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Photoselective vaporization of the prostate in ambulatory surgery
Home Study Program
FEBRUARY 2006, VOL 83, NO 2
Home Study Program Photoselective vaporization of the prostate in ambulatory surgery
T
he article “Photoselective vaporization of the prostate in ambulatory surgery” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, education program professional, Center for Perioperative Education. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Feb 28, 2009. Complete the examination answer sheet and learner evaluation found on pages 349-350 and mail with appropriate fee to
AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711 or fax the information with a credit card number to (303) 750-3212. You also may access this Home Study via AORN Online at http://www.aorn.org/journal/homestudy/default.htm.
BEHAVIORAL OBJECTIVES After reading and studying the article on photoselective vaporization of the prostate in ambulatory surgery, nurses will be able to
1. describe laser safety credentialing requirements, 2. discuss the pathological effects of benign prostatic hypertrophy (BPH) on normal male anatomy,
3. explain treatment options for BPH, and 4. discuss perioperative care of the patient undergoing photoselective vaporization of the prostate.
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. A minimum score of 70% on the multiplechoice examination is necessary to earn 3 contact hours for this independent study. Purpose/Goal: To educate perioperative nurses about photoselective vaporization of the prostate in ambulatory surgery.
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Home Study Program Photoselective vaporization of the prostate in ambulatory surgery Margaret Wojcik, RN; Denise Dennison, RN
P
hotoselective vaporization of the prostate is a significant advancement in the treatment of benign prostatic hypertrophy (BPH), one of the most common ailments experienced by men older than age 50.1 Although this procedure was pioneered in 1997 at the Mayo Clinic,2 Rochester, Minn, it only recently was introduced at Christiana Care Health System, Newark, Del. Initially, the procedure was performed only in the main OR; however, it now is performed in two associated surgery centers. When this treatment was first introduced at Christiana Care Health System, the laser could be used only in one specially outfitted room because of plumbing and electrical requirements. Initially, patients were admitted for 23-hour observation. After a number of these proce-
ABSTRACT •
PHOTOSELECTIVE VAPORIZATION of the prostate is a significant advancement in the treatment of benign prostatic hypertrophy (BPH), one of the most common ailments experienced by men older than age 50.
•
MANY MEN WITH BPH who are not candidates for transurethral resection of the prostate because they are undergoing anticoagulation therapy may be excellent candidates for the photoselective vaporization procedure.
•
BENEFITS of the photoselective vaporization procedure over conventional procedures include reduced length of the procedure, decreased length of hospital stay, reduced postoperative recovery time, fewer complications, little or no pain, and faster return to normal activities. AORN J 83 (February 2006) 330-345.
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dures were performed, perioperative team members decided that a majority of patients could be treated on an outpatient basis, and the team began the planning process to offer the procedure in the Christiana Surgicenter. Staff members from the main OR and the Surgicenter were trained in laser safety and operation of a high-powered potassium-titanyl-phosphate (KTP) laser. The physician determines at which facility the patient receives treatment. The laser then is moved from one facility to the other to accommodate the patient’s and physician’s needs.
LASER SAFETY CREDENTIALING A designated individual trained in laser safety and approved by Christiana Care Health System is responsible for operating the laser, monitoring all safety requirements, and observing the laser fiber for any breaks or malfunction. To be classified as competent in laser use, staff members must attend a basic laser course provided by the facility laser safety officer. After attending the fivehour course, each person must demonstrate proficiency on each specific laser by operating the laser during three supervised procedures. To become nationally certified, staff members must take a national laser examination and then demonstrate proficiency with documentation of procedures performed. Only physicians credentialed by Christiana Care Health System to operate the laser may perform the procedure at these facilities. Credentialing requires physicians to provide documentation of having attended a course on the specific laser and to demonstrate proficient operation of the laser during at least three procedures proctored by a qualified physician.
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ANATOMY
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AND
PHYSIOLOGY
Benign prostatic hypertrophy is a condition in which the prostate increases in size, gradually pinching the urethra and resulting in a host of uncomfortable and painful symptoms. The prostate is a male reproductive gland that makes seminal fluid, which helps nourish and transport sperm. It is located in front of the rectum just below the bladder and wraps around the urethra. Other than adding a small amount of fluid to his ejaculate, it serves no known purpose after a man’s reproductive years have passed. The prostate usually is the size of a small walnut, but as a man ages, the prostate increases in size and can become as large as a grapefruit. The cause of enlargement is not well understood; it usually begins in the early to mid forties and continues throughout life.3 SYMPTOMS. Half of all men over age 50 will develop BPH. During their mid fifties, many men experience changes in their pattern of urination, and these changes can become progressively worse. By the time men reaches their seventies or eighties, 80% will experience urinary symptoms, including • a weak urinary stream, • frequent urination, • difficulty initiating a urinary stream, • intermittent flow during urination, and • frequently awakening at night to urinate. In some instances, blockage of the urethra from BPH can lead to urinary retention, urinary tract infections, or bladder or kidney damage.1
DIAGNOSIS
OF
BPH
Annual prostate examinations should be performed on all men older than age 45, or earlier if there is a family history of prostate cancer. Diagnosis of BPH is accomplished with a digital
rectal examination. This examination gives the physician a general idea of the size and condition of the prostate. A prostate-specific antigen (PSA) blood test is ordered to rule out prostate cancer. Prostate-specific antigen, a protein produced by prostate cells, may become elevated in the blood of men who have prostate cancer. Currently, less than 4 ng/mL is considered normal; howProstate-specific ever, some physicians believe that 2.5 ng/mL antigen results should be considered the highest normal level.4 between 4 ng/mL Results between 4 ng/mL and 10 ng/mL are consid- and 10 ng/mL are ered high and require that the test be repeated.5 considered high
TREATMENT OPTIONS FOR BPH
and require that the test be repeated.
After diagnosing a patient with BPH, the urologist tracks the growth of the patient’s prostate and the severity of the patient’s symptoms. Medications such as alphaadrenergic blockers and 5-alpha reductase inhibitors are used as the first and second lines of proactive treatment. These medications are expensive and are successful in only about 60% of all cases, and they must be taken for the remainder of the patient’s life. Precautions are necessary if the patient has a history of liver problems or is being treated for hypertension. Possible side effects of the medications include erectile dysfunction, abnormal ejaculation, and decreased libido.3 When medical treatment of BPH has been unsuccessful, surgery is the next step. The gold standard of treatment for BPH is transurethral resection of the prostate (TURP). Two minimally invasive procedures currently available are transurethral needle ablation (TUNA)
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and transurethral microwave thermotherapy (TUMT). More recently, however, urologists have been using a minimally invasive laser procedure called photoselective vaporization of the prostate to treat BPH. TURP. The TURP procedure traditionally has been considered the best longterm solution for patients with BPH.1 The enlarged prostate tissue is removed during surgery; the rest of the prostate tissue and capsule remain intact. Although TURP has been the treatment of choice for patients who have significant outlet obstruction from BPH, the procedures has disadvanPhotoselective tages. Anticoagulants, invaporization of cluding aspirin, must be discontinued for a desigthe prostate uses nated period before the procedure because of the a high-energy potential for blood loss, and a catheter must be potassium-titanyl- inserted postoperatively for continuous bladder phosphate laser irrigation. The catheter is removed when the pato vaporize the tient’s urine is free of significant bleeding or blood obstructive tissue, clots. The patient usually remains in the hospital for thus relieving the one to two days after a procedure. Patients patient’s benign TURP are instructed to avoid strenuous activity and prostatic sexual activity for approximately six weeks after hypertrophy surgery. TUNA. The TUNA prosymptoms. cedure uses low-level radiofrequency energy that is delivered via needles placed into the prostate. This produces localized necrotic lesions in the hyperplastic tissue. This procedure can be performed on an outpatient basis in the physician’s office and usually takes approximately one hour. One disadvan-
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tage of TUNA is possible urinary retention within the first 24 to 36 hours after surgery. Another common complication is irritative voiding symptoms (eg, urinary frequency, burning on urination). All anticoagulant medications, including aspirin, must be discontinued before a TUNA procedure because of the potential for bleeding complications. Furthermore, 12.7% to 14% of patients will need treatment for BPH from some other modality within two years of undergoing the TUNA procedure.1(p1385-1389) TUMT. The TUMT procedure uses a transurethral catheter with a microwave antenna to transmit electromagnetic radiation to the prostate at frequencies typically between 915 MHz and 1,296 MHz. This causes a transfer of energy to the tissue in the form of heat and induces coagulation necrosis. Like TUNA, this procedure can be performed on an outpatient basis in the physician’s office and takes about one hour to complete. The complications of urinary retention and irritative voiding symptoms are similar to those for the TUNA procedure. Contraindications to the TUMT procedure include having • a ball-valve middle lobe of the prostate, • a penile or urinary sphincter implant, • a urethral stricture, • an implanted active pacemaker or defibrillator, • clinical or histological evidence of prostate or bladder cancer, • metallic implants in the pelvis or hip region, and with inter• peripheral arterial disease mittent claudication.6 MINIMALLY INVASIVE LASER PROCEDURE. Photoselective vaporization of the prostate is an innovative, minimally invasive procedure that uses a highenergy KTP laser to vaporize the obstructive tissue, thus relieving the patient’s BPH symptoms.2 Candidates
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for photoselective vaporization laser therapy have tried pharmacological therapy but have not achieved adequate results. A distinct advantage of this laser procedure is that patients receiving anticoagulant therapy need not discontinue their medications. Other advantages of photoselective vaporization over the more traditional approaches (ie, TURP, TUNA, TUMT) include • decreased blood loss, • shorter hospital stays, • less discomfort, • quicker recovery, and • fewer complications.
LASER THERAPY Laser light is unique because of three main In addition to properties: collimation, vaporization, the monochromaticity, and coherency. The term collilaser beam mated means that wave patterns are locked in coagulates phase, and the laser creates a light beam that to a depth of stays together tightly over long distances. The term 1 mm to 2 mm. monochromatic means that the laser produces pure The coagulation colors of light. Each laser produces light specific for zone creates that laser. The term coherence describes the phasing hemostasis, of the wave patterns.7 Laser light is used resulting in a because of its thermal and effects on tisvirtually bloodless mechanical sue. The wavelength of the laser light determines surgical field. the action (ie, cutting, coagulating, vaporizing). Collimated laser light that travels in a parallel beam can be guided through optical fibers and focused on a small spot. This allows the energy to be delivered endoscopically.7 A specific high-powered KTP laser is used to perform photoselective vaporiza-
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tion for BPH. The hemoglobin in the prostate selectively absorbs the KTP laser beam at the 532-nm wavelength. The laser delivers power up to 80 watts in a short-pulsed mode through a double, side-firing optical fiber at a 70-degree angle relative to the fiber axis. Heat generated by the absorption of the laser energy within the targeted tissue causes vapor bubbles to form whenever the intracellular temperature of the water contained within the tissue reaches the boiling point (ie, 100° C [212° F]). The laser light penetrates into the tissue to a depth of 800 micrometers (ie, 0.8 mm). The laser beam rapidly heats the superficial tissue, resulting in highly efficient vaporization of the prostatic adenoma. In addition to vaporization, the laser beam coagulates to a depth of 1 mm to 2 mm. The coagulation zone creates hemostasis, resulting in a virtually bloodless surgical field.8
PREOPERATIVE PREPARATION When a surgeon determines that a patient is a good candidate for the photoselective vaporization procedure, the patient begins the admission process. The surgeon obtains a thorough medical history and performs a comprehensive physical examination, including a digital rectal examination, and orders laboratory tests (eg, PSA, urinalysis, routine blood work including blood urea nitrogen and creatinine). The surgeon also may order optional tests such as a transrectal ultrasound or cystometrogram. A transrectal ultrasound is a screening method that uses an endorectal probe/ultrasonic transducer to obtain an image of the prostate for echogenicity (ie, localization of areas suspected for malignancy). Cystometrogram is a test that measures bladder pressure to determine such factors as bladder capacity and bladder wall compliance. A perioperative evaluation and preparation team nurse then schedules the patient for a preoperative evaluation.
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The nurse interviews the patient either in person or by telephone. During this interview, the nurse reviews the patient’s past medical history and performs a comprehensive preoperative nursing assessment. He or she identifies preexisting conditions (eg, morbid obesity, limited mobility) that may require special positioning aids. If the nurse determines that additional testing is needed, he or she orders the tests to be performed before the day of surgery. The nurse verifies with the patient the date, time, and location of the scheduled surgery, as well as information regarding when to arrive at the facility and what items the patient may or may not bring. At this time, the nurse determines whether a consultation with an anesthesia care provider is necessary before surgery, and if so, schedules it to be performed before the day the patient is admitted. If the surgery is scheduled to be performed on an outpatient basis, the nurse instructs the patient that he will need someone to transport him home after the procedure and someone to stay with him for at least 24 hours after surgery.
ADMISSION Typically, patients scheduled for a photoselective vaporization procedure are instructed to arrive at the surgical facility at least two hours before the procedure. The admissions nurse greets the patient and begins to prepare him for the surgical procedure. The nurse places all previously collected information, including the patient’s medical history, test results, and the signed informed consent form, on the patient’s medical record. The nurse then obtains and documents the patient’s initial vital signs, allergies, and height and weight, after which the nurse initiates a perioperative nursing care plan (Table 1). Communication is essential in the assessment process.
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The nurse confirms previously collected data with the patient, including history, past hospitalizations, previous surgeries, and medications he is currently taking, especially over-thecounter medications such as aspirin and herbal remedies. During this process, the nurse assesses the The laser operator patient’s and family members’ understandand circulating ing of BPH and the surgical procedure, answers nurse ensure that any questions they may have, and evaluates the laser safety patient’s anxiety level. The anesthesia care standards provider then interviews the patient to determine determined by the the most appropriate anesthetic approach (ie, American general anesthesia, spinal anesthesia, pudendal National block with supplemental IV sedation). The nurse Standards inserts an IV line and administers preoperaInstitute and tive medications and antibiotics as ordered. AORN are followed The nurse transports the throughout the patient and family members to a quiet waiting procedure. area until the time of surgery and offers the patient warm blankets and any other comfort measures needed.
OR PREPARATION The laser operator and circulating nurse ensure that laser safety standards, as determined by the American National Standards Institute and AORN, are followed throughout the entire procedure.9,10 An external watercooling system is required because the laser emits high-powered laser energy. This requirement is met using a wallmounted plumbing system for inflow AORN JOURNAL •
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TABLE 1
Nursing Care Plan for Patients Undergoing Photoselective Vaporization of the Prostate Diagnosis Knowledge deficient related to surgical outcomes
• • •
• • Risk of injury related to the surgical experience
• • • • •
Risk of inadvertent hypothermia
Interim outcome criteria
Outcome statement
Determines knowledge level, assesses readiness to learn, and identifies barriers to communication. Explains expected sequence of events and reinforces teaching about treatment options. Provides instruction (ie, verbal, written) regarding the surgical procedure and discharge instructions based on age and identified need, to include • caring for indwelling urinary catheter, • removing catheter at appropriate time, • drinking plenty of fluids, • avoiding heavy lifting or straining, and • using a mild laxative if necessary. Communicates patient concerns to appropriate surgical team members. Evaluates response to instruction.
Patient verbalizes decreased anxiety and understanding of surgical procedure.
Patient demonstrates knowledge of the expected responses to photoselective vaporization of the prostate and discharge care.
Verifies patient’s identity, allergies, NPO status, and informed consent. Assesses skin integrity, sensory impairments, and musculoskeletal status. Applies sequential compression devices to prevent deep vein thrombosis. Places patient carefully in the modified lithotomy position and implements measures to protect the patient from injury (eg, padding bony prominences adequately). Evaluates patient for signs and symptoms of injury.
Patient’s skin remains smooth and intact, and neuromuscular functions are maintained or improved from baseline.
Patient is free from signs and symptoms of physical injury.
Monitors patient’s body temperature. Implements thermoregulation measures, to include • offering warm blankets, • applying a temperature-regulating blanket to the patient’s upper body.
Patient’s temperature is within normal limits (>36° C [96.8° F]) at discharge.
Patient is at or returning to normothermia at the conclusion of the perioperative period.
Nursing interventions
• •
and drainage of the water. The laser operator checks the electrical cord of the laser for breaks or fraying before plugging it in and connects the watercooling system hosing to the rear of the laser panel. The laser operator ensures that the power cord and hosing system are placed such that traffic patterns are not compromised. The laser operator tests the laser for proper functioning before the patient is brought to the OR. After the laser operator plugs in the
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Patient and family members are able to accurately describe postoperative care.
Patient participates in decisions affecting his plan of care.
laser, attaches the water hoses, and turns on the laser, the laser runs through a self-test and alerts the laser operator when it is ready to be used or if there are any problems. The location where the procedure is to be performed is designated as a nominal hazard zone. The laser operator posts laser warning signs and places additional laser safety glasses specific for this laser (ie, laser safety goggles for an 80-watt KTP laser
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TABLE 1
Nursing Care Plan for Patients Undergoing Photoselective Vaporization of the Prostate (continued) Diagnosis Risk of acute pain related to the surgical procedure
• • • • • •
Risk of fluid volume imbalance
Interim outcome criteria
Outcome statement
Assesses patient’s pain preoperatively. Identifies patient’s accepted postoperative pain threshold. Provides pain management instruction and pain scale to assess pain control. Implements pain management guidelines. Collaborates with anesthesia care provider to provide pain medications as needed. Evaluates patient’s response to pain management interventions.
Patient demonstrates adequate pain management.
Patient demonstrates and reports adequate pain control throughout the perioperative period.
Uses a continuous irrigation system. Monitors input and outflow of irrigating fluids. Monitors for fluid deficit. Monitors for signs of hypervolemia and hypovolemia. Monitors color and amount of urine output from urinary catheter.
Irrigating fluid deficit is within acceptable volume (ie, irrigation output is within 300 mL of irrigation input).
Nursing interventions
• • • • •
Patient’s vital signs are equal to or improved from preoperative values.
Patient’s urinary output is within normal range at discharge and remains clear or only slightly blood-tinged. Risk of injury related to laser therapy
• • • • •
Verifies that surgeon is accredited to perform laser surgery. Controls the laser equipment by identifying nominal hazard zone and securing laser key. Ensures that the patient’s eyes are protected and appropriate laser safety eye wear is available for all staff members. Protects patient’s skin and nontargeted tissues from unintended beam exposure. Ensures that all perioperative personnel follow laser safety protocol.
labeled 5 OD [optic disc] at 532 nm) at all entrances to the OR. The laser operator also covers all windows with an opaque covering (eg, fire-retardant window shades). During the laser procedure, the laser operator ensures that all doors are kept shut but not locked and limits access only to staff members who are knowledgeable about laser safety precautions. All personnel present in the OR must wear safety goggles specific to this laser while the laser is in
Patient reports vision unchanged from preoperative status.
Patient’s fluid, electrolyte, and acid-base balances are consistent with or improved from baseline levels established preoperatively.
Patient is free from signs and symptoms of laser injury.
Patient reports comfort in all nontargeted areas at discharge.
use. The circulating nurse and anesthesia care provider place laser-specific safety goggles on the patient if he is awake during surgery. If the patient is undergoing general anesthesia, the anesthesia care provider applies a water-soluble ointment to the patient’s eyes and places moist sponges or a wet towel over the patient’s closed eyelids. As with any laser procedure, fire prevention is a top priority. The OR is equipped with an operational portable AORN JOURNAL •
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fire extinguisher. The circulating nurse ensures that the scrub person has a basin of water on the sterile field for use in the event of a fire.
THE PHOTOSELECTIVE VAPORIZATION PROCEDURE The circulating nurse goes to the preoperative area to greet the patient. The nurse has the patient verbally identify himself while the nurse simultaneously checks the patient’s idenThe circulating tification band. The nurse nurse cleanses the then has the patient verbalize any allergies and confirm the procedure to patient’s skin, be performed. The nurse avoiding the use also verifies that the correct procedure is indicated of flammable prep on the informed consent form and ensures that the patient, a witness, and the solutions and surgeon have all signed ensuring that the the consent form. At Christiana Care Health prep solution does System, the patient usually walks to the OR or, if the not pool because patient is unable to ambulate independently, the cirof the increased culating nurse transfers the patient by stretcher or risk of fire during recovery room chair. The circulating nurse and aneslaser use. thesia care provider help the patient move onto the OR bed. The circulating nurse places warm blankets on the patient and remains to offer emotional support to the patient and assistance to the anesthesia care provider during induction of anesthesia. After anesthesia has been induced, the circulating nurse places a temperature-regulating blanket on the patient’s upper body. The anesthesia care provider administers fluids and medications as needed throughout the procedure. The circulating nurse initiates the
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surgical time-out with all members of the surgical team by clearly announcing the patient’s name, the operating surgeon’s name, and the type and site of procedure as listed on the informed consent. All members of the surgical team, including the anesthesia care provider and the surgeon, must acknowledge their agreement verbally. The laser operator then alerts the entire surgical team of the higher risk of fire as a result of the use of the laser and fiberoptic videotape equipment. The patient’s knees will be flexed for an hour or more during the procedure, so the circulating nurse initiates deep venous thrombosis prophylaxis, if it is not contraindicated. This includes applying sequential compression devices to the patient’s lower extremities. The circulating nurse and another team member then carefully place the patient in the modified lithotomy position by slowly and simultaneously raising the patient’s legs to place them in adjustable boot-type stirrups. The circulating nurse ensures that the patient’s ankles and calves are well padded and that no pressure is being placed on the popliteal fossa (ie, hollow behind the knee). The staff members secure the patient’s legs with padded straps attached to the stirrups. The circulating nurse ensures that all bony prominences are padded to prevent contact with the OR bed and avoid prolonged pressure. The circulating nurse cleanses the patient’s skin, avoiding the use of flammable prep solutions because of the increased risk of fire from the laser. The circulating nurse ensures that prep solution has not pooled, which could cause skin irritation and further increase the risk of fire during laser use. The scrub person and surgeon then drape the patient in accordance with aseptic technique. The circulating nurse and laser operator place the laser
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close to the surgical field and position the videotape system so that the surgeon and laser operator can both view the monitor. The circulating nurse and scrub person ensure that instruments, equipment, and supplies for a standard cystoscopic procedure are readily available. Typically, the procedure is performed using a 23-Fr continuous irrigation cystoscope with a 30-degree lens. The scrub person ensures that the light cable, which is another possible source of ignition, is not activated until it is attached to the cystoscope lens. To prevent direct viewing of the laser beam that could cause eye injury to staff members or damage the videotape system because of its intensity, the scrub person ensures that a sterile lens filter is placed between the camera head and the cystoscope. The scrub person also encloses the fiber in a wet towel for further protection; if broken, the laser fiber delivery system could cause an inadvertent release of the laser beam from the site of the break. Sterile normal saline at room temperature is used for continuous irrigation to cool the laser fiber cap and to flush vapor bubbles and tissue particles away from between the fiber and tissue. To allow the laser beam to transmit through the irrigation fluid, it is important to keep the fluid clear. A drainage system is used for release of fluid from the bladder as necessary. The circulating nurse carefully monitors the irrigation fluid intake and output throughout the procedure. Under direct visualization, the surgeon inserts the laser fiber into the operating channel of the 23-Fr cystoscope. He or she uses a near-contact technique by holding the laser fiber 0.5 mm from the prostate. The surgeon uses 80 watts of power, which causes the targeted tissue to reach the vaporization threshold of greater than 100° C (212° F). The ther-
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mal effect allows for heat defusion, causing a coagulation depth of 1 mm to 2 mm. This produces very precise tissue vaporization and hemostasis. Unlike the TURP procedure, continuous bladder irrigation is not necessary after photoselective vaporization of the prostate. After the procedure is completed, the surgeon decides whether to insert a two-way indwelling urinary catheter. If a catheter is inserted, the scrub person attaches it to a urinary drainage bag and the circulating nurse secures the catheter to the patient’s leg or abdomen. The circulating nurse and The circulating scrub person then simultaneously lower the panurse carefully tient’s legs. The surgical team carefully moves the monitors the patient to a stretcher, and the circulating nurse and irrigation fluid anesthesia care provider transfer the patient to the intake and output postanesthesia care unit (PACU). throughout the
POSTOPERATIVE CARE
procedure to
The PACU nurse monitors the patient’s electroprevent fluid cardiogram, blood presimbalance. sure, pulse oximetry, and respirations. The PACU nurse takes care to maintain normothermia by adding warm blankets or continuing use of the temperature-regulating blanket. The nurse also continues use of the sequential compression device until the patient is ambulatory. If spinal anesthesia has been used, the nurse monitors and documents the patient’s sensory and motor control. The nurse continues administering IV fluid until the patient is able to take fluids by mouth. Postoperative pain should be minimal to nonexistent, and bladder spasms rarely occur. Urine should be clear to pink-tinged. Small clots may be present, but the PACU AORN JOURNAL •
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nurse immediately reports large clots or bleeding to the surgeon. The PACU nurse transfers the patient to the discharge area when he meets PACU discharge criteria.
DISCHARGE TEACHING If the patient is to be discharged within two to three hours after surgery, the discharge nurse gives the patient the normal instructions for any patient receiving genanesthesia. Patients When providing eral are required to have someone stay with them discharge for the first 24 hours after If it is acceptable instructions, the surgery. to the patient, the nurse the discharge innurse emphasizes gives structions to both the and the designatthat the patient patient ed caregiver. If the patient is discharged with an should increase indwelling urinary catheter in place, the nurse his intake of instructs him in the care of fluids unless this the catheter and drainage bag. The patient usually is instructed to remove is contraindicated the catheter the next morning and to call the because of a physician within six hours of removal if he is preexisting unable to void or if large blood clots are present. It medical is not unusual for the urine color to range from condition. clear to pink-tinged. The nurse emphasizes that the patient should increase his intake of fluids unless this is contraindicated because of a preexisting medical condition. The nurse instructs the patient not to drive or operate heavy equipment for 48 hours after surgery. The nurse instructs the patient to limit his activities for two to three days, after which he may return to light work, such as a desk job. The patient should avoid heavy lifting or
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sexual activity for at least 14 days. If preoperative antibiotics were ordered, the patient is instructed to continue taking the medication until it is gone. The nurse tells the patient to avoid caffeine and alcohol for the first three days because these substances can cause bladder irritation. Irregular bowel habits are not unusual after the procedure, so the nurse instructs the patient not to strain during bowel movements. The nurse also tells the patient that he may use a mild over-the-counter laxative if necessary. The nurse explains that the surgeon should be notified immediately if the patient • develops a fever of more than 38.3° C (101° F); • is passing heavy clots; or • cannot urinate for more than six hours. Some patients may experience mild dysuria that usually subsides within one or two weeks. For that reason, the surgeon may order a mild analgesic, such as acetaminophen or ibuprofen. The nurse instructs the patient to call his surgeon if he needs a stronger pain reliever in the following 24 hours. Postoperative care of the patient does not end on discharge from the surgery center environment. Within the next 24-hour period, one of the perioperative nurses calls the patient at home. Any problems that the patient may be experiencing are discussed. If those problems need to be addressed, the perioperative nurse offers instruction or provides a referral.
INCREASING PATIENT SATISFACTION WITH BPH TREATMENT Patient response to photoselective vaporization of the prostate in the outpatient setting has been very positive. Many men with BPH who are not candidates for TURP because they are undergoing anticoagulation therapy may be excellent candidates for the
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photoselective vaporization procedure. Benefits of the photoselective vaporization procedure over the conventional TURP procedure include reduction in the length of the procedure, reduced hospital stay and postoperative recovery time, and decreased complications. Patients experience little or no pain and may return to normal activity quickly. This results in increased patient satisfaction. ❖ Margaret Wojcik, RN, CMLSO, CNOR, is a specialty coordinator laser safety officer at Christiana Care Health System, Newark, Del. Denise Dennison, RN, BSN, CNOR, is a staff development specialist, perioperative services, at Christiana Care Health System, Newark, Del.
NOTES 1. P Walsh, ed, Campbell’s Urology, eighth ed (Philadelphia: W B Saunders, 2002). 2. R S Malek, K Nahen, “Photoselective vaporization of the prostate: KTP laser therapy of obstructive benign prostatic hyperplasia,” Lithicum: AUA Update Series 23 (June 2004) 254-159. 3. S C Smeltzer, B G Bare, Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 10th ed, L S Brunner, D S Suddarth, eds (Philadelphia: Lippincott Williams & Wilkins, 2004) 1324. 4. “Detection methods,” Prostate Cancer Foundation, http://www.prostatecancer
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foundation.org/site/c.itIWK2OSG/b.47289 /k.ACCF/Detection_Methods.htm (accessed 9 Dec 2005). 5. “Outpatient laser surgery of the prostate for bladder outlet obstruction due to benign prostatic hyperplasia,” Mayo Clinic, http://www.mayo.edu/cprel/sum05-urology.html (accessed 8 Dec 2005). 6. K Walmsley, S A Kaplan, “Transurethral microwave thermotherapy for benign prostate hyperplasia: Separating truth from marketing hype,” Journal of Urology 172 (October 2004) 1249-1255. 7. G T Absten, “The fundamentals of . . . medical laser technology,” Biomedical Instrumentation & Technology 36 (May/June 2002) 203-207. 8. T Malloy, “Emerging high-power KTP laser applications in urology,” Contemporary Urology (February 2005), http://www.contem poraryurology.com/conturo/issue/issueDetail .jsp?id=5653 (accessed 28 Dec 2005). 9. American National Standards Institute, American National Standard for the Safe Use of Lasers in Health Care Facilities (New York: American National Standards Institute, 1996) Z136.3. 10. “Recommended practices for laser safety,” in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2005) 405-410.
RESOURCES Ball, K A. Lasers: The Perioperative Challenge, third ed (St Louis: Mosby, 2004). Conner, R. Ambulatory Surgery Principles and Practices: Standards and Recommend Practices for Ambulatory Surgery, second ed (Denver: AORN, Inc, 2001). Nagle, G M. “Genitourinary surgery,” in Alexander’s Care Of The Patient In Surgery 12th ed, J C Rothrock, ed (St Louis: Mosby, 2003) 519-618.
Abuse of Opioid Analgesics Is Increasing
P
rescription drug abuse is on the rise in rural, suburban, and small- to medium-sized urban communities, according to an Oct 19, 2005, news release from the American Pain Society. A study on trends in opioid drug abuse between 2002 and 2004 found that the cases of prescription drug abuse were reported by key informants, such as pain management specialists, addiction treatment professionals, and methadone specialists, in 60% of the areas that were surveyed. Abuse of oxycodone and hydrocodone products was by far the
most prevalent and widespread during the course of the study. The study also found that • more than 90% of oxycodone abusers classify themselves as Caucasian, • 87% had past and current histories of multiple drug use and abuse, and • 70% said a physician’s prescription was their major source of obtaining the drug. Study Documents Rise in OxyContin Abuse (news release, Glenview, Ill; American Pain Society, Oct 19, 2005). AORN JOURNAL •
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Home Study Program Photoselective vaporization of the prostate in ambulatory surgery
T
he article “Photoselective vaporization of the prostate in ambulatory surgery” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Rebecca Holm, RN, MSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS, BC, education program professional, Center for Perioperative Education. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is Feb 28, 2009. Complete the examination answer sheet and learner evaluation found on pages 349-350 and mail with appropriate fee to
AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 80231-5711 or fax the information with a credit card number to (303) 750-3212. You also may access this Home Study via AORN Online at http://www.aorn.org/journal/homestudy/default.htm.
BEHAVIORAL OBJECTIVES After reading and studying the article on photoselective vaporization of the prostate in ambulatory surgery, nurses will be able to
1. describe laser safety credentialing requirements, 2. discuss the pathological effects of benign prostatic hypertrophy (BPH) on normal male anatomy,
3. explain treatment options for BPH, and 4. discuss perioperative care of the patient undergoing photoselective vaporization of the prostate.
This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements. A minimum score of 70% on the multiplechoice examination is necessary to earn 3 contact hours for this independent study. Purpose/Goal: To educate perioperative nurses about photoselective vaporization of the prostate in ambulatory surgery.
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Home Study Program Photoselective vaporization of the prostate in ambulatory surgery Margaret Wojcik, RN; Denise Dennison, RN
P
hotoselective vaporization of the prostate is a significant advancement in the treatment of benign prostatic hypertrophy (BPH), one of the most common ailments experienced by men older than age 50.1 Although this procedure was pioneered in 1997 at the Mayo Clinic,2 Rochester, Minn, it only recently was introduced at Christiana Care Health System, Newark, Del. Initially, the procedure was performed only in the main OR; however, it now is performed in two associated surgery centers. When this treatment was first introduced at Christiana Care Health System, the laser could be used only in one specially outfitted room because of plumbing and electrical requirements. Initially, patients were admitted for 23-hour observation. After a number of these proce-
ABSTRACT •
PHOTOSELECTIVE VAPORIZATION of the prostate is a significant advancement in the treatment of benign prostatic hypertrophy (BPH), one of the most common ailments experienced by men older than age 50.
•
MANY MEN WITH BPH who are not candidates for transurethral resection of the prostate because they are undergoing anticoagulation therapy may be excellent candidates for the photoselective vaporization procedure.
•
BENEFITS of the photoselective vaporization procedure over conventional procedures include reduced length of the procedure, decreased length of hospital stay, reduced postoperative recovery time, fewer complications, little or no pain, and faster return to normal activities. AORN J 83 (February 2006) 330-345.
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dures were performed, perioperative team members decided that a majority of patients could be treated on an outpatient basis, and the team began the planning process to offer the procedure in the Christiana Surgicenter. Staff members from the main OR and the Surgicenter were trained in laser safety and operation of a high-powered potassium-titanyl-phosphate (KTP) laser. The physician determines at which facility the patient receives treatment. The laser then is moved from one facility to the other to accommodate the patient’s and physician’s needs.
LASER SAFETY CREDENTIALING A designated individual trained in laser safety and approved by Christiana Care Health System is responsible for operating the laser, monitoring all safety requirements, and observing the laser fiber for any breaks or malfunction. To be classified as competent in laser use, staff members must attend a basic laser course provided by the facility laser safety officer. After attending the fivehour course, each person must demonstrate proficiency on each specific laser by operating the laser during three supervised procedures. To become nationally certified, staff members must take a national laser examination and then demonstrate proficiency with documentation of procedures performed. Only physicians credentialed by Christiana Care Health System to operate the laser may perform the procedure at these facilities. Credentialing requires physicians to provide documentation of having attended a course on the specific laser and to demonstrate proficient operation of the laser during at least three procedures proctored by a qualified physician.
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ANATOMY
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AND
PHYSIOLOGY
Benign prostatic hypertrophy is a condition in which the prostate increases in size, gradually pinching the urethra and resulting in a host of uncomfortable and painful symptoms. The prostate is a male reproductive gland that makes seminal fluid, which helps nourish and transport sperm. It is located in front of the rectum just below the bladder and wraps around the urethra. Other than adding a small amount of fluid to his ejaculate, it serves no known purpose after a man’s reproductive years have passed. The prostate usually is the size of a small walnut, but as a man ages, the prostate increases in size and can become as large as a grapefruit. The cause of enlargement is not well understood; it usually begins in the early to mid forties and continues throughout life.3 SYMPTOMS. Half of all men over age 50 will develop BPH. During their mid fifties, many men experience changes in their pattern of urination, and these changes can become progressively worse. By the time men reaches their seventies or eighties, 80% will experience urinary symptoms, including • a weak urinary stream, • frequent urination, • difficulty initiating a urinary stream, • intermittent flow during urination, and • frequently awakening at night to urinate. In some instances, blockage of the urethra from BPH can lead to urinary retention, urinary tract infections, or bladder or kidney damage.1
DIAGNOSIS
OF
BPH
Annual prostate examinations should be performed on all men older than age 45, or earlier if there is a family history of prostate cancer. Diagnosis of BPH is accomplished with a digital
rectal examination. This examination gives the physician a general idea of the size and condition of the prostate. A prostate-specific antigen (PSA) blood test is ordered to rule out prostate cancer. Prostate-specific antigen, a protein produced by prostate cells, may become elevated in the blood of men who have prostate cancer. Currently, less than 4 ng/mL is considered normal; howProstate-specific ever, some physicians believe that 2.5 ng/mL antigen results should be considered the highest normal level.4 between 4 ng/mL Results between 4 ng/mL and 10 ng/mL are consid- and 10 ng/mL are ered high and require that the test be repeated.5 considered high
TREATMENT OPTIONS FOR BPH
and require that the test be repeated.
After diagnosing a patient with BPH, the urologist tracks the growth of the patient’s prostate and the severity of the patient’s symptoms. Medications such as alphaadrenergic blockers and 5-alpha reductase inhibitors are used as the first and second lines of proactive treatment. These medications are expensive and are successful in only about 60% of all cases, and they must be taken for the remainder of the patient’s life. Precautions are necessary if the patient has a history of liver problems or is being treated for hypertension. Possible side effects of the medications include erectile dysfunction, abnormal ejaculation, and decreased libido.3 When medical treatment of BPH has been unsuccessful, surgery is the next step. The gold standard of treatment for BPH is transurethral resection of the prostate (TURP). Two minimally invasive procedures currently available are transurethral needle ablation (TUNA)
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and transurethral microwave thermotherapy (TUMT). More recently, however, urologists have been using a minimally invasive laser procedure called photoselective vaporization of the prostate to treat BPH. TURP. The TURP procedure traditionally has been considered the best longterm solution for patients with BPH.1 The enlarged prostate tissue is removed during surgery; the rest of the prostate tissue and capsule remain intact. Although TURP has been the treatment of choice for patients who have significant outlet obstruction from BPH, the procedures has disadvanPhotoselective tages. Anticoagulants, invaporization of cluding aspirin, must be discontinued for a desigthe prostate uses nated period before the procedure because of the a high-energy potential for blood loss, and a catheter must be potassium-titanyl- inserted postoperatively for continuous bladder phosphate laser irrigation. The catheter is removed when the pato vaporize the tient’s urine is free of significant bleeding or blood obstructive tissue, clots. The patient usually remains in the hospital for thus relieving the one to two days after a procedure. Patients patient’s benign TURP are instructed to avoid strenuous activity and prostatic sexual activity for approximately six weeks after hypertrophy surgery. TUNA. The TUNA prosymptoms. cedure uses low-level radiofrequency energy that is delivered via needles placed into the prostate. This produces localized necrotic lesions in the hyperplastic tissue. This procedure can be performed on an outpatient basis in the physician’s office and usually takes approximately one hour. One disadvan-
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tage of TUNA is possible urinary retention within the first 24 to 36 hours after surgery. Another common complication is irritative voiding symptoms (eg, urinary frequency, burning on urination). All anticoagulant medications, including aspirin, must be discontinued before a TUNA procedure because of the potential for bleeding complications. Furthermore, 12.7% to 14% of patients will need treatment for BPH from some other modality within two years of undergoing the TUNA procedure.1(p1385-1389) TUMT. The TUMT procedure uses a transurethral catheter with a microwave antenna to transmit electromagnetic radiation to the prostate at frequencies typically between 915 MHz and 1,296 MHz. This causes a transfer of energy to the tissue in the form of heat and induces coagulation necrosis. Like TUNA, this procedure can be performed on an outpatient basis in the physician’s office and takes about one hour to complete. The complications of urinary retention and irritative voiding symptoms are similar to those for the TUNA procedure. Contraindications to the TUMT procedure include having • a ball-valve middle lobe of the prostate, • a penile or urinary sphincter implant, • a urethral stricture, • an implanted active pacemaker or defibrillator, • clinical or histological evidence of prostate or bladder cancer, • metallic implants in the pelvis or hip region, and with inter• peripheral arterial disease mittent claudication.6 MINIMALLY INVASIVE LASER PROCEDURE. Photoselective vaporization of the prostate is an innovative, minimally invasive procedure that uses a highenergy KTP laser to vaporize the obstructive tissue, thus relieving the patient’s BPH symptoms.2 Candidates
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for photoselective vaporization laser therapy have tried pharmacological therapy but have not achieved adequate results. A distinct advantage of this laser procedure is that patients receiving anticoagulant therapy need not discontinue their medications. Other advantages of photoselective vaporization over the more traditional approaches (ie, TURP, TUNA, TUMT) include • decreased blood loss, • shorter hospital stays, • less discomfort, • quicker recovery, and • fewer complications.
LASER THERAPY Laser light is unique because of three main In addition to properties: collimation, vaporization, the monochromaticity, and coherency. The term collilaser beam mated means that wave patterns are locked in coagulates phase, and the laser creates a light beam that to a depth of stays together tightly over long distances. The term 1 mm to 2 mm. monochromatic means that the laser produces pure The coagulation colors of light. Each laser produces light specific for zone creates that laser. The term coherence describes the phasing hemostasis, of the wave patterns.7 Laser light is used resulting in a because of its thermal and effects on tisvirtually bloodless mechanical sue. The wavelength of the laser light determines surgical field. the action (ie, cutting, coagulating, vaporizing). Collimated laser light that travels in a parallel beam can be guided through optical fibers and focused on a small spot. This allows the energy to be delivered endoscopically.7 A specific high-powered KTP laser is used to perform photoselective vaporiza-
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tion for BPH. The hemoglobin in the prostate selectively absorbs the KTP laser beam at the 532-nm wavelength. The laser delivers power up to 80 watts in a short-pulsed mode through a double, side-firing optical fiber at a 70-degree angle relative to the fiber axis. Heat generated by the absorption of the laser energy within the targeted tissue causes vapor bubbles to form whenever the intracellular temperature of the water contained within the tissue reaches the boiling point (ie, 100° C [212° F]). The laser light penetrates into the tissue to a depth of 800 micrometers (ie, 0.8 mm). The laser beam rapidly heats the superficial tissue, resulting in highly efficient vaporization of the prostatic adenoma. In addition to vaporization, the laser beam coagulates to a depth of 1 mm to 2 mm. The coagulation zone creates hemostasis, resulting in a virtually bloodless surgical field.8
PREOPERATIVE PREPARATION When a surgeon determines that a patient is a good candidate for the photoselective vaporization procedure, the patient begins the admission process. The surgeon obtains a thorough medical history and performs a comprehensive physical examination, including a digital rectal examination, and orders laboratory tests (eg, PSA, urinalysis, routine blood work including blood urea nitrogen and creatinine). The surgeon also may order optional tests such as a transrectal ultrasound or cystometrogram. A transrectal ultrasound is a screening method that uses an endorectal probe/ultrasonic transducer to obtain an image of the prostate for echogenicity (ie, localization of areas suspected for malignancy). Cystometrogram is a test that measures bladder pressure to determine such factors as bladder capacity and bladder wall compliance. A perioperative evaluation and preparation team nurse then schedules the patient for a preoperative evaluation.
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The nurse interviews the patient either in person or by telephone. During this interview, the nurse reviews the patient’s past medical history and performs a comprehensive preoperative nursing assessment. He or she identifies preexisting conditions (eg, morbid obesity, limited mobility) that may require special positioning aids. If the nurse determines that additional testing is needed, he or she orders the tests to be performed before the day of surgery. The nurse verifies with the patient the date, time, and location of the scheduled surgery, as well as information regarding when to arrive at the facility and what items the patient may or may not bring. At this time, the nurse determines whether a consultation with an anesthesia care provider is necessary before surgery, and if so, schedules it to be performed before the day the patient is admitted. If the surgery is scheduled to be performed on an outpatient basis, the nurse instructs the patient that he will need someone to transport him home after the procedure and someone to stay with him for at least 24 hours after surgery.
ADMISSION Typically, patients scheduled for a photoselective vaporization procedure are instructed to arrive at the surgical facility at least two hours before the procedure. The admissions nurse greets the patient and begins to prepare him for the surgical procedure. The nurse places all previously collected information, including the patient’s medical history, test results, and the signed informed consent form, on the patient’s medical record. The nurse then obtains and documents the patient’s initial vital signs, allergies, and height and weight, after which the nurse initiates a perioperative nursing care plan (Table 1). Communication is essential in the assessment process.
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The nurse confirms previously collected data with the patient, including history, past hospitalizations, previous surgeries, and medications he is currently taking, especially over-thecounter medications such as aspirin and herbal remedies. During this process, the nurse assesses the The laser operator patient’s and family members’ understandand circulating ing of BPH and the surgical procedure, answers nurse ensure that any questions they may have, and evaluates the laser safety patient’s anxiety level. The anesthesia care standards provider then interviews the patient to determine determined by the the most appropriate anesthetic approach (ie, American general anesthesia, spinal anesthesia, pudendal National block with supplemental IV sedation). The nurse Standards inserts an IV line and administers preoperaInstitute and tive medications and antibiotics as ordered. AORN are followed The nurse transports the throughout the patient and family members to a quiet waiting procedure. area until the time of surgery and offers the patient warm blankets and any other comfort measures needed.
OR PREPARATION The laser operator and circulating nurse ensure that laser safety standards, as determined by the American National Standards Institute and AORN, are followed throughout the entire procedure.9,10 An external watercooling system is required because the laser emits high-powered laser energy. This requirement is met using a wallmounted plumbing system for inflow AORN JOURNAL •
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TABLE 1
Nursing Care Plan for Patients Undergoing Photoselective Vaporization of the Prostate Diagnosis Knowledge deficient related to surgical outcomes
• • •
• • Risk of injury related to the surgical experience
• • • • •
Risk of inadvertent hypothermia
Interim outcome criteria
Outcome statement
Determines knowledge level, assesses readiness to learn, and identifies barriers to communication. Explains expected sequence of events and reinforces teaching about treatment options. Provides instruction (ie, verbal, written) regarding the surgical procedure and discharge instructions based on age and identified need, to include • caring for indwelling urinary catheter, • removing catheter at appropriate time, • drinking plenty of fluids, • avoiding heavy lifting or straining, and • using a mild laxative if necessary. Communicates patient concerns to appropriate surgical team members. Evaluates response to instruction.
Patient verbalizes decreased anxiety and understanding of surgical procedure.
Patient demonstrates knowledge of the expected responses to photoselective vaporization of the prostate and discharge care.
Verifies patient’s identity, allergies, NPO status, and informed consent. Assesses skin integrity, sensory impairments, and musculoskeletal status. Applies sequential compression devices to prevent deep vein thrombosis. Places patient carefully in the modified lithotomy position and implements measures to protect the patient from injury (eg, padding bony prominences adequately). Evaluates patient for signs and symptoms of injury.
Patient’s skin remains smooth and intact, and neuromuscular functions are maintained or improved from baseline.
Patient is free from signs and symptoms of physical injury.
Monitors patient’s body temperature. Implements thermoregulation measures, to include • offering warm blankets, • applying a temperature-regulating blanket to the patient’s upper body.
Patient’s temperature is within normal limits (>36° C [96.8° F]) at discharge.
Patient is at or returning to normothermia at the conclusion of the perioperative period.
Nursing interventions
• •
and drainage of the water. The laser operator checks the electrical cord of the laser for breaks or fraying before plugging it in and connects the watercooling system hosing to the rear of the laser panel. The laser operator ensures that the power cord and hosing system are placed such that traffic patterns are not compromised. The laser operator tests the laser for proper functioning before the patient is brought to the OR. After the laser operator plugs in the
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Patient and family members are able to accurately describe postoperative care.
Patient participates in decisions affecting his plan of care.
laser, attaches the water hoses, and turns on the laser, the laser runs through a self-test and alerts the laser operator when it is ready to be used or if there are any problems. The location where the procedure is to be performed is designated as a nominal hazard zone. The laser operator posts laser warning signs and places additional laser safety glasses specific for this laser (ie, laser safety goggles for an 80-watt KTP laser
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TABLE 1
Nursing Care Plan for Patients Undergoing Photoselective Vaporization of the Prostate (continued) Diagnosis Risk of acute pain related to the surgical procedure
• • • • • •
Risk of fluid volume imbalance
Interim outcome criteria
Outcome statement
Assesses patient’s pain preoperatively. Identifies patient’s accepted postoperative pain threshold. Provides pain management instruction and pain scale to assess pain control. Implements pain management guidelines. Collaborates with anesthesia care provider to provide pain medications as needed. Evaluates patient’s response to pain management interventions.
Patient demonstrates adequate pain management.
Patient demonstrates and reports adequate pain control throughout the perioperative period.
Uses a continuous irrigation system. Monitors input and outflow of irrigating fluids. Monitors for fluid deficit. Monitors for signs of hypervolemia and hypovolemia. Monitors color and amount of urine output from urinary catheter.
Irrigating fluid deficit is within acceptable volume (ie, irrigation output is within 300 mL of irrigation input).
Nursing interventions
• • • • •
Patient’s vital signs are equal to or improved from preoperative values.
Patient’s urinary output is within normal range at discharge and remains clear or only slightly blood-tinged. Risk of injury related to laser therapy
• • • • •
Verifies that surgeon is accredited to perform laser surgery. Controls the laser equipment by identifying nominal hazard zone and securing laser key. Ensures that the patient’s eyes are protected and appropriate laser safety eye wear is available for all staff members. Protects patient’s skin and nontargeted tissues from unintended beam exposure. Ensures that all perioperative personnel follow laser safety protocol.
labeled 5 OD [optic disc] at 532 nm) at all entrances to the OR. The laser operator also covers all windows with an opaque covering (eg, fire-retardant window shades). During the laser procedure, the laser operator ensures that all doors are kept shut but not locked and limits access only to staff members who are knowledgeable about laser safety precautions. All personnel present in the OR must wear safety goggles specific to this laser while the laser is in
Patient reports vision unchanged from preoperative status.
Patient’s fluid, electrolyte, and acid-base balances are consistent with or improved from baseline levels established preoperatively.
Patient is free from signs and symptoms of laser injury.
Patient reports comfort in all nontargeted areas at discharge.
use. The circulating nurse and anesthesia care provider place laser-specific safety goggles on the patient if he is awake during surgery. If the patient is undergoing general anesthesia, the anesthesia care provider applies a water-soluble ointment to the patient’s eyes and places moist sponges or a wet towel over the patient’s closed eyelids. As with any laser procedure, fire prevention is a top priority. The OR is equipped with an operational portable AORN JOURNAL •
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fire extinguisher. The circulating nurse ensures that the scrub person has a basin of water on the sterile field for use in the event of a fire.
THE PHOTOSELECTIVE VAPORIZATION PROCEDURE The circulating nurse goes to the preoperative area to greet the patient. The nurse has the patient verbally identify himself while the nurse simultaneously checks the patient’s idenThe circulating tification band. The nurse nurse cleanses the then has the patient verbalize any allergies and confirm the procedure to patient’s skin, be performed. The nurse avoiding the use also verifies that the correct procedure is indicated of flammable prep on the informed consent form and ensures that the patient, a witness, and the solutions and surgeon have all signed ensuring that the the consent form. At Christiana Care Health prep solution does System, the patient usually walks to the OR or, if the not pool because patient is unable to ambulate independently, the cirof the increased culating nurse transfers the patient by stretcher or risk of fire during recovery room chair. The circulating nurse and aneslaser use. thesia care provider help the patient move onto the OR bed. The circulating nurse places warm blankets on the patient and remains to offer emotional support to the patient and assistance to the anesthesia care provider during induction of anesthesia. After anesthesia has been induced, the circulating nurse places a temperature-regulating blanket on the patient’s upper body. The anesthesia care provider administers fluids and medications as needed throughout the procedure. The circulating nurse initiates the
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surgical time-out with all members of the surgical team by clearly announcing the patient’s name, the operating surgeon’s name, and the type and site of procedure as listed on the informed consent. All members of the surgical team, including the anesthesia care provider and the surgeon, must acknowledge their agreement verbally. The laser operator then alerts the entire surgical team of the higher risk of fire as a result of the use of the laser and fiberoptic videotape equipment. The patient’s knees will be flexed for an hour or more during the procedure, so the circulating nurse initiates deep venous thrombosis prophylaxis, if it is not contraindicated. This includes applying sequential compression devices to the patient’s lower extremities. The circulating nurse and another team member then carefully place the patient in the modified lithotomy position by slowly and simultaneously raising the patient’s legs to place them in adjustable boot-type stirrups. The circulating nurse ensures that the patient’s ankles and calves are well padded and that no pressure is being placed on the popliteal fossa (ie, hollow behind the knee). The staff members secure the patient’s legs with padded straps attached to the stirrups. The circulating nurse ensures that all bony prominences are padded to prevent contact with the OR bed and avoid prolonged pressure. The circulating nurse cleanses the patient’s skin, avoiding the use of flammable prep solutions because of the increased risk of fire from the laser. The circulating nurse ensures that prep solution has not pooled, which could cause skin irritation and further increase the risk of fire during laser use. The scrub person and surgeon then drape the patient in accordance with aseptic technique. The circulating nurse and laser operator place the laser
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close to the surgical field and position the videotape system so that the surgeon and laser operator can both view the monitor. The circulating nurse and scrub person ensure that instruments, equipment, and supplies for a standard cystoscopic procedure are readily available. Typically, the procedure is performed using a 23-Fr continuous irrigation cystoscope with a 30-degree lens. The scrub person ensures that the light cable, which is another possible source of ignition, is not activated until it is attached to the cystoscope lens. To prevent direct viewing of the laser beam that could cause eye injury to staff members or damage the videotape system because of its intensity, the scrub person ensures that a sterile lens filter is placed between the camera head and the cystoscope. The scrub person also encloses the fiber in a wet towel for further protection; if broken, the laser fiber delivery system could cause an inadvertent release of the laser beam from the site of the break. Sterile normal saline at room temperature is used for continuous irrigation to cool the laser fiber cap and to flush vapor bubbles and tissue particles away from between the fiber and tissue. To allow the laser beam to transmit through the irrigation fluid, it is important to keep the fluid clear. A drainage system is used for release of fluid from the bladder as necessary. The circulating nurse carefully monitors the irrigation fluid intake and output throughout the procedure. Under direct visualization, the surgeon inserts the laser fiber into the operating channel of the 23-Fr cystoscope. He or she uses a near-contact technique by holding the laser fiber 0.5 mm from the prostate. The surgeon uses 80 watts of power, which causes the targeted tissue to reach the vaporization threshold of greater than 100° C (212° F). The ther-
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mal effect allows for heat defusion, causing a coagulation depth of 1 mm to 2 mm. This produces very precise tissue vaporization and hemostasis. Unlike the TURP procedure, continuous bladder irrigation is not necessary after photoselective vaporization of the prostate. After the procedure is completed, the surgeon decides whether to insert a two-way indwelling urinary catheter. If a catheter is inserted, the scrub person attaches it to a urinary drainage bag and the circulating nurse secures the catheter to the patient’s leg or abdomen. The circulating nurse and The circulating scrub person then simultaneously lower the panurse carefully tient’s legs. The surgical team carefully moves the monitors the patient to a stretcher, and the circulating nurse and irrigation fluid anesthesia care provider transfer the patient to the intake and output postanesthesia care unit (PACU). throughout the
POSTOPERATIVE CARE
procedure to
The PACU nurse monitors the patient’s electroprevent fluid cardiogram, blood presimbalance. sure, pulse oximetry, and respirations. The PACU nurse takes care to maintain normothermia by adding warm blankets or continuing use of the temperature-regulating blanket. The nurse also continues use of the sequential compression device until the patient is ambulatory. If spinal anesthesia has been used, the nurse monitors and documents the patient’s sensory and motor control. The nurse continues administering IV fluid until the patient is able to take fluids by mouth. Postoperative pain should be minimal to nonexistent, and bladder spasms rarely occur. Urine should be clear to pink-tinged. Small clots may be present, but the PACU AORN JOURNAL •
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nurse immediately reports large clots or bleeding to the surgeon. The PACU nurse transfers the patient to the discharge area when he meets PACU discharge criteria.
DISCHARGE TEACHING If the patient is to be discharged within two to three hours after surgery, the discharge nurse gives the patient the normal instructions for any patient receiving genanesthesia. Patients When providing eral are required to have someone stay with them discharge for the first 24 hours after If it is acceptable instructions, the surgery. to the patient, the nurse the discharge innurse emphasizes gives structions to both the and the designatthat the patient patient ed caregiver. If the patient is discharged with an should increase indwelling urinary catheter in place, the nurse his intake of instructs him in the care of fluids unless this the catheter and drainage bag. The patient usually is instructed to remove is contraindicated the catheter the next morning and to call the because of a physician within six hours of removal if he is preexisting unable to void or if large blood clots are present. It medical is not unusual for the urine color to range from condition. clear to pink-tinged. The nurse emphasizes that the patient should increase his intake of fluids unless this is contraindicated because of a preexisting medical condition. The nurse instructs the patient not to drive or operate heavy equipment for 48 hours after surgery. The nurse instructs the patient to limit his activities for two to three days, after which he may return to light work, such as a desk job. The patient should avoid heavy lifting or
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sexual activity for at least 14 days. If preoperative antibiotics were ordered, the patient is instructed to continue taking the medication until it is gone. The nurse tells the patient to avoid caffeine and alcohol for the first three days because these substances can cause bladder irritation. Irregular bowel habits are not unusual after the procedure, so the nurse instructs the patient not to strain during bowel movements. The nurse also tells the patient that he may use a mild over-the-counter laxative if necessary. The nurse explains that the surgeon should be notified immediately if the patient • develops a fever of more than 38.3° C (101° F); • is passing heavy clots; or • cannot urinate for more than six hours. Some patients may experience mild dysuria that usually subsides within one or two weeks. For that reason, the surgeon may order a mild analgesic, such as acetaminophen or ibuprofen. The nurse instructs the patient to call his surgeon if he needs a stronger pain reliever in the following 24 hours. Postoperative care of the patient does not end on discharge from the surgery center environment. Within the next 24-hour period, one of the perioperative nurses calls the patient at home. Any problems that the patient may be experiencing are discussed. If those problems need to be addressed, the perioperative nurse offers instruction or provides a referral.
INCREASING PATIENT SATISFACTION WITH BPH TREATMENT Patient response to photoselective vaporization of the prostate in the outpatient setting has been very positive. Many men with BPH who are not candidates for TURP because they are undergoing anticoagulation therapy may be excellent candidates for the
Wojcik — Dennison
photoselective vaporization procedure. Benefits of the photoselective vaporization procedure over the conventional TURP procedure include reduction in the length of the procedure, reduced hospital stay and postoperative recovery time, and decreased complications. Patients experience little or no pain and may return to normal activity quickly. This results in increased patient satisfaction. ❖ Margaret Wojcik, RN, CMLSO, CNOR, is a specialty coordinator laser safety officer at Christiana Care Health System, Newark, Del. Denise Dennison, RN, BSN, CNOR, is a staff development specialist, perioperative services, at Christiana Care Health System, Newark, Del.
NOTES 1. P Walsh, ed, Campbell’s Urology, eighth ed (Philadelphia: W B Saunders, 2002). 2. R S Malek, K Nahen, “Photoselective vaporization of the prostate: KTP laser therapy of obstructive benign prostatic hyperplasia,” Lithicum: AUA Update Series 23 (June 2004) 254-159. 3. S C Smeltzer, B G Bare, Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, 10th ed, L S Brunner, D S Suddarth, eds (Philadelphia: Lippincott Williams & Wilkins, 2004) 1324. 4. “Detection methods,” Prostate Cancer Foundation, http://www.prostatecancer
FEBRUARY 2006, VOL 83, NO 2
foundation.org/site/c.itIWK2OSG/b.47289 /k.ACCF/Detection_Methods.htm (accessed 9 Dec 2005). 5. “Outpatient laser surgery of the prostate for bladder outlet obstruction due to benign prostatic hyperplasia,” Mayo Clinic, http://www.mayo.edu/cprel/sum05-urology.html (accessed 8 Dec 2005). 6. K Walmsley, S A Kaplan, “Transurethral microwave thermotherapy for benign prostate hyperplasia: Separating truth from marketing hype,” Journal of Urology 172 (October 2004) 1249-1255. 7. G T Absten, “The fundamentals of . . . medical laser technology,” Biomedical Instrumentation & Technology 36 (May/June 2002) 203-207. 8. T Malloy, “Emerging high-power KTP laser applications in urology,” Contemporary Urology (February 2005), http://www.contem poraryurology.com/conturo/issue/issueDetail .jsp?id=5653 (accessed 28 Dec 2005). 9. American National Standards Institute, American National Standard for the Safe Use of Lasers in Health Care Facilities (New York: American National Standards Institute, 1996) Z136.3. 10. “Recommended practices for laser safety,” in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2005) 405-410.
RESOURCES Ball, K A. Lasers: The Perioperative Challenge, third ed (St Louis: Mosby, 2004). Conner, R. Ambulatory Surgery Principles and Practices: Standards and Recommend Practices for Ambulatory Surgery, second ed (Denver: AORN, Inc, 2001). Nagle, G M. “Genitourinary surgery,” in Alexander’s Care Of The Patient In Surgery 12th ed, J C Rothrock, ed (St Louis: Mosby, 2003) 519-618.
Abuse of Opioid Analgesics Is Increasing
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rescription drug abuse is on the rise in rural, suburban, and small- to medium-sized urban communities, according to an Oct 19, 2005, news release from the American Pain Society. A study on trends in opioid drug abuse between 2002 and 2004 found that the cases of prescription drug abuse were reported by key informants, such as pain management specialists, addiction treatment professionals, and methadone specialists, in 60% of the areas that were surveyed. Abuse of oxycodone and hydrocodone products was by far the
most prevalent and widespread during the course of the study. The study also found that • more than 90% of oxycodone abusers classify themselves as Caucasian, • 87% had past and current histories of multiple drug use and abuse, and • 70% said a physician’s prescription was their major source of obtaining the drug. Study Documents Rise in OxyContin Abuse (news release, Glenview, Ill; American Pain Society, Oct 19, 2005). AORN JOURNAL •
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