What the Anesthesiologist Should Know before the Operative Procedure
Benign prostatic hyperplasia (BPH) is a progressive condition associated with symptoms of the lower urinary tract, specifically urinary retention or obstructed urinary flow. The prevalence of BPH increases with patient age, affecting more than half of men in their sixth decade of life. Traditionally, the management approaches to patients with BPH were limited. At the present time, both medical and interventional therapies are available.
Medical management is typically reserved for patients with moderate to severe symptoms since mild symptoms may not benefit over placebo.
Treatment is with monotherapy or combination therapy with an α-1-adrenergic receptor antagonist (i.e., doxazosin, terazosin, etc.) and/or a 5-α-reductase inhibitor (i.e., finasteride, dutasteride, etc.).
α-1-Adrenoceptor antagonists: α-blockade can provide fairly rapid relief of obstructive symptoms due to reduced prostatic smooth muscle tone, but may also result in dizziness and orthostatic hypotension from decreased α-1-adrenergic activity of blood vessels and interruption of the baroreflex response.
Tamsulosin may have fewer of these side effects because of its enhanced α-1A-receptor selectivity. 5-α-Reductase inhibitors slowly reduce prostatic volume by decreasing serum dihydrotestosterone levels over time. Side effects more commonly relate to sexual dysfunction and endocrine effects but also include dizziness and orthostatic hypotension.
Treatment may be less effective than α-blockers at relieving overall symptoms.
Other emerging medical therapies include phosphodiesterase type 5 inhibitors, anticholinergics, beta-3 agonists, and botulinum toxin A.
Transurethral resection of the prostate (TURP)
For many years, TURP has been considered the “gold standard” surgical therapy for BPH. It involves transurethral visualization and debulking of obstructive prostate tissue, using electrocautery or sharp dissection.
Historically reserved for those with moderate to severe urinary obstructive symptoms, which impact daily quality of life, or those with acute urinary retention, recurrent infection, recurrent hematuria, and azotemia.
Procedure: Various surgical techniques have been described and depend on prostate size and configuration. Typically, surgeons begin resection ventrally to create better exposure to adenomatous prostate tissue, and then continue resection dorsally towards the pelvic floor.
The bladder is first filled with a nonconducting, nonhemolytic, and preferably isotonic irrigation solution. The resection begins at the bladder neck. If the bladder neck still appears to be partially obstructed after initial resection, particularly if the initial prostate size is <20 grams, incising the bladder neck at the 6 o’clock position is often performed. The resection then continues to the prostatic capsule.
Excess capsule material causing the urinary obstructive symptoms is removed until normal prostate tissue is identified by the surgeon. A Foley catheter is then inserted into the bladder after completion of the procedure, typically for 1 to 5 days, to minimize effects of edema or other obstructions, which could impede urinary flow.
Although TURP has a fairly high success rate at improving lower urinary tract symptoms, it is associated with significant morbidity and a fairly high intraoperative complication rate of 3.2%.
Advantages: Has been considered the standard of care for many years due to its high success rate. There are significant improvements in both patient symptom scores and objective measures, such as increased urinary flow rate, decreased post-void residual urine volume, and a low overall retreatment rate on long-term follow-up.
Disadvantages: Most disadvantages of TURP are related to its complication rate and risk of severe complications. Patients are at increased risk for higher morbidity outcomes, especially those who are anticoagulated, have indwelling catheters, larger prostates, or bleeding disorders.
Frequently reported complications include acute urinary retention (AUR), clot retention, recurrent hematuria, and urinary tract infection/fever.
More severe complications include hemorrahge requiring transfusion (2%-3%), TURP syndrome (2%), capsular perforation (1%-2%), and prolonged catheterization.
Intraoperative bleeding: during active resection, the reported average rate of blood loss is about 2 to 4 mL/min.
TURP syndrome, which occurs from intravascular absorption of a large volume of irrigant into exposed venous sinuses, results in fluid overload, profound electrolyte abnormalities, and subsequent mental status changes.
The risk of developing significant hemorrhage or TURP syndrome increases with increased vascularity or number of exposed venous sinuses.
Late complications: urethral strictures (4.1%), persistent urgency (2.2%), and bladder neck strictures (~2%).
Minimally invasive surgical therapy for BPH (MIST)
While TURP remains a highly effective treatment for BPH, MIST therapies are improving and are an option for patients who are considered poor surgical candidates and those who wish to reduce the potential risk of sexual dysfunction.
Laser therapies involve principles of vaporization or coagulation. Each laser has a distinct wavelength, with a specific tissue interaction.
Therapies are divided into two categories based on the final tissue effects: procedures with immediate tissue ablation and those with delayed tissue ablation.
Immediate tissue ablation procedures include laser resection and vaporization techniques.
1. Tissue vaporization is achieved with a high-density laser therapy energy which raises the tissue temperature to several hundred degrees Celsius. The result ranges from vaporization, resection, or enucleation of obstructing prostatic tissue, allowing anatomical de-obstruction of the prostatic urethra.
2. Different lasers: There are primarily four different types of lasers being used currently.
a. Potassium-titanyl-phosphate (KTP) laser vaporization (GreenLight; Laserscope, San Jose, CA): induces strong absorption of KTP laser energy by hemoglobin. Because wavelength of 532 nm is selectively absorbed by hemoglobin, penetration is superficial and there is a small thermal coagulation zone (1-2 mm). This prevents a large volume of necrotic tissue from sloughing.
i. KTP laser is the most poplar laser. Higher power lasers, such as the 80-W “GreenLight” KTP laser, allow more efficient vaporization, with virtually no blood loss. This provides an excellent option for anticoagulated patients.
ii. Compared to TURP, there is a significantly lower side effect profile, with often equivalent results. However, it may not be as effective in treating larger sized prostates.
b. Holmium laser enucleation of the prostate (HoLEP): Unlike typical vaporization techniques, which resect prostate lobes into small pieces, HoLEP allows enucleation of entire lobes of the prostate from the prostatic capsule.
i. Meta-analysis results show a greater improvement in International Prostate Symptom Scores (IPSS) for HoLEP than for TURP, and a higher increase in peak urinary flow rate than for TURP.
ii. Late complication rates (including capsular rupture, etc.) are comparable to those for TURP.
c. Holmium: YAG laser: Often used for a procedure involving laser resection of the prostate (referred to by the acronym HoLRP).
i. Tissue is resected by vaporizing and incising pieces from the prostate, using a more directed energy.
ii. The procedure can be lengthy, requires long laser irradiation time, and is not a good option for large prostates.
d. Visual laser ablation of the prostate (VLAP): wavelength of 1064 nm allows for the deepest optical penetration of any laser. Direct vaporization and coagulation necrosis result in tissue necrosis and sloughing.
i. No longer popular because of high reoperation rates and complications, related specifically to long-term urinary retention and extended catheterization.
e. Other options:
i. Continuous-wave laser, a newer vaporesection technique, uses wavelength of 2013 nm to vaporize and incise prostate tissue.
1) Compared to the pulsed wave technique of other lasers, the continuous wave allows smoother incisions and superior hemostasis, while avoiding damage to surrounding structures.
Delayed tissue ablation procedures include thermal coagulation, such as interstitial laser coagulation.
1. Unlike immediate ablation techniques in which prostate tissue is directly incised and resected using a focused high-density laser, thermal coagulation uses lower temperatures, typically 85-100 degrees Celcius, to induce coagulative necrosis of inner prostate tissue, which atrophies and sloughs off in abour 4-8 weeks.
2. Laser fibers are transurethrally inserted deep inside prostate tissue, at a safe distance from the prostatic urethra, and laser energy is then delivered to the laser fiber tip, in attempts to preserve the prostatic urethra.
3. Compared to immediate ablation techniques, patient discomfort is minimal because the urethra is preserved.
4. Necrosis of less vascular prostatic adenoma is easily attained. Vascular tissue such as the prostate capsule are protected by cooling from blood flow.
5. Procedure is most commonly performed with transurethral cystoscopy, and less commonly may require a perineal approach. Trocars are necessary with perinal approach, but not necessary with transurethral technique.
6. Postprocedural follow-up after 2 and 12 months revealed an improvement in the average American Urological Association (AUA) Symptom Score by 70%.
1. What is the urgency of the surgery?
What is the risk of delay in order to obtain additional preoperative information?
Emergent/Urgent: “Emergent” or “urgent” surgical intervention is uncommon.
American Urological Association guidelines recommend surgical intervention in the following situations: inability to urinate causing refractory urinary retention, recurrent urinary tract infections, renal failure/insufficiency, bladder stones, or persistent gross hematuria. In the past, patients with gross hematuria would have been treated surgically. Current guidelines, however, recommend trying medical management first.
Elective: Elective surgical intervention is typically considered when medical management fails or per patient preference.
Often patients prefer “watchful waiting” due to the typically slow and unpredictable course of disease progression. However, in a 3-year study period, twice as many treatment failures occurred with “watchful waiting” and about 24% of patients eventually underwent surgical intervention.
2. Preoperative evaluation
BPH is a common disease of elderly men. Geriatric patients have the highest mortality rate in the adult surgical population because of significant aging-related, coexisting morbidities and polypharmacy. While morbidity and mortality increase with age, coexisting disease has been shown to be a better predictor of adverse postoperative outcomes than age alone. Specifically, elderly patients undergoing transurethral intervention have demonstrated an increased incidence of cardiac, pulmonary, and renal complications.
As this is primarily an elective procedure, medically unstable conditions warrant futher evaluation, and consideration of delaying surgery
3. What are the implications of co-existing disease on perioperative care?
All geriatric patients likely have some degree of atherosclerosis from the natural mechanisms of aging. It is important to obtain a thorough clinical history about cardiac symptoms and functional capacity. Workup should at least include a 12-lead ECG. If the patient has active cardiac symptoms, the patient should be evaluated and treated in accordance with guidelines outlined by the ACC/AHA.
1. Since perioperative hypotension is more frequent and severe in the elderly, caution is advised regarding continuing α-1-antagonists and 5-α-reductase inhibitors on the day of surgery.
2. α-1 blockers may exacerbate hypotension and blunt the vasopressor response to α-1 agonists such as phenylephrine.
3. 5-α-reductase inhibitors may also exacerbate postural hypotension and contribute to hemodynamic instability perioperatively.
4. Patients should withhold angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers before surgery (ARBs).
a. Several studies have demonstrated that continuing ACEIs and ARBs can cause refractory hypotension during induction.
5. Diuretics should also be held since the patient will be NPO before surgery.
6. Beta-blockers should be continued since they have been shown to decrease perioperative morbidity.
a. Patients with one or more risk factors such as system hypertension, active smoker, hyperlipidemia, or diabetes mellitus may benefit from prophylactic perioperative beta-blockade.
Elderly patients are more prone to respiratory fatigue and increased risk of respiratory failure.
They have a decreased resting PaO2, and are more prone to opioid-induced chest wall rigidity, especially with remifentanil. Regional anesthesia may be a better option than general anesthesia in these patients, as there is less risk of postoperative hypoxemia.
The most common clinical manifestations of BPH are urinary symptoms. Untreated BPH can lead to renal deterioration from hydronephrosis, urinary retention, and recurrent urinary tract infections. In addition, the effects of aging on the kidneys must be taken into consideration in this patient population.
1. Preexisting renal disease, advanced age, and cardiac failure are strongly predictive for a postoperative renal failure.
2. GFR is a better indicator of renal disease. Consider adjusting medications in the elderly as GFR is decreased by 30% by age 60 and 50% by age 80.
3. Avoid drugs excreted renally with active metabolities (morphine, meperidine, etc.). If muscle relaxation is needed, consider using cisatracurium in patients with compromised renal function.
b. Cardiovascular system
g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
4. What are the patient's medications and how should they be managed in the perioperative period?
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
i. What should be recommended with regard to continuation of medications taken chronically?
j. How To modify care for patients with known allergies –
k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
l. Does the patient have any antibiotic allergies
m. Does the patient have a history of allergy to anesthesia?
Malignant hyperthermia (MH)
Documented: Avoid all trigger agents such as succinylcholine and inhalational agents:
Proposed general anesthetic plan:
Ensure MH cart available:
5. What laboratory tests should be obtained and has everything been reviewed?
Preoprative lab work
Preoperative labs are not indicated unless the patient has coexisting diseases that may cause abnormalities.
1. BUN, creatinine, and potassium levels are indicated if patients have preexisting renal disease or are taking medications that may affect the kidneys or cause electrolyte disturbances.
2. As opposed to TURP surgery, baseline sodium level is not crucial. The risk of TURP syndrome is significantly decreased because saline is used for irrigation instead of nonelectrolyte fluids.
3. Blood loss is expected to be minimal However, some patients with BPH may have chronic anemia from recurrent hematuria. A CBC should be obtained in a patient with a history of bleeding or anemia.
4. Coagulation studies should be obtained in patients who have liver disease, signs or symptoms or bleeding or bruising, are on anticoagulation, or if neuraxial technique is planned. T&S is not necessary.
Preoperative imaging studies
Routine imaging is not indicated.
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
Choice of anesthetic technique for MIST
Procedure can be performed using local anesthesia, with or without supplemental IV sedation, neuraxial technique, or general anesthesia.
This procedure can be performed in an outpatient setting using local anesthesia with transperineal, transrectal, and retropubic prostatic block by an experienced urologist. Supplemental sedation may be provided. The procedure time is usually less than 1 hour and recovery time is approximately 30 minutes.
1. This type of anesthesia is especially ideal for high-risk patients with significant comorbidities. Technique also permits early detection of mental status changes.
2. Chilled 2% lidocaine gel inserted through the urethra 20-30 minutes before the block may enhance patient comfort.
3. Average volume of anesthesia depends on the prostate size. Some studies reported using 45 mL of 1%-2% lidocaine or 0.25% bupivicaine with or without epinephrine (1:100,000), or 23 mL is used along with IV sedation.
4. Local anesthetic toxicity may occur but is uncommon. The most popular is the perineal block, which requires significantly less local anesthetic than the retropubic block.
a. Toxicity may present with slurred speech, diaphoresis, ringing in the ears, or numbness in the tongue.
b. Signs of toxicity may be masked under general anesthesia and may present as seizures, hypoxemia, prolonged PR or QT intervals, and dysrrhythmias.
Neuraxial technique is beneficial in this patient population because the complications associated with general anesthesia can be avoided and postoperative pain management is provided.
1. Neuraxial techniques may decrease the incidence of postoperative delirium in the elderly. Cognitive function in elderly patients undergoing TURP with regional anesthesia without sedation was shown to be better preserved.
2. A large study reported a reduction in the overall mortality and incidence of myocardial infarction by one-third in patients who received neuraxial block, compared with general anesthesia.
3. Epidural or spinal anesthesia may be contraindicated in patients with preexisting coagulopathy or thrombocytopenia, patients on anticoagulation, and those with severe hypovolemia.
General anesthesia with LMA or endotracheal tube has been used successfully.
1. There is increased risk of complications associated with general anesthesia such as nausea, vomiting, sore throat, and postoperative cognitive dysfunction.
2. The use of desflurane for maintenance of general anesthesia has been shown to facilitate faster postoperative recovery time in short urologic procedures compared with isoflurane.
3. Depending on the surgeon’s preference, muscle relaxation may or may not be needed.
Intraoperative management for MIST
1. Monitors: Standard ASA monitors. Invasive monitoring is typically not needed.
2. Position: Dorsal lithotomy
3. Antibiotics: Fluoroquinolone class
4. Safety precautions
a. It is important to exercise safety precautions when using a laser.
i. Decrease the risk of OR fire by having adequate smoke evacuation with appropriate filters.
ii. Need for eye protection: All physicians, nursing staff, and the patient should wear eye protection.
5. Possible intraoperative complications
a. Bladder perforation: May cause peritoneal irritation and severe pain; can be more difficult to diagnose under general anesthesia, and may present as hemodynamic instability, such as bradycardia, tachycardia, hypertension, or hypotension.
b. Bleeding: Significant hemorrahge requiring transfusion is rare since laser therapy should provide adequate coagulation and hemostasis.
c. TURP syndrome: Incidence is low with laser therapy, as well as with other minimally invasive therapies, because the procedure is relatively short, a small amount of irrigation is used, and laser therapy permits the use of normal saline. The procedure should not be in close proximity to the venous plexus.
i. The three major nonconductive fluids used for TURP procedure are glycine, sorbitol, and mannitol. Glycine itself can cause altered mental status, as one of its metabolities is ammonia. In addition, glycine is an inhibitory transmitter in the retina and can lead to transient visual abnormalities.
ii. The most common manifestations of TURP syndrome is altered mental status from dilutional hyponatremia. Patients may also exhibit hypertension, hypotension, bradycardia, pulmonary edema, hypoxemia, seizures, and abnormal ECG changes (widened QRS, ST elevations), which can progress to dyssrhthmias as sodium levels increase. Abnormal laboratory findings include significant hyponatremia and elevated serum osmolal gap.
Treatment of intraoperative complications
a. Bladder perforation: General anesthesia is imperative if a large perforation requires conversion to an open abdomen or peritoneal irritation causes significant pain or hemodynamic changes.
b. TURP syndrome:
If possible, terminate the procedure.
The mainstay treatment is IV furosemide.
Hypertonic saline may be used in symptomatic patients with marked hyponatremia.
1. It is prudent not to correct sodium more than 12 mEqQ/L in the first 24 hours to avoid risk of osmotic demyelination. Hypertonic NS should be discontinued when patient is no longer symptomatic or Na is >120 mEq/L.
c. Local anesthetic toxicity
In most cases, toxicity is not severe and symptoms are transient and resolve without medical intervention.
Signs of CNS toxicity usually occur before cardiovascular complications, and may be masked under general anesthesia. Injection should be discontinued immediately. Oxygen should be administered. Intravenous thiopental and midazolam may terminate seizures.
If cardiac toxicity ensues, oxygenation and ventilation must be initiated immediately. ACLS may be necessary.
Dysrhythmias may be refractory to treatment and may require larger doses of medication. There have been reports of refractory cardiac arrest induced by bupivacaine.
6. What is the author's preferred method of anesthesia technique and why?
b. If the patient is intubated, are there any special criteria for extubation?
c. Postoperative management
Postoperative Management after MIST
1. Type of analgesia: Typically, ILC is tolerated quite well. Choice of postoperative analgesia depends on the type of intraoperative anesthesia and the patient’s tolerance to pain medications.
a. Pain control options should be multimodal. Choices range form Tylenol to narcotics, with consideration of other adjunct pain medications as well. A more conservative route should be initiated in this geriatric population, since narcotics can cause respiratory depression and urinary retention.
2. Parameters to monitor: Objective assessment includes indwelling catheter duration, postvoid residual urine volume, and maximum urinary flow rate. Additional assessment of symptom severity and recurrence of symptoms can be done with the American Urology Association (AUA) symptom score and International Prostate Symptom Score (IPSS).
3. Level of care: Postoperative level of care depends on the type of anesthesia and the intraoperative course.
a. Local anesthesia: Generally well tolerated and often done in an office-based setting. The patient should stay in a monitored setting for a short period of time before discharge. If the postoperative plan includes keeping a Foley catheter in place, education on foley care is addressed prior to discharge.
b. Neuraxial anesthesia: Patients should be monitored in a PACU setting at least until sensory, motor, and sympathetic blocks have worn off.
c. General anesthesia: Patients are generally monitored in the PACU until standard discharge criteria are met. Standard criteria include adequate respiration, O2 saturation, consciousness, blood pressure, control of bleeding, pain, and nausea/vomiting, and ability to ambulate. Patient disposition will depend on the intraoperative course. If an intraoperative complication occurred or if comorbidities require closer monitoring, the patient should be considered for hospital admission.
4. In a study of elderly patients undergoing outpatient transurethral procedures, in which postoperative recovery was examined, after general anesthesia compared to spinal anesthesia without continuous supplemental intraoperative sedation, results showed similar PACU phase 1 recovery and discharge times. However, there was a greater incidence of hemodynamic instability with GA.
5. Possible postoperative complications
a. Related to anesthesia:
Neuraxial anesthesia: backache, postdural puncture headache, respiratory depression from rostral spread of intrathecal narcotics, inadequate sensory analgesia, systemic local anesthetic toxicity with epidural doses (less risk with lower spinal doses), total spinal, spinal or epidural hematoma, neurological injury, transient neurological symptoms.
General anesthesia: acute delirium, postoperative cognitive dysfunction, sore throat, shivering, nausea, vomiting, etc.
iii. Exacerbation of preexisting comorbidities, from neuraxial or general anesthesia, can also occur.
iv. Improper dosing or choice of antibiotics will increase the risk of a postoperative infection.
b. Related to surgical procedres (ILC)
i. Short-term: Improper laser tip position intraoperatively during ILC may damage the prostatic urethra, and result in prolonged Foley catheter duration and increased risk for urinary tract infection. Urinary tract infection has been reported as the most common adverse event after ILC of the prostate, occurring at a frequency of 20%-35% in some studies.
1) Foley catheter should be removed as soon as possible to minimize infection risks. If an infection does occur, appropriate antibiotics should be given per local protocol, and Foley replacement may be indicated.
2) Bleeding, dysuria, blood clot retention, and acute urinary retention are additional potential complications.
c. Long-term: Recurrence of symptoms may necessitate retreatment. Retreatment rates for ILC range up to 15.4% at follow-up after 1 year and about 16% in another study after 2 years.
i. Sexual dysfunction, retrograde ejaculation, urethral stricture, and transient dysuria are also potential side effects.
What's the Evidence?
Outcomes studies comparing laser therapy with traditional TURP procedure
There has been a gradual decline in the number of TURP procedures being performed, and an increased use of MIST for surgical management of lower urinary tract symptoms from BPH. Recent studies have produced promising data to suggest that some of the MIST procedures may have the potential to replace TURP.
1. Potassium-titanyl-phosphate (KTP) laser:
a. An early prospective study on KTP vaporization reported durable improvement of AUA symptoms scores and peak flow rates at 1, 2, 3, and 5 years postoperatively.
b. Another study comparing outcome data after KTP versus TURP reported decreased incidence of perioperative complications and shorter hospital stays with KTP, comparable improvement in symptoms in both groups sustained until 2-year follow-up, but also a higher rate of repeat TURP/KTP in the KTP laser group.
c. A meta-analysis of KTP laser techniques also reported a higher incidence of late complications relating to surgical reintervention, transient dysuria, and urethral stricture.
d. Currently, for small to mid-sized prostates, the available data demonstrate that the KTP laser has comparable efficacy to TURP. For larger prostates, however, more long-term follow-up studies are warranted.
2. Holmium laser:
a. Compared to TURP, HoLEP has produced superior results in terms of decreased hospital stay, blood loss, and catheterization times.
b. An early study comparing outcomes after HoLEP versus TURP at 12-month follow-up found comparable results with regard to relief of bladder outflow obstruction, resulting in improved symptom scores, peak urinary flow rates, and postvoid residual urine measurements.
c. More recent long-term outcome data on HoLEP after 5-year follow-up confirm comparable functional results to TURP.
d. In summary, given the advantage conferred by the HoLEP procedure, in that it is prostate-size independent, in addition to recent data suggesting that it is at least as effective as TURP, HoLEP is gaining popularity as a front-line surgical treatment for BPH.
3. Interstitial laser coagulation:
a. Early studies reported comparable short- to immediate- term outcomes to other minimally invasive surgical procedures and TURP for small to medium-sized prostates. A multicenter randomized control trial comparing ILC to TURP after a 2-year follow-up reported similar results in AUA symptoms score reduction or quality of life measures.
b. However, longer-term follow-up has revealed high retreatment rates. One study found that retreatment ranged from 0% to 15% at 1 year, 20% at 2 years, and 41% at 3 years. In fact, ILC retreatment rates are comparable to those following primary medical therapy with α-blockers. Specifically, Tamsulosin, Alfuzosin, and Terazosin, produced retreatment rates of 27%, 37%, and 49%, respectively, at 3-year follow-up. These results are inferior to the average annual incidence rate of repeat TURP after primary TURP of 0.8% to 2.5%.
c. Additionally, ILC is associated with high early postoperative morbidity, with urinary tract infections reported in up to 35% of patients and prolonged catheterization with an average duration ranging from 18.3 days to 1 month.
d. In summary, in light of postoperative complications and high retreatment rates, the popularity of ILC has declined over the past few years. The main advantage of ILC is that it offers decreased operative morbidity compared with TURP, and is currently only recommended for patients with coagulation disorders.
4. Continuous-wave laser
a. A recent prospective trial comparing a continuous-wave laser with TURP reported comparable efficacy outcomes at 12-month follow-up, with a lower incidence of intraoperative and postoperative complications in the continuous-wave laser group.
b. Early results from continuous-wave vaporesection have been promising, although given that the continuous-wave laser is a fairly new development in laser technology, long-term follow-up is still needed.
5. Other minimially invasive methods:
a. Transurethral microwave thermotherapy (TUMT): heats tissue with eventual coagulation necrosis by delivering high microwave energy to the prostate.
i. A systematic review of six randomized controlled trials evaluating the efficacy of TUMT compared with TURP found that although TUMT carried a considerably lower morbidity with shorter hospital stays, being performed as an outpatient procedure compared to a mean hospital stay of 5 days for TURP, TUMT was not as effective as TURP in improvement of symptoms or peak urinary flow rates. In addition, retreatment rates were significantly higher following TUMT.
ii. Currently TUMT is considered a safe, short-term alternative to TURP for partially relieving mild obstructive symptoms, but is not as effective as TURP for long-term improvement in symptoms, objective urinary flow variables, and low rates of retreatment.
b. Transurethral needle ablation of the prostate (TUNA): uses low-level radiofrequency energy delivered by needles to create cavities in the inner region of the prostate. The prostatic uroepithelium is preserved.
i. A recent meta-analysis of TUNA studies reported improvement in IPSS symptom scores by 50% in patients with severe symptom scores at baseline, and this improvement persisted 5 years after treatment. Additionally, low perioperative complication rates have been reported with TUNA. Nonetheless, TURP produced consistently greater improvements in symptom scores and urinary flow rates at long-term follow-up.
ii. In summary, TUNA is considered a suitable option for patients with severe symptoms, who may not be candidates for TURP. It is more effective than medical therapy, although less effective than TURP overall.
Currently, there are several promising minimally invasive options for patients with BPH. Each minimally invasive therapy presents its own risks and benefits, and the most appropriate therapy depends on the individual patient’s clinical profile and preferences. For instance, while interstitial laser coagulation has provided a more beneficial safety profile, it also carries its own risk of morbidities, and has shown an increased rate of recurrence when compared to TURP. As a result, the most appropriate candidates for ILC include those who want to avoid significant surgery, have small to medium-sized prostates, are on anticoagulation, or have significant medical comorbidities which make them poor candidates for surgery and anesthesia. Given the increased surgical and anesthesia-related perioperative risks inherent in the elderly population, minimally invasive therapies provide an important alternative to standard surgical TURP.
|Comparison of Laser Procedures for Treatment of BPH|
|Diode (ILC)||No surgical morbidity||Symptom scoresPeak flow ratesHigh retreatment rateUrinary tract Infection|
|KTP (PVP)||Low retreatment rateNo blood lossSymptom scores||Cost of fibersNo tissue for histology|
|Holmium (HoLEP)||Multiple-use laserTissue for histologySymptom scoresPeak flow ratesLow morbidity Low blood lossShort catheterization||Steep learning curveCost of laser plus morcellatorOperation time|
|Nd:YAG (VLAP)||No blood transfusionsNo strictures||No tissue for histologySymptom ScoresPeak flow ratesProstate volumeHigh retreatment rateLong-term retentionExtended catheterization|
HoLEP: Holmium Laser Enucleation of the Prostate, KTP (PVP): Potassium Titanyl Phosphate (Photoselective Vaporization of the Prostate), ILC: Interstitial Laser Coagulation, Nd:YAG (VLAP): Neodymium;yttrium-aluminum-garnet (Visual laser ablation of the prostate)
Fred NM. New laser treatment approaches for benign prostatic hyperplasia.
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Fredman, B. “Fast-track eligibility of geriatric patients undergoing short urologic surgery procedures”. Anesth Analg. vol. 74. 2002. pp. 560-4. (Supports preoperative evaluation and perioperative care.)
Campbell, HT, Fincher, ME, Sklar, AH. “Severe hyponatremia without severe hypoosmolality following transurethral resection of the prostate (TURP) in end-stage renal disease”. Am J Kidney Dis. vol. 12. 1988. pp. 152(Supports preoperative evaluation and perioperative care.)
Ornek, D, Metin, S, Deren, S. “The influence of various anesthesia techniques on postoperative recovery and discharge criteria among geriatric patients”. Clinics (Sao Paulo). vol. 65. 2010. pp. 941-6. (Supports anesthesia recommendations.)
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- What the Anesthesiologist Should Know before the Operative Procedure
- 1. What is the urgency of the surgery?
- What is the risk of delay in order to obtain additional preoperative information?
- 2. Preoperative evaluation
- 3. What are the implications of co-existing disease on perioperative care?
- b. Cardiovascular system
- c. Pulmonary
- d. Renal-GI:
- e. Neurologic:
- f. Endocrine:
- g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
- 4. What are the patient's medications and how should they be managed in the perioperative period?
- h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
- i. What should be recommended with regard to continuation of medications taken chronically?
- j. How To modify care for patients with known allergies -
- k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
- l. Does the patient have any antibiotic allergies
- m. Does the patient have a history of allergy to anesthesia?
- 5. What laboratory tests should be obtained and has everything been reviewed?
- Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
- 6. What is the author's preferred method of anesthesia technique and why?
- a. Neurologic:
- b. If the patient is intubated, are there any special criteria for extubation?
- c. Postoperative management
- What's the Evidence?