Operating Room Case Study

I. Patients Data Name: Age: Gender: Date of Operation and Case Number: Preoperative Diagnosis: Operation Performed: Type of Surgery: Surgeon: Anesthesiologist: Type of Anesthesia: Antonio P. Abad 62y/o Male Sept. 12, 2012 /1064849 Benign Prostatic Hyperplasia Cystoscopy trans urethral electrosurgical resection of the prostate Minor Dr. Donald Jude Meguizo Dr. Dominador Acosta Spinal Anesthesia

II. Anatomy/Structure/Function Transurethral resection of the prostate (TURP) is a type of prostate surgery done to relieve moderate to severe urinary symptoms caused by an enlarged prostate. During TURP, a combined visual and surgical instrument (resectoscope) is inserted through the tip of your penis and into the tube that carries urine from your bladder (urethra). The urethra is surrounded by the prostate. Using the resectoscope, your doctor trims away excess prostate tissue that's blocking urine flow. TURP is one of the most effective options for treating an enlarged prostate, a condition also known as benign prostatic hyperplasia (BPH). To determine whether TURP or another treatment is the best choice for you, your doctor will consider how severe your symptoms are, what other health problems you have, and the size and shape of your prostate.

The prostate gland is located under the urinary bladder, in front of the rectum and wraps around the urethra (the tube that carries urine through the penis). It is basically composed of three different cell types the glandular cells, smooth muscle cells and stromal cells the central area of the prostate that wraps around the urethra is called the transition zone. The entire prostate gland is surrounded by a dense, fibrous capsule. The prostate gland provides the following functions: (1) the glandular cells produce a milky fluid, and during sex the smooth muscles contract and squeeze this fluid into the urethra. Here, it mixes with sperm and other fluids to make semen. (2) the prostate also secretes another substance that may have antibacterial properties. (3) the prostate gland also contains an enzyme called 5 alphareductase that converts testosterone to dihydrotestosterone, another male hormone that has a major impact on the prostate. The prostate gland undergoes many changes during the course of a man's life. At birth, the prostate is about the size of a pea. It grows only slightly until puberty, when it begins to enlarge rapidly, attaining normal adult size and shape, about that of a walnut, when a man reaches his early 20s. The gland generally remains stable until about the mid-forties, when, in most men, the prostate begins to enlarge again through a process of cell multiplication. Hormonal changes also occur in the prostate gland; testosterone levels fall while dihydrotestosterone remain at normal levels.

Causes: The causes of benign prostatic hyperplasia are not fully understood. Several theories have been proposed to explain benign cell growth in older men. Hormonal Changes Male Hormones. Androgens (male hormones) most likely play a role in prostate growth. The most important androgen is testosterone, which is produced in the testes throughout a man's lifetime. The prostate converts testosterone to a more powerful androgen, dihydrotestosterone (DHT). DHT stimulates cell growth in the tissue that lines the prostate gland (the glandular epithelium) and is the major cause of the rapid prostate enlargement that occurs between puberty and young adulthood. DHT is a prime suspect in prostate enlargement in later adulthood. Female Hormones. The female hormone estrogen may also play a role in BPH. (Some estrogen is always present in men.) As men age, testosterone levels drop, and the proportion of estrogen increases, possibly triggering prostate growth. Late Activation of Cell Growth Another theory focuses on cells in a certain section of the gland that may become active late in life, signaling other prostate cells to replicate or causing them to be sensitive to growthstimulating hormones.

Possible Complications TUR syndrome (occurs in about 2% of patients, usually within the first 24 hours) might occur. Symptoms may include:

Increase or decrease in blood pressure Abnormal heart rhythm Increased breathing rate Nausea or vomiting Blurred vision Confusion Agitation

Other complications may include:

Urinary tract infection (most common) Bleeding, which may require blood transfusion (second most common) Incontinence (inability to control urine) Retrograde ejaculationsperm goes into the bladder rather than out the end of the penis (not dangerous)
o

If you plan on having children in the future, talk to your doctor about this surgical side effect before surgery.

Reaction to anesthesia

Prior to Procedure Your doctor may do the following:

Physical exam Review of medicines and supplements Blood tests, urine tests, and a urine culture Ultrasound a test that uses sound waves to visualize the kidney, bladder, and/or prostate Urine flow studies X-rays

Leading up to your procedure:

Talk to your doctor about your medicines. You may be asked to stop taking some medicines up to one week before the procedure like:
o o

Aspirin or other anti-inflammatory drugs Blood thinners, such as clopidogrel (Plavix) or warfarin(Coumadin)

The night before, eat a light dinner. Do not eat or drink anything after midnight.

Anesthesia TURP requires general or spinal anesthesia. General will make you sleep. Spinal will make your lower body numb. Skin preparation Cleanse entire pubic area (including scrotum and perineum), extending from the umbilicus to the mid-thighs. The anus is prepped last; discard each sponge after wiping the anus. Description of Procedure Your doctor will use a special scope that looks like a thin tube with a light on the end. This scope is put into the hole at the tip of your penis where urine comes out. The bladder will then be filled with a solution. The solution will let the doctor see the inside of your body better. The prostate gland is examined through the scope. A small surgical tool will be inserted through the scope. The tool will be used to remove a part of the enlarged prostate. A catheter (tube) will be left in the bladder to allow for urine flow after the procedure. It may also be used to flush the bladder and to remove blood clots.

References: Griffith HW, Moore S, Yoder K. Complete Guide to Symptoms, Illness & Surgery . New York, NY: Putnam Publishing Group; 2000. Leocdio DE, Frenkl TL, Stein BS. Office based transurethral needle ablation of the prostate with analgesia and local anesthesia. J Urol . 2007 Nov;178(5):2052-4; discussion 2054. Lynch M, Anson K. Time to rebrand transurethral resection of the prostate? Curr Opin Urol . 2006;16:20-4. Michielsen DP, Debacker T, De Boe V, Van Lersberghe C, Kaufman L, Braeckman JG, et al. Bipolar transurethral resection in salinean alternative surgical treatment for bladder outlet obstruction? J Urol . 2007 Nov;178(5):2035-9; discussion 2039. Nakagawa T, Toguri AG. Early catheter removal following transurethral prostatectomy: a study of 431 patients. Med Princ Pract . 2006;15(2):126-30. Surgical management of BPH. American Urological Association website. Available at: http://www.urologyhealth.org/adult/index.cfm?cat=09&topic=131 . Accessed October 13, 2009. Tan A, Liao C, Mo Z, Cao Y. Meta-analysis of holmium laser enucleation versus transurethral resection of the prostate for symptomatic prostatic obstruction. Br J Surg . 2007 Oct;94(10):1201-8. TURP. National Cancer Institute website. Available at:http://www.cancer.gov/Templates/db_alpha.aspx?CdrID=44469 . Accessed July 10, 2008. Wendt-Nordahl G, Bucher B, Hacker A, Knoll T, Alken P, Michel MS. Improvement in mortality and morbidity in transurethral resection of the prostate over 17 years in a single center. J Endourol . 2007 Sep;21(9):1081-7.