilitating early detection of signs of TURP syndrome.


  • It can allow for earlier detection of prostate capsular tears or bladder perforation via patient reports of peritoneal or diaphragmatic (shoulder) pain, provided spinal level is below T10.


  • It promotes vasodilation and peripheral pooling of blood, thereby reducing the severity of circulatory overloading.


  • It reduces blood loss by lowering arterial and venous blood pressure during surgery.


  • It provides postoperative analgesia, thereby reducing the incidence of postoperative hypertension and tachycardia, which often accompanies recovery from general anesthesia.


  • Currently, less emphasis is placed on regional anesthesia (vs. general anesthesia) for TURP because of the increased use of bipolar electrode and laser resection surgical techniques.


  • Regional anesthesia may not be a safe option in an anticoagulated patient.



Malhotra V. Transurethral resection of prostate. Anesthesiol Clin North America. 2000;18:883-897.

Miller RD, Cohen NH, Eriksson LI, et al, eds. Miller’s Anesthesia. 8th ed. Philadelphia, PA: Elsevier Saunders; 2015:2217-2243.

O’Donnell AM, Foo ITH. Anaesthesia for transurethral resection of the prostrate. Contin Educ Anaesth Crit Care Pain. 2009;9(3):92-96.

Mar 18, 2021 | Posted by in ANESTHESIA | Comments Off on Transurethral Resection of the Prostate

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