Benign Prostatic Hyperplasia (BPH)

Alpha-blocker hypotension - Tamsulosin, alfuzosin, terazosin, and doxazosin are usually still on board. Orthostatic hypotension is reported in up to 18% when an alpha-blocker is paired with dutasteride, so expect an exaggerated drop with spinal or induction and have phenylephrine ready.

Check the kidneys first - High-pressure chronic retention causes silent renal failure. Look at the basic metabolic panel for baseline creatinine and at the renal ultrasound for hydronephrosis in anyone with a large post-void residual.

Post-obstructive diuresis - Once the bladder is decompressed, urine output can run away and take electrolytes with it. Track hourly output and replace about half the urine volume with isotonic saline, following serial electrolytes.

TURP syndrome - Monopolar resection needs non-conducting irrigation (glycine, sorbitol, mannitol, or water) and roughly 20 to 30 mL is absorbed per minute — about 6 L over two hours. Dilutional hyponatremia and hypo-osmolality give restlessness, headache, nausea, visual disturbance, bradycardia, blood pressure swings, pulmonary edema, and can progress to seizures, coma, and arrest.

Awake is the best monitor - Mental status change is the earliest sign of TURP syndrome and it is invisible under general anesthesia. Spinal keeps the patient talking; the outcome data comparing spinal and general are not actually different, so if you go general, watch the vitals and the I&O closely.

Treating TURP syndrome - Stop the resection, support oxygenation and circulation, and send electrolytes, glucose, and an ABG with a 12-lead. Mild cases (Na above 120) get furosemide and fluid restriction; severe or symptomatic cases get 3% saline at no more than 100 mL/hr, stopped once sodium passes 120. Correct gradually — no more than half the estimated deficit — and treat seizures with a benzodiazepine.

Irrigation-specific effects - Glycine gives hyperammonemia, encephalopathy, and transient visual disturbance; distilled water hemolyzes and drops sodium; mannitol causes an osmotic diuresis; sorbitol raises glucose. Bipolar resection in normal saline eliminates TUR syndrome but still volume-loads, with reports of hyperchloremic metabolic acidosis and upper airway edema.

Limit the exposure - Keep resection near an hour, keep the irrigation bag no higher than 30 cm above the table early and 15 cm late, and send a sodium if the case runs past 60 minutes, the preop sodium was low, or bleeding is heavy.

Bladder perforation - Abdominal distension with bradycardia (an efferent vagal response) and hypotension, plus abdominal or shoulder pain in an awake patient. Tell the surgeon and get the case finished.

Bleeding is hidden - High-volume irrigation makes blood loss hard to judge, so have the circulator run the I&O. Routine VTE prophylaxis is skipped in TURP because of bleeding risk, and two weeks of preoperative finasteride reduces microvascular density and intraoperative loss in large glands.

Emergency retention cases - Men taken straight to surgery after acute retention bleed more, have more sepsis from bacteriuria, and carry higher 30- and 90-day mortality than elective prostatectomy patients. Treat the urgent case as the higher-risk one.

Lithotomy and the postop urge - The case is done in lithotomy. Afterward patients often report an urgent need to void from involuntary detrusor contraction around the catheter — reassure them rather than treating it as a complication.

Benign prostatic hyperplasia (BPH) is stromal and epithelial proliferation in the transition zone of the prostate, the ring of tissue wrapped around the urethra. Dihydrotestosterone, converted from testosterone by 5-alpha-reductase, drives the growth. Obstruction has a static component — the gland compressing the urethra — and a dynamic one from prostatic smooth muscle tone, which is why 5-alpha-reductase inhibitors shrink and alpha-blockers relax. Histologic prevalence runs 50% to 60% of men in their 60s and 80% to 90% over 70.

Left alone it produces lower urinary tract symptoms, acute retention, and high-pressure chronic retention with hydronephrosis and silent renal failure. For anesthesia it matters twice over: the drugs used to treat it change your hemodynamics, and the operation used to fix it — TURP — carries its own syndrome.