TURP (Transurethral Resection of Prostate)
Patient phenotype
Typically 65-80 year old male with BPH causing obstructive symptoms (hesitancy, weak stream, incomplete emptying). Comorbidities common — CAD, HTN, DM, CKD. Lithotomy position.
Procedure
Resectoscope + cutting loop through urethra. Continuous bladder irrigation (historically glycine or sorbitol; modern bipolar TURP uses saline). 30-90 min surgical time. Resection time inversely correlates with complication risk.
Anesthetic plan
Spinal anesthesia GOLD STANDARD (T10 level for bladder + prostate, allows awake monitoring for TURP syndrome). GA acceptable if neuraxial contraindicated. Hyperbaric bupi 0.75% 10-12 mg.
Setup
- ·Standard ASA monitors
- ·PIV (one is enough for routine spinal case)
- ·Spinal kit + 25g pencil-point Whitacre
- ·Lithotomy stirrups + perineal post
- ·Type & screen
- ·Awake state monitoring (mental status changes are first sign of TURP syndrome)
Biggest concerns by phase
Cardiac risk in elderly + lithotomy autotransfusion
TURP patients are old + sick. Lithotomy position causes leg autotransfusion of ~500-1000 mL — sudden preload increase can decompensate borderline LV. Dropping legs at end causes opposite — sudden drop in venous return.
Spinal — perfect indication, awake patient detects TURP syndrome
T10 sensory level. Awake patient reports first signs of TURP syndrome (confusion, headache, visual changes) — this is the BIGGEST advantage over GA. Premed minimal — light sedation (midaz 1 mg) preserves communication.
TURP syndrome — hyponatremia + fluid overload + ammonia toxicity
Glycine/sorbitol irrigant absorbed through prostatic venous sinuses. Severe: Na drops to 110-120 (cerebral edema, seizures, coma), pulmonary edema (volume overload), hypoosmolar hyponatremia. Treatment: stop irrigation, surgeon controls bleeding, hypertonic saline 3% 100-200 mL slowly, furosemide, supportive. Early signs (HA, anxiety, confusion, n/v, visual changes) IF AWAKE = call it early. RISK FACTORS: resection time > 60 min, irrigation height > 60 cm, prostate size > 60 g.
Hypothermia from cool irrigation
Continuous irrigation with 'room temp' fluid drops core temp rapidly. Use warmed irrigation if available. Otherwise BAIR upper body, monitor temp, expect 0.5-1 °C drop per hour.
Bladder perforation + autonomic hyperreflexia (rare)
Resection through bladder wall = sudden upper abdominal pain (in awake patient — another reason for spinal). Surgeon will often catch on irrigation flow change. Significant perforation needs surgical exploration.
Continued bleeding + clot retention
Continuous bladder irrigation continues postop with three-way catheter. Watch hematocrit, urine color (cherry → tea → clear), blood pressure trend. If clots block catheter, painful bladder distension + reflex bradycardia possible.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
65-year-old male, 45 minutes into TURP under spinal at T10. He becomes anxious, complains of headache and 'weird feeling.' BP 165/95, HR 55, ETCO₂ N/A (awake). Sodium just came back at 122. What's happening and what do you do?
What an examiner probes for
- ▹TURP syndrome — recognizes early presentation in awake patient
- ▹First moves: tell surgeon to stop, finish quickly, lower irrigation height
- ▹Send STAT chemistry, treat hyponatremia with hypertonic saline 100 mL slow
- ▹Furosemide 20 mg, supplemental O₂, monitor for seizure
- ▹Anticipates: ICU admission, slow Na correction (avoid CPM)
Sources
- Miller's Ch 67 (urologic)
- Stoelting Anesthesia & Co-Existing Disease
- AUA TURP Guidelines
Anatomy reference
Sourced reference images. 4 matches for "prostate bladder urinary".
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