What the Anesthesiologist Should Know before the Operative Procedure

Transurethral procedures are performed for a variety of medical problems that may be either elective or emergent. Different anesthetic techniques may be appropriate for the same procedure. Patient comorbidities are common, particularly in elderly patients undergoing transurethral resection of the prostate (TURP) or resection of a bladder tumor (TURBT).

Obstruction of the ureters may cause acute renal failure, electrolyte abnormalities, and acid-base disturbances. Each case must be evaluated individually for the most appropriate anesthetic plan, and comorbidities must be carefully assessed, hemodynamic monitors chosen, and appropriate postoperative care determined.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

Transurethral procedures may be performed to diagnose or treat cancers of the prostate and bladder. The vast majority of such cases are performed electively. If the preoperative assessment of the patient is incomplete, it is reasonable to delay these cases to obtain necessary information. Delaying a diagnosis of prostate cancer by one or two days is unlikely to adversely affect patient outcome. In cases where a transurethral procedure is being performed to evaluate gross hematuria, or a ureteral obstruction is causing acute renal failure, delay of the procedure may not be acceptable and the case should proceed as an emergency.

Emergent: Emergent indications for transurethral procedures include gross hematuria causing profound anemia or significant hemodynamic instability or acute renal failure or sepsis due to ureteral obstruction. Patients with significant hematuria may be hypotensive and anemic upon presentation. Volume resuscitation and blood product transfusion may be indicated. In cases of ureteral obstruction leading to acute renal failure, electrolyte abnormalities may be present and require immediate correction. Severe hyperkalemia (K > 6) should be treated prior to induction of anesthesia.

Urgent: Patients with mild hematuria may be evaluated urgently as long as they are hemodynamically stable and not profoundly anemic. Patients with ureteral obstruction but without evidence of renal failure, infection, or electrolyte abnormalities may be evaluated and treated urgently as opposed to emergently. The development of hyperkalemia or a significant increase in creatinine is a sign that the procedure should be performed emergently.

Elective: Most transurethral procedures are performed to diagnose and treat cancers of the prostate and bladder. While the diagnosis of cancer should be made in a timely fashion, these cases may be scheduled when the patient is medically optimized and adequate preoperative assessment has been made.

2. Preoperative evaluation

Age is one of the greatest risk factors for prostate cancer, with most cancers presenting in patients over 50. Age is also a risk factor for cardiopulmonary disease, cerebrovascular disease, renal insufficiency, peripheral vascular disease, and endocrine conditions. These comorbidities may be present in the patient presenting for a transurethral procedure to diagnose or treat prostate or bladder cancer.

Cardiopulmonary disease

A thorough evaluation of the patient’s cardiopulmonary system is critical before proceeding with the procedure. It is well known that advanced age is a risk factor for hypertension, coronary artery disease, and valvular dysfunction. Indications of cardiopulmonary disease include the presence of angina, syncope, or dyspnea with minimal exertion. Proper preoperative workup may include an EKG, stress test, echocardiography, chest x-ray, and consultation with appropriate medical subspecialists.

Certain cardiac conditions may contraindicate different anesthetic techniques; for example, aortic stenosis is usually a contraindication for spinal anesthesia. Although rarely indicated, pulmonary function studies may help classify the severity of a patient’s asthma or COPD and help to determine if preoperative steroids are indicated. It is important to evaluate for COPD, particularly if it is severe enough to require home oxygen therapy.

Cerebrovascular disease

Patients will usually know if they have suffered a stroke with residual motor or sensory deficits. Weakness or paralysis in the extremities, or altered sensorium, due to stroke may greatly influence anesthetic management. It is important to evaluate and document any preoperative deficits in strength or sensation prior to the induction of general anesthesia or the placement of a neuraxial anesthetic.

Renal insufficiency

Renal insufficiency may be present in patients presenting for transurethral procedures. It is important to identify if the patient’s renal failure is acute or chronic. Chronic renal failure may be due to long standing conditions that are common in the elderly population, such as poorly controlled hypertension or diabetes. Acute renal failure may be due to obstruction from an enlarged prostate or a stone in the ureter.

Both acute and chronic renal failure may be associated with electrolyte abnormalities, which may be less well tolerated when they develop acutely. Serious electrolyte abnormalities, such as hyper or hypokalemia, should be resolved before proceeding with surgery. In some circumstances, dialysis may be necessary.

Peripheral vascular disease (PVD)

This is more common in patients with hypertension, diabetes, and connective tissue disorders. Patients with vascular disease may also have co-existing renal insufficiency, coronary artery disease, aortic disease, and cerebrovascular disease. Patients with significant PVD need a thorough evaluation of end organ function. Obtaining peripheral IV access may be challenging, and central venous access may be necessary.

Endocrine Disease

Diabetes mellitus (DM) is common in elderly patients and may affect every organ system. Hemoglobin A1C is a useful measurement to assess how well a patient’s DM is controlled. Poorly controlled DM is associated with renal disease, vascular disease, delayed gastric emptying, electrolyte abnormalities, hyperosmolar states, and neuropathies. It is important to know when a patient last used insulin and to check blood glucose levels immediately prior to surgery.

Medically unstable conditions warranting further evaluation include acute renal failure associated with electrolyte abnormalities and patients with hemodynamic instability. Hyperkalemia with K > 6 may require immediate treatment, potentially with hemodialysis. Patients with urinary tract obstruction may develop signs of sepsis, including fever, tachycardia, leukocytosis, and hypotension. Rapid evaluation and resuscitation of the septic patient may be necessary before proceeding with surgery.
Delaying surgery may be indicated for electrolyte correction in acute renal failure or volume resuscitation in a hypotensive patient.

3. What are the implications of co-existing disease on perioperative care?

The perioperative evaluation should include the evaluation of each organ system as noted above. Preoperative evaluation may be minimized to only the essentials if the procedure is emergent.

Perioperative risk reduction includes ensuring the proper timing of preoperative antibiotics (within one hour before incision), maintaining normothermia, adequate deep venous thrombosis (DVT) prophylaxis, and control of blood glucose.

b. Cardiovascular system

Acute/unstable conditions

Unless the patient has severe hemorrhage, or an obstruction of the urinary tract resulting in acute renal failure of urosepsis, patients with acute or unstable cardiac conditions should have their transurethral procedure delayed.

Baseline coronary artery disease (CAD) or cardiac dysfunction

Patients with baseline cardiac dysfunction should be medically optimized before surgery. In the case of CAD, this will likely include initiation of beta blocker and statin therapy, adequate control of BP and heart rate, and preoperative evaluation of ventricular function and the extent of coronary disease. Depending on the patient’s symptoms, coronary angiography and CABG may be indicated.

c. Pulmonary

COPD

COPD is common in elderly patients with a history of tobacco use. Bronchodilators and steroids are the mainstays for management of this condition, and home oxygen may be required.

Bronchodilators and steroids should be taken on the day of surgery. Stress dose steroids may be administered based on clinician preference. Patients with severe disease may have trouble weaning from mechanical ventilation if GETA and muscle relaxants are used. In such cases, regional anesthesia may be employed. If MAC or regional anesthesia is being considered, it is important to enquire about the patient’s ability to lie flat for the entire procedure. If they are short of breath while supine, GETA may be more appropriate.

Reactive Airway Disease/Asthma

Asthma is common in young patients and is managed with inhaled bronchodilators and steroids. It is important to listen to the patient’s lungs preoperatively. If there is active wheezing, albuterol may be administered. If wheezing persists, the surgery should be postponed.

Intraoperative bronchospasm may be managed by increasing the fraction of inspired oxygen, deepening the anesthetic, particularly volatile anesthetic, inhaled bronchodilators through the ETT, subcutaneous or intravenous terbutaline, and epinephrine. As with COPD patients, it is best to avoid instrumentation of the airway in a patient with severe asthma. Regional anesthesia with intravenous sedation (MAC) may be preferable.

d. Renal-GI:

Renal failure may be a pre-existing condition, or the reason a patient is presenting for a transurethral procedure. As discussed above, optimization of electrolytes and acid-base status before induction is important. Chronic renal failure (CRI) ranges from mild and asymptomatic cases to severe cases requiring hemodialysis. One should avoid further insult to the kidneys, and so antibiotics must be renally dosed, the patient maintained normotensive, and proper muscle relaxants chosen. Cisatracurium is the preferred non-depolarizing muscle relaxant due to its metabolism independent of the kidneys.

Patients who require hemodialysis should be dialyzed before the procedure. If dialysis occurred more than 24 hours before the case, it is useful to check a preoperative basic metabolic panel to ensure that no dangerous electrolyte abnormalities are present. The patient may need postoperative dialysis if large volumes of intravenous fluid are used, and prolonged mechanical ventilation may be required if pulmonary edema is present.

Diseases of the GI system may increase the risk of aspiration. Patients with gastroparesis, for example, should have rapid sequence inductions to minimize the risk of aspiration. In the presence of a full stomach or a patient with severe GERD, promotility agents (metoclopramide), H2 blockers (ranitidine), and oral antacids may be administered before induction.

e. Neurologic:

Elderly patients may suffer from strokes or degenerative neurologic conditions such as Alzheimer’s disease or Parkinson’s disease. If the patient has a history of stroke, pre-existing motor and sensory deficits should be noted. Motor deficits may preclude the use of succinylcholine due the risk of hyperkalemia.

Preoperative sensory deficits are important to note if neuraxial or regional anesthesia is planned in the event that postoperative neurologic deficits are found. Management of Alzheimer’s and Parkinson’s diseases will depend on the severity of the disease and patient symptoms. Constant verbal reassurance may be necessary.

f. Endocrine:

Diabetes mellitus (DM) is common in elderly patients. Perioperative management of diabetic medications and insulin is discussed below. All patients with DM should have a blood glucose checked preoperatively and intermittently through the case. An insulin infusion may be used in patients with Type I DM.

Long standing disease can affect every organ system, and end organ dysfunction should be noted preoperatively. Particular attention should be paid to diabetic gastroparesis, peripheral neuropathies, CAD, stroke, and nephropathy.

Thyroid disease is common in the elderly. If the patient has clinical symptoms of hyper or hypothyroid, a serum TSH and free T3/ T4 should be checked. Most patients with hypothyroidism are managed on oral thyroid replacement hormones. There are no specific concerns in these patients when they are undergoing transurethral procedures.

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)

N/A

4. What are the patient's medications and how should they be managed in the perioperative period?

Cardiac medications

Antihypertensive and antiarrhythmic medications should be continued through the day of surgery.

Pulmonary medications

Bronchodilators, inhaled steroids, and other medications for asthma and COPD should be continued through the day of surgery.

Renal and GI medications

Although not common, medications for renal disease should be continued through the day of surgery. Proton pump inhibitors, H2 blockers, and other drugs for GERD should be continued through the morning of surgery. Alpha blocking agents used to relieve urinary track obstruction from an enlarged prostate may contribute to hypotension, and clear guidelines do not exist as to when or if they should be discontinued preoperatively.

Endocrine medications

Oral DM medications should probably be continued until the day before surgery, but held while the patient is NPO. Although metformin does not appear to be associated with perioperative lactic acidosis, it may be prudent to hold it preoperatively for 24-48 hours in patients with renal insufficiency or those receiving IV contrast.

There are many ways to manage perioperative insulin therapy. It is reasonable to continue basal insulin infusions through the day of surgery, while administering a smaller dose of long and intermediate acting insulin on the morning of surgery and holding all short and rapid acting insulin on the day of surgery.

Anticoagulants

The length of time to hold anticoagulants should be based on the patient’s individual comorbidities, the type of surgery being performed, and the planned anesthetic technique. For the purposes of neuraxial blockade, anticoagulants should be managed according to the guidelines issued by the American Society of Regional Anesthesia and Pain Medicine (ASRA).

Herbal medications and vitamins

These are common among patients presenting for surgery. More than 20% of pre-surgical patients report using herbal medicines, and more than 50% take vitamins. Many patients do not inform their health care providers about these alternative therapies.

Gingko biloba, garlic, and ginger all interfere with platelet function or coagulation pathways. The safety of neuraxial anesthetics in patients taking these medications is not known. Ephedra and ginseng are sympathomimetics and contribute to hypertension and arrhythmias. These drugs should be discontinued preoperatively. St John’s wort, valerian, and kava-kava cause sedation and should also be discontinued preoperatively, although the optimal timing is unknown.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

Alpha blocking agents

Agents such as terazosin, doxazosin, and tamsulosin help relax smooth muscles in the urinary track and prostate. Non-selective alpha blockers may cause orthostatic hypotension and contribute to an exaggerated hypotensive effect under anesthesia. Hemodynamic changes should be anticipated in patients taking these medications.

Anticoagulants and anti-platelet drugs

Medications such as warfarin, heparin, Plavix, and aspirin are important to take note of when regional anesthesia is planned. ASRA guidelines are clear in their recommendations for how to manage these agents perioperatively. The surgeon should also be aware of when the anticoagulants were discontinued, as recent administration may be a contraindication for surgery.

i. What should be recommended with regard to continuation of medications taken chronically?

Cardiac

Antihypertensive medications, antiarrhythmics, and medications for heart failure should all be continued through the day of surgery.

Pulmonary

Bronchodilators and inhaled steroids should be continued through the day of surgery. If wheezing is present preoperatively, beta agonists (albuterol) may be given.

Renal

Diuretics should be continued through the day of surgery. Patients should have a recent basic metabolic panel to check for electrolyte abnormalities, particularly hypokalemia, which is commonly seen with loop diuretics.

Neurologic

Medications for Parkinson’s disease, Alzheimer’s disease, and epilepsy should all be continued through the day of surgery.

Anti-platelet

Perioperative management of anticoagulants and anti-platelet medications should be made in conjunction with the surgeon. Anti-platelet agents should be held for 1 week before neuraxial anesthesia.

Psychiatric

These drugs should be continued through the perioperative period. Tricyclic antidepressants and MAO inhibitors interact with certain anesthetic drugs. Demerol and indirect acting vasopressors (ephedrine) should be avoided. If the QT interval is prolonged on the EKG, antipsychotics and drugs that exacerbate this situation should be avoided.

j. How To modify care for patients with known allergies –

Patients with known allergies should avoid medications or equipment that contain the allergens. It is important to know the reaction and decide if a true allergy is present before making changes to the standard care. For example, an upset stomach is normal after antibiotics and not a reason to deviate from the normal perioperative antibiotic choice.

Patients may note an allergy to local anesthetics after experiencing palpitations and tachycardia following local anesthesia for a dental procedure. This is often due to the epinephrine in the anesthetic, not the anesthetic itself, and does not preclude the use of regional anesthesia.

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.

Latex allergies are more commonly seen in health care providers, children with spina bifida, and patients who have undergone multiple surgical procedures. Reactions range from mild dermatitis to severe anaphylaxis. In a patient with suspected or documented latex allergy, the operating room should be prepared with latex-free products.

l. Does the patient have any antibiotic allergies- – Common antibiotic allergies and alternative antibiotics]

Penicillin allergies

Approximately 10% of people report an allergy to penicillin, however, only 10-15% of these individuals have true allergies. Approximately 2% of patients with confirmed penicillin allergy will react to a cephalosporin. Carbepenems are safe in greater than 99% of patients with confirmed penicillin allergy, and there is no risk with monobactams (aztreonam).

Vancomycin allergies

The most common reaction to vancomycin is red-man syndrome, which is related to the rate of antibiotic infusion. An immunologic mechanism for red-man syndrome has not been demonstrated. True allergies to vancomycin range from mild skin rashes to cardiovascular collapse. Vancomycin is only used perioperatively in patients with beta-lactam allergy and/ or MRSA. Alternative drugs that may be useful in patients with MRSA include daptomycin and linezolid.

m. Does the patient have a history of allergy to anesthesia?

Malignant hyperthermia

Documented

Avoid all trigger agents such as succinylcholine and inhalational agents.

Proposed GETA plan: General anesthesia may be induced with the usual induction agents (propofol, etomidate, fentanyl, midazolam, etc.) Succinylcholine should be avoided, and rocuronium may be used if rapid sequence induction is necessary. Total intravenous anesthesia (TIVA) is common when GETA is needed in a patient at high risk of malignant hyperthermia. The patient may be extubated in the usual fashion.
Insure MH cart available: An MH cart should be immediately available at any location where anesthetics are being administered.

Family history or risk factors for MH

MH follows an autosomal dominant pattern of inheritance, and is commonly due to a mutation in the ryanodine receptor located in the sarcoplasmic reticulum. MH triggering agents lead to a large increase in intracellular calcium, which in turn leads to muscle contraction, hyperthermia, hypercarbia, electrolyte abnormalities, acid-base disorders, and potentially hemodynamic collapse.

Local anesthetics

Allergic reactions are more common for ester local anesthetics as compared to amides. Allergies to esters are commonly due to sensitivity to their PABA metabolites. This reactivity does not cross over to the amide family. Patients may note a history of allergy to local anesthetics based on the symptoms of tachycardia and the palpitations that occurred after local anesthesia was administered by a dentist. It is important to determine if this represents a true allergy or if this was a normal reaction to the epinephrine that was injected with the local anesthetic.

Neuromuscular blocking drugs

Allergies to NMBD occur in 1/3,000- 1/110,000 anesthetics, and are mediated by an IgE mechanism. Because of cross-reactivity between different drugs, patients who have experienced an allergy to a NMBD should undergo testing to determine which drugs they are allergic to and which ones may be safely administered. In the absence of this information, it is prudent to avoid all NMBD in a patient who has a documented history of allergy.

5. What laboratory tests should be obtained and has everything been reviewed?

Patients presenting for elective TURP or TURBT should have a preoperative basic metabolic panel, complete blood count, and coagulation studies performed. Patients presenting for emergent transurethral procedures should, at the minimum, have a basic metabolic panel to confirm that dangerous electrolyte abnormalities are not present.

Common laboratory normal values will be same for all procedures, with a difference by age and gender. The normal upper limit for creatinine decreases with age due to decreased muscle mass.

Hemoglobin levels: Patients with prostate or bladder cancer may be anemic from bleeding. Chronic renal failure may cause anemia due to low erythropoietin levels.

Electrolytes: Hyperkalemia may develop in acute or chronic renal failure. Potassium levels should always be checked preoperatively in any patient presenting with impaired renal function, even for urgent procedures.

Coagulation panel: These studies should be obtained if neuraxial anesthesia is planned, if a patient has a history of bleeding, or if the patient uses anticoagulants.

Imaging: A chest x-ray may be useful in elderly patients (> 60 yrs), or patients with suspected pulmonary disease, such as individuals with a long smoking history, COPD, dyspnea, a chronic cough, or low oxygen saturation levels on pulse oximetry. Except in the case of poor oxygenation, it is almost never necessary to delay an urgent procedure for a chest x-ray.

Cardiac imaging, including EKG, echocardiography, and stress testing, may be obtained on a case by case basis, following the ACC/ AHA guidelines for perioperative cardiovascular evaluation for noncardiac surgery.

Renal imaging, including bladder scans, CT scans, ultrasounds of the prostate and bladder, and x-rays of the kidneys, may be obtained by the urologist. Results of these imaging studies rarely change anesthetic management, but may dictate the urgency of the procedure.

Other tests: Other diagnostic studies, including a chest CT or determining thyroid hormone levels, pulmonary function, arterial blood gases, glucose levels, etc., may be obtained on a case specific basis. Pulmonary function tests may be indicated in the preoperative evaluation for dyspnea or in patients with known asthma and COPD. There are no definitive guidelines as to when they are necessary preoperatively.

An arterial blood gas may be useful to assess acid-base status in a patient with acute renal failure. A profoundly acidotic patient may need resuscitation and correction of the acidosis before anesthetic induction. All diabetic patients should have their blood glucose levels checked preoperatively and monitored periodically throughout the case.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Transurethral procedures may be performed under general, regional, or monitored anesthetic care (MAC). The decision regarding which technique to use must take into account several factors, including patient and surgeon preference, medical contraindications to one technique or the other, length of the procedure, coagulation and NPO status of the patient, and the ability of the patient to understand and cooperate during the procedure if regional anesthesia or MAC is used.

a. Regional anesthesia

This includes neuraxial anesthesia (spinal or epidural) and peripheral nerve blockade.

1. Neuraxial

Benefits: Early recognition of potential complications, including TURP syndrome and bladder perforation, decreased operative blood loss, lower incidence of DVT, and improved postoperative analgesia. This avoids common side effects of GETA, including nausea, drowsiness, sore throat from intubation, etc.
Drawbacks: Patient must be agreeable and able to cooperate with instructions intraoperatively, the airway is not secured, and contraindications are more common than for GA. Risks of neuraxial anesthesia include bleeding, infection, headache, and nerve damage.
Issues: Neuraxial anesthesia is contraindicated in patients on anticoagulation, and the risks versus benefits of holding anticoagulation must be considered. Holding anti-platelet agents such as Plavix may place the patient at increased risk for coronary stent thrombosis or stroke. This increased risk may be justified in a patient with severe COPD, for example, where there is concern about using mechanical ventilation necessary for GA.

Intravenous sedation may be used to supplement neuraxial anesthesia if the patient is concerned about “being awake” during the procedure. Small doses of a benzodiazepine (midazolam) may be used, or a propofol infusion may be appropriate for a long procedure. Most transurethral procedures are relatively short and can be accomplished with a single dose spinal. However, if the procedure is anticipated to take several hours and neuraxial anesthesia is planned, it is more appropriate to place an epidural catheter that can be re-dosed as necessary.

2. Peripheral nerve block

Benefits: Maintains hemodynamic stability (useful in patients with severe cardiopulmonary disease), extended postoperative analgesia, has few contraindications, and there are none of the side effects of general anesthesia.
Drawbacks: Nerve blocks may be complex and require ultrasound guidance, may require supplemental MAC, and anesthetic toxicity.
Issues: Many simple transurethral procedures may be performed under local anesthesia, sometimes supplemented with MAC. Lidocaine injected into the urethra is the most common local anesthetic technique for transurethral procedures. It is almost always performed by the urologist, and allows a cystoscope to be inserted through the urethra.

If more extensive prostate surgery is planned, a blockade of the nerve supply to the prostate is possible. This is not a common form of anesthesia for prostate surgery, is often performed under ultrasound guidance by the urologist, and often requires supplemental MAC. Its primary use is in patients who are not candidates for neuraxial or general anesthesia.

b. General anesthesia

GA may be used when regional anesthesia is contraindicated, there is patient preference, or there are concerns that the patient will not be able to follow instructions or cooperate if awake or mildly sedated during the procedure.

Benefits: Complete anesthesia and analgesia for any procedure length, secures the airway, patient may remain on anticoagulation, and easy to volume resuscitate if hemodynamics become unstable.
Drawbacks: Include delayed recognition of mental status changes seen with TURP syndrome, delay in recognition of bladder perforation, possible increase in operative blood loss and DVT, increased need for analgesics postoperatively, and side effects, which include nausea, sore throat, etc.
Other issues: GA will provide adequate anesthesia and analgesia for all transurethral procedures. Many patients are afraid of regional anesthesia because they think they will be awake during their surgery- if the patient is otherwise a good candidate for neuraxial anesthesia, it should be explained to them that regional anesthesia with intravenous sedation may be the best option.
Airway concerns: There are no airway concerns that are specific to patients undergoing transurethral procedures. Muscle relaxation is rarely necessary in these procedures, so LMAs are usually appropriate, as long as the patient has no contraindications, such as severe gastric reflux, gastroparesis, or full stomach. The procedure table is rarely turned during transurethral procedures, so the anesthesiologist usually has easy access to the airway.

c. Monitored Anesthesia Care

MAC may be used to supplement neuraxial or local anesthesia. Sedation may be provided with a combination of benzodiazepine and narcotics (midazolam and fentanyl, for example), or with a propofol infusion.

Benefits:
Supplements neuraxial or local anesthesia, amnesia, and improved patient comfort on the procedure table.
Drawbacks:
Unprotected airway, risk of over-sedation, and paradoxical reaction to sedative causing agitation.
Other issues:
Most regional anesthetics are supplemented with MAC. MAC does not provide surgical levels of analgesia – in the case of neuraxial anesthesia, this is provided by a spinal or epidural. In the case of local anesthesia, the surgeon assumes the responsibility of providing analgesia.

6. What is the author's preferred method of anesthesia technique and why?

1. What prophylactic antibiotics should be administered?

Preoperative antibiotics should be administered according to the Surgical Care Improvement Project guidelines (SCIP, 2008). In patients without allergies, cefoxitin 1-2 g IV is indicated. If the patient has a beta lactam allergy, metronidazole 500 mg and ciprofloxacin 400 mg are indicated. Other antibiotics may be selected based on known bacterial sensitivities in the patient or hospital.

2. What do I need to know about the surgical technique to optimize my anesthetic care?

It is important to know the approximate length of the procedure, the positioning of the patient, particularly if steep Trendelenburg will be used or if the patient’s arms will be tucked and inaccessible. For example, spinal anesthesia is not appropriate for a 5 hour case. Similarly, if an arterial line may be necessary for hemodynamic monitoring, and the patient’s arms will be tucked, it is prudent to place the monitor before positioning.

3. What can I do intraoperatively to assist the surgeon and optimize patient care?

Bleeding may be encountered during prostate resection, which may be minimized by ensuring the patient is normotensive. Close communication with the surgeon throughout the procedure is critical, particularly if a change in stimulus intensity is anticipated, so the anesthetic depth can be adjusted, bleeding is anticipated, so volume may be administered or the blood pressure lowered, or the procedure is almost complete, so preparations for a timely wake up can be planned.

4. What are the most common intraoperative complications and how can they be avoided/treated?

While intraoperative complications during transurethral procedures are rare, they include bleeding, perforation of the bladder or prostatic capsule, TURP syndrome, sepsis, and perforation into the rectum.

Bleeding may be arterial or venous, and must be managed surgically. The role of the anesthesiologist is geared towards volume resuscitation and hemodynamic support, potentially with blood product transfusion if necessary.
Perforation of the bladder, prostatic capsule, or rectum must also be managed surgically, with the anesthesiologist focusing on supporting vital organ function. If the patient is awake during the procedure (spinal or epidural anesthesia), they may complain of abdominal and back pain, nausea, and a tense abdomen if the prostatic capsule or bladder is perforated. It is important to communicate this information to the surgeon immediately.
TURP syndrome is due to absorption of hypotonic irrigation fluids by blood vessels at the surgical site. It is characterized by confusion, hemodynamic instability (including hypertension and bradycardia), congestive heart failure, cerebral edema, and pulmonary edema. Lab work is most notable for hyponatremia.

Patients are more susceptible to TURP syndrome when the resection time is long (more than 60 minutes), excessive irrigation fluids are used (more than 2 liters), the height of the irrigation fluid is more than 70-80 cm above the patient, they are hypovolemic, or surgical blood loss is excessive (implying numerous open blood vessels at the surgical site). Cerebral edema may occur with profound hyponatremia (sodium less than 115).

It may be difficult to recognize many of the symptoms of TURP syndrome if the patient is under GA, but any suspicion should be communicated to the surgeon. The procedure should be terminated as quickly as possible, a full set of labs drawn, and hemodynamics closely monitored. Furosemide may be administered to help reduce volume overload, hypertonic saline may be administered, and the patient should be monitored postoperatively in the ICU.

Sepsis following transurethral procedures is well described, but it is less common for symptoms to develop intraoperatively. Preexisting prostatic infection may be exacerbated by instrumentation, and may present intraoperatively with hypotension, tachycardia, and fever. Broad spectrum antibiotics should be initiated immediately, ensuring coverage for gram negative organisms. Appropriate volume resuscitation and hemodynamic support is critical. Any patient developing signs of intraoperative septic shock should be managed postoperatively in the ICU.

i. Cardiac complications

Transurethral procedures are not associated with an excessive rate of cardiovascular complications. Patients undergoing such procedures often have cardiac co-morbidities and may be at risk of volume overload or heart failure if excessive irrigation fluid is used during TURP. However, this is uncommon, and invasive monitoring or other techniques are not usually warranted.

ii. Pulmonary

Transurethral procedures are not associated with an excessive rate of pulmonary complications. In a patient with significant pulmonary disease – for example, an individual with COPD on home oxygen – it may be prudent to use neuraxial anesthesia to avoid the need for mechanical ventilation.

iii. Neurologic

Such complications may occur in the presence of TURP syndrome, and include altered mental status, seizures, and cerebral edema. The presence of these complications necessitates an immediate conclusion to the surgical procedure, treatment of (likely) severe hyponatremia with diuretics and/ or hypertonic saline, and ICU admission postoperatively.

a. Neurologic:

N/A

b. If the patient is intubated, are there any special criteria for extubation?

There are no special considerations for the extubation of patients following transurethral procedures. The majority of such procedures are relatively short in duration and are associated with minimal blood loss and hemodynamic changes. Extubation is customary at the end of the procedure, unless complications such as TURP syndrome and neurologic changes occur. The usual criteria for extubation of the surgical patient may be used, including assessment of tidal volume, respiratory rate, hemodynamics, level of alertness, strength, temperature, and adequate analgesia.

c. Postoperative management

1. What analgesic modalities can I implement?

If an epidural was used, this may be continued postoperatively. Intravenous or oral narcotics may also be used.

2. What level bed acuity is appropriate?

If no complications are encountered, the majority of patients undergoing transurethral procedures may be discharged to the regular floor. If the patient has a significant cardiac history, telemetry may be warranted. If intraoperative blood loss was significant, the patient was hemodynamically unstable, or major complications, such as TURP syndrome, were encountered, ICU admission is appropriate.

3. What are common postoperative complications, and ways to prevent and treat them?

Postoperative complications include delirium, bleeding, respiratory failure, and DVT/ PE.

Risk factors for postoperative delirium include old age, preoperative dementia, impaired functional status, and hypoalbuminemia. Management includes ensuring adequate hydration and oxygenation, adequate analgesia, providing a quiet, peaceful environment, reorienting the patient to time and place, and medication as needed (antipsychotics). Most cases will resolve with time.

Bleeding in the PACU must be assessed to determine if it is due to oozing and clotting factor deficiency or surgical bleeding from a misplaced suture. Transfusion of fresh frozen plasma and platelets may be sufficient to stop slow oozing, but considerable bleeding may necessitate surgical re-exploration.

Respiratory failure is usually due to residual anesthetics or muscle relaxants. Oxygenation and ventilation should be supported as necessary (mask ventilation, intubation, etc) while the cause is determined. Narcan, flumazenil, and neostigmine may be administered to reverse their respective respiratory depressants if this is believed to be the cause of respiratory failure.

DVT and PE are rare postoperative complications following transurethral procedures. In a patient with risk factors for DVT, preoperative prophylaxis (subcutaneous heparin and compression stockings) may be employed to reduce this risk. Treatment of a small DVT or PE may require anticoagulation, depending on the anatomical location. A large PE will require aggressive management and ICU admission.

What's the Evidence?

“ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery)”. Anesth Analg.. vol. 106. 2008. pp. 685-712. (This article gives guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery.)

Joshi, GP, Chung, F, Vann, MA, Ahmad, S, Gan, TJ, Goulson, DT, Merrill, DG, Twersky, R. “Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery”. Anesth Analg.. vol. 111. 2010. pp. 1378-87. (This article provides guidelines for perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Many transurethral procedures are ambulatory procedures.)

Horlocker, TT, Wedel, DJ, Rowlingson, JC, Enneking, FK, Kopp, SL, Benzon, HT, Brown, DL, Heit, JA, Mulroy, MF, Rosenquist, RW, Tryba, M, Yuan, CS. “Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Third Edition)”. Reg Anesth Pain Med.. vol. 35. 2010. pp. 4-7. (This article gives guidelines on the use of regional anesthesia in patients receiving antithrombotic or thrombolytic therapy.)

Jensen, V. “The TURP syndrome”. Can J Anaesth. vol. 38. 1991. pp. 90-6. (This article reviews the TURP syndrome.)

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