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Southern urology- lectures

• Operative mortality 0.2 per cent• Most common cause of death was sepsis • 77% of patients had significant pre-existing • Defined as those requiring transfusion• Intraoperative bleeding - 2.5 %• Postoperative bleeding 3.7 %• Average blood loss 250 - 400 mls• Bleeding related to size of gland and length of surgery ie greater than 90 min ( 7.3% vs 0.9% ) and greater than 45 gms ( 10% vs 0.9 % ) • Arterial bleeding a problem - requires surgical correction at the time or take back • Venous bleeding difficult to stop surgically occurs at the end of the procedure and due to venous sinuses being opened • Can be controlled by catheter traction • Inflate balloon to 50 ccs• Ten minutes at a time• Can be left on continuous traction for up to 24 Hrs.
• In some circumstances - especially after resection of prostatic carcinoma - can get DIC - use of Amicar ( Epsilom amino caproic acid ) • Must make sure complete evacuation of clot • Rise in patients BP, decrease in pulse, • Can lead to cardiac arrythmias and death• Due to dilutional hyponatremia• Related to: – Size of gland 45 gms ( 1.5 vs 0.8 )– Resection time 90 min ( 2 % vs 0.7 % )– Surgical experience - deep exposure of capsule • Usually do not become symptomatic until • Generally corrected with N saline and lasix sometimes have to give hypertonic 2N or 3 N Saline plus lasix ( must be accompanied by a diuretic to avoid pulmonary odema ) • Post operative incontinence occurs in 1.7 % of patients with 0.4% having total incontinence • Source of many malpractice suits• 2 sphincter mechanism internal and external • Internal Sphincter always removed• External Sphincter controls continence ( at level of • Three things are important in post operative – Sphincteric injury– Detrusor Instability– Residual obstruction which impairs external • Rely on internal Sphincter and Distal sphincter may become lax - Pelvic floor exercises • If patients remain incontinent after a few – Urodynamics - diagnose instability / Genuine Stress incontinence / bladder outlet obstruction – Cystoscopy to look at obstructing apical • Incontinence persists for 1 year options:- • AUS• Contagen or macroplasique• ? Protrac device • 6.5 % of patients fail to void after TURP• 50% of these have hypotonic bladder• Risk factors for hypotonic bladder:- • Painless urinary retention vs painful retention• Long history of prostatism• Neuropathic bladder ie diabetics• Known high residuals • Cannot predict which patients will void • If fail to void after surgery need to perform Urdynamics ( Hypocontractile vs Obstructed ) • Better to leave SPC on free drainage to give bladder a chance to recover then repeat Urodynamics - if no return of function leave SPC on Staubli valve or teach ICSC • Consider patients voiding successfully even if have high residual as long as they are free of infection and void with low bladder pressure • Variously quoted 4 - 40 %• Due to nerve injury by current leak to • Retrograde ejaculation in 100 % of men • Incidence about 2.7 %]• Why ? Small glands which have bladder neck hypertrophy ? Over coagulation at bladder neck region ? procedure, consider a bladder neck incision • In some instances all you need in BNI ( 6 0’ • Incidence 2.5 %• Related to the length of time IDC in before • After TURP most important cause is trauma • Most common site is external urinary • Preoperative UTI was found in 11 % of • Postoperative rate of 2.3 %• Role of prophylactic antibiotics remains induction and oral antibiotics given until 3 days after catheter removal. Take catheter out early – Closed catheter drainage system– Use of pumps to break up clot rather than – Take catheter out as soon as possible • Pyuria and microscopic haematuria can • Can get secondary bleed 10-14 days post op - as long as you can void generally settles by 24-48 hours • Avoid Constipation. 1 tsp nulax nocte straining---> • Need 6 weeks off work• Sexual activity after 6 weeks• Gradual physical activity to normal by 6 weeks• Drive car at 6 weeks ( sit on prostate )• Wont be happy with waterworks for up to three • First symptom to improve is the flow rate, then daytime frequency will improve finally nocturia will improve but may take 6 months • Penile tip pain after voiding common until • Flow rate may decrease from that immediately • Recommence NSAID or aspirin after 4 weeks • Stopping Aspirin before operation• Length of time to stop aspirin preop• Use of Calciparine and Calf compressors

Source: http://www.shireurology.com/pdf/turp-complications.pdf

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