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Transurethral Prostate Resection
AORN JOURNAL
AUGUST 1993, VOL 58, NO 2
Transurethra1 Prostate Resection A FRUSTRATION-FREE SURGICAL METHOD David M. Cumes, MD
A
transurethral resection of the prostate (TURP) is performed when patients, usually elderly men with enlarged, noncancerous prostate glands, find urination increasingly difficult as they age. The procedure is indicated if the patient believes that the symptoms (eg, multiple trips to the bathroom during the night, difficulty emptying the bladder) adversely affect his life-style. Surgery also is performed if a urologist discovers signs of upper urinary tract dilation or significant increase in residual urine (ie, above 100 mL). Combining the Reuter suprapubic trocar system and a single-fill bladder evacuator with a nonreturn valve eliminates many frustrations currently associated with TURP. Patients who otherwise would undergo open prostatectomy now can have surgery during which the prostate gland is resected quickly and safely under continuous, low-pressure irrigation.
Complications
S
everal problems can make resecting a large, vascular prostate technically challenging for the urologist and the operating room team. One problem is maintaining a clear field of vision and a low-pressure resection. When using a conventional resectoscope, the repeated filling and emptying of the bladder required to see and resect the prostate prolongs the procedure. If rapid bleeding occurs as the bladder fills and pressure increases, the visual field quickly becomes obscured by the lack of inflow. This is true especially if the 302
patient has a small-capacity bladder. Normal venous pressure usually is 10 to 15 cm of water. Using the conventional surgical method, however, intravesical pressure often reaches 60 to 100 cm of water as the bladder fills. This increases vascular absorption of irrigation fluid through the venous sinuses of the prostate and dilutes the total amount of sodium in the vascular space. This absorption can cause dilutional hyponatremia (ie, TURP syndrome), particularly if the resection time is lengthy. Resection time may increase if the size of the prostate is underestimated. When this happens, the surgeon must decide whether to complete the resection and risk postoperative dilutional hyponatremia or abort the procedure. The TURP syndrome can arise, although to a lesser extent, with continuous-flow resectoscopes. These instruments have been improved technologically and usually provide the surgeon with continuous, unimpeded vision; however, the system can become intermittently plugged with prostatic tissue. This obscures the surgeon’s visual field and increases the patient’s bladder pressure. The suction section of the continuous-flow system resectoscope loop occupies enough space that a 28 F instrument only can accommodate a 26 F resectoscope
David M . Cumes, MD,FACS, FRCS, FCS, is a urologist in private practice in Santa Barbara, Calif. He earned his medical degree from the University of the Witwatersrand Medical School, Johannesburg, South Africa.
AUGUST 194.1, VOL 58. NO 2
AORN JOURNAL
loop. This reduces the size of the cutting loop and decreases efficiency. Repeatedly irrigating the bladder using an Ellick evacuator or a Toomey syringe at the end of a long resection to evacuate prostate chips from the bladder also may prolong the procedure. Resection of a large prostate may require the bladder to be filled and drained several times to clear all the remaining chips. Using a bulb syringe to evacuate chips can allow chips to return to the bladder because of the pumping action of the bulb. The surgical team can overcome these problems, including TURP syndrome, by u s i n g a s u p r a p u b i c trocar system t o achieve unimpeded continuous-flow irrigation under low pressure and using a more efficient bladder evacuator that needs to be filled only once and will retrieve tissue efficiently.
pressure. An experienced surgeon, however, often knows when the holes of the trocar have been occluded with chips and bladder pressure is rising. The most important indication of this is a change in the configuration of the prostate as bladder volume and pressure increase and fill the prostatic urethra with irrigation fluid. The perioperative nurse also should monitor this vent, because fluid dripping out of it may indicate that intravesical pressure is rising. In this case, the surgeon can slide the inner cannula upward and away from the outer cannula. This strips off clinging prostate chips and restores flow when the cannula is reinserted. The top of this cannula is covered with a rubber hood with a hole in the center so that the surgeon can slide the trocar and the inner cannula in place to keep the system watertight.
Suprapubic Trocar
bladder evacuator with a nonreturn valve was developed to eliminate the problem .of evacuating prostate chips from the bladder. Figure 3 shows a single-fill evacuator with a flap valve that prevents chips from returning to the bladder when the rubber bulb is pumped. The reservoir is big enough to accommodate even the largest specimen. The device consists of a glass reservoir, a rubber bulb, and an inset valve system that allows the surgeon to empty the bladder chips after filling the reservoir only once and pumping several times. To fill the evacuator, it is immersed in a basin of sterile water, and all air is removed from it. The valve is inserted into the valve nozzle and the rubber bulb into the bulb nozzle. The evacuator is easier to assemble when all parts are wet. The outlet nozzle of the evacuator is connected by conventional latex tubing to thc appropriate adapter used for the resectoscope. To ensure that all chips are floating free in the bladder for evacuation, the outflow tubing exiting the inner suprapubic cannula needs to be occluded, and the inner cannula should be stripped away from the outer cannula. After surgery, prostate chips are removed from the evacuator by taking it apart. The Reuter system
T
he continuous-flow irrigation technique (ie, inflow irrigation through the resectoscope, outflow irrigation through the suprapubic trocar to speed resection) is not a new concept.' What is new is that the Reuter suprapubic trocar is used postoperatively for inflow irrigation to promote bladder drainage and prevent the formation of clots. The Reuter system uses a trocar and cannula designed in four parts (Fig 1). This system contains the following pieces: a sharp trocar that is removed from the cannula after placement in the bladder, an atraumatic, hollow inner cannula with multiple terminal side holes, through which fluid exits, that replaces the sharp trocar, an outer cannula, through which the trocar and hollow inner cannula pass, and 0 an outer sheath that surrounds the whole system and can be used to insert a Foley catheter into the bladder at the end of the case (Fig 2). The outer cannula of this system has a side vent designed by Reuter to monitor intravesical 304
Bladder Evacuation
A
AUGUST 1993, VOL 58, NO 2
AORN JOURNAL
Fig I . Reuter suprapubic trocar and cannulas.
Fig 2 . Placement of Foley catheter through outer sheath of Reuter system.
Fig 3. Single-fill bladder evacuator with oneway valve system. 305
AUGUST IY91, VOL 58,NO 2
AORN JOURNAL
and the evacuator are nondisposable and easily cleaned, assembled, and disassembled. They can be sterilized by autoclave or gas sterilization, or they can be high-level disinfected.
Preoperative Care
A
patient undergoing TURP usually is admitted to the hospital through the outpatient department. Hospital personnel complete laboratory studies (eg, uric acid test, urine culture, complete blood count, electrocardiogram if the patient is over 40 years of age). The nurse reviews the patient’s chart for consent, a list of allergies, and a medical history and checks the patient’s identification band. The nurse should explain to the patient that he will be put in a lithotomy position during surgery, that an IV will be inserted so that anesthesia personnel can administer antianxiety medications, and that he may receive nasal oxygen. The nurse also should assess the patient’s skin condition and range of hip motion for problems such as arthritis to ensure that the lithotomy position will not be uncomfortable during surgery. Because the genitals will be exposed during the procedure, the nurse should reassure the patient that every effort will be made to preserve privacy and dignity during the perioperative period. If the patient receives spinal anesthesia, the nurse should tell the patient that the surgeon, anesthesia personnel, and nurse will explain the procedure as it progresses and answer any questions the patient has. The surgeon counsels the patient about the possible complications of a TURP (eg, retrograde ejaculation, urethral stricture, total permanent incontinence, impotence). The surgeon also tells the patient that a small instrument known as a trocar cannula will be inserted above the pubic bone and into the bladder to expedite the surgery and that this instrument will be replaced by a catheter after the surgery for postoperative irrigation. Few patients are upset by the prospect of a minor additional procedure, especially after the surgeon explains that postoperative irrigation will prevent clot retention. 306
The setup for this procedure includes 0 the Reuter suprapubic punch cystostomy kit, 0 a 20-gauge spinal needle to locate the bladder after bladder distention, 0 additional latex tubing that attaches to the cannula for siphon or gravity drainage, a 14 F, 10 mL Foley catheter that can be placed through the outer sheath of the Reuter system, 0 3-0 silk on a Keith needle to suture the suprapubic catheter in place after it is inserted into the bladder, and irrigation fluid (eg, sorbitol, glycine) heated to body temperature. Because irrigation is continuous, the perioperative nurse should double the amount of irrigation fluid that is used for a conventional TURP. The additional cost of extra fluid is offset by the increased speed of the resection. This decreases the time the patient spends in the OR, and consequently, the cost of the procedure.
intruoperutive Care conferring with anesthesia personregarding the proposed anesthesia , spinal, general, caudal with suprapubic block), the nurse transports the patient to the cystoscopy room. He or she helps the patient into a comfortable position that permits the administration of anesthesia. After administration of anesthesia, the surgical team positions the patient in a lithotomy position, pads all potential pressure points, and covers the patient’s upper body with warm blankets. The nurse shaves the patient’s suprapubic area and preps this area and the genitals and perineum. The surgeon drapes the patient for a TURP and includes the suprapubic area within the surgical field.
Intruoperative Procedure
T
he surgeon uses a spinal needle to locate and confirm aspiration of irrigation fluid from the bladder before inserting the trocar into the patient’s full bladder through a
AUGUST 1993, VOL 5X, NO 2
AORN JOURNAL
small (ie, 1 cm) suprapubic incision. could cause voiding difficulties and less chance The Reuter system is preassembled for easy of perforation of the capsule. If a perforation bladder insertion. The resectoscope sheath is occurs, extravasation of irrigation fluid usually assembled with an obturator that has a slight is minimal because low-pressure irrigation is curve to it. Using a lubricant, the surgeon used. inserts it into the bladder in a fashion similar to The irrigation fluid should be kept at approximately 30 to 40 cm of water pressure. This a urethral sound. The surgeon also can insert the sheath into the bladder under direct vision pressure is measured by simple manometry, using a 12- to 30-degree lens that allows the and the surgeon uses a centimeter ruler to measurgeon to visually negotiate the sheath into the sure the height of the irrigation fluid bags bladder. He or she then connects the sheath to above the patient’s symphysis pubis. inflow tubing using a small stopcock that Continuous-flow irrigation is achieved by allows fluid to pass through the sheath. The hooking the Reuter inner cannula to convenobturator is removed and replaced by a resectotional latex tubing and allowing the fluid to scope. drain into a stainless steel kick bucket, which is The patient then is placed in Trendelenburg’s emptied as necessary, on the floor. The sound position to keep the puncture site extraperiof fluid dripping into the bucket is a sign that toneal. After the Reuter system is in place, the the surgeon’s continuous-flow irrigation is prosharp trocar is replaced by the blunt inner canceeding correctly. nula with multiple side holes for continuous The surgeon can elevate the outflow irrigation tubing a few inches above the patient’s irrigation (Fig 4). This continuous-flow reseclower abdomen to increase bladder pressure toscope system is very efficient because the and volume slightly. This is useful in cases in irrigation outlet through the Reuter inner canwhich the bladder wall collapses into the bladnula is slightly less than a 14 F, which is larger der neck region and around the cannula as the than what can be used by any self-contained, bladder empties. There is no advantage to concontinuous-flow instrument. necting the outflow irrigation tubing to a sucA continuous, low-pressure resection of the tion device because simple siphon or gravity prostate using this system is possible with little drainage works as well. absorption of irrigation fluid into prostatic At the end of the procedure, the inner three venous sinuses, and clarity of vision is excelcomponents of the Reuter system are removed, lent. In patients with very large glands, addileaving behind the outer sheath. A 14 F Foley tional time may be required to complete the catheter can then be placed through the suprapuresection. The low-pressure system offers bic tract via the outer sheath for postoperative increased safety for these patients. Reuter has reported resecting glands as large as 200 g with this technique.2 Resecting a 100-g gland is well within the range of most experienced urologists and operating room teams. Because the configuration of the prostatic fossa does not vary much during the procedure, anatomical landmarks remain constant (especially in the area of the external sphincter), and this makes resection safer. Using this procedure, there is less Fig 4. Reuter trocar and cannula are placed into the bladder. possibility of leaving an excessive The trocar is removed and the inner cannula inserted in its amount of apical tissue that later place. 307
AORN JOURNAL
continuous-flow irrigation. The flow now is reversed, and irrigation is coming in through the suprapubic tube and exiting the urethral Foley catheter. This minimizes postoperative clot retention. If the urine is clear, the suprapubic catheter usually is removed the next day. It can remain in a patient who has an atonic or a reflexic bladder detrusor and is expected to have residual urine despite the TURP. This patient can monitor his residual urine at home using the suprapubic tube until the amount of urine is sufficiently low enough to have the tube removed.
Postoperative Care, Teaching
F
ollowing surgery, the patient is taken to the postanesthesia care unit (PACU), where irrigation fluid (ie, glycine, sorbitol, saline) is instilled through the suprapubic Foley catheter and drained out of the urethral Foley catheter. Manual irrigation can be done, but if a “continuous flow to keep clear” policy is used, clots rarely form, and a clear, patent catheter irrigation is assured. The rate of irrigation can vary according to the severity of the bleeding. A slow, steady drip is usual. It is important that the irrigation system is not allowed to run dry, because clots can form in the bladder, rendering the Reuter irrigation system useless. Irrigation fluid should not be hung more than 12 to 24 inches above the bed to ensure that bladder pressure is not too high if the urethral catheter becomes blocked. Depending on the surgeon’s orders and the color of the urine, the nurse can clamp or remove the suprapubic catheter the day after surgery. If the nurse clamps the catheter, he or she can leave the sterile irrigation system at the bedside for possible reuse. In some instances in which the patient is known to be retaining considerable residual urine and may possibly have an atonic bladder, the suprapubic catheter can be left in until after the urethral catheter is removed. This way, if the patient fails to void, he can be discharged from the hospital safely with a suprapubic catheter in place and with instructions on how to manage it.
AUGUST 1993, VOL 58, NO 2
Postoperative teaching should begin in the PACU, where the nurse explains the irrigation procedure the patient is undergoing and the importance of it. Additional patient teaching in the unit should be given to any patient who is being discharged with a suprapubic catheter in place. The nurse explains to the patient how to manage his voiding regime at home using the suprapubic catheter. The patient should be shown how to unclamp the catheter for a period of five minutes after voiding to monitor the residual urine and how to chart the amount of urine voided. The nurse also should explain how the catheter can be repeatedly reclamped during the day or, if necessary, left undamped during the night. The patient should be taught how to change the suprapubic dressing every other day. For a patient incapable of understanding or perfoming the care required, a visiting nurse can see the patient daily to supervise dressing changes and ensure that the patient’s voiding regime is proceeding correctly. When the residual urine is 25% or less of the total volume voided, the suprapubic catheter can be removed. Patients usually remain hospitalized for two to three days following surgery. They do not routinely receive antibiotics, and they usually experience minimal pain that can be managed with oral analgesics.
Patient Outcomes
P
atients with atonic bladders are uncommon, and discharging patients with suprapubic Foley catheters in place is unusual. On rare occasions, especially in elderly patients with severely atonic bladders, suprapubic catheters may have to be left in as long-term drainage systems. The catheters can be changed in the urologist’s office on a monthly basis. The urologist can easily increase the size of each catheter until a 24 F catheter is in place in the bladder. This provides elderly, debilitated patients who are unable to void despite the TURP with an excellent method of urine drainage. The advantage of a suprapubic catheter is
AUGUST 1993, VOL 58, NO 2
twofold. It makes it unnecessary to remove and replace catheters in patients who are unable to void, especially following a TURP when urethral manipulation could lead to bleeding or distortion of the prostatic fossa. Additionally, long-term drainage of a suprapubic catheter is better than that of a urethral catheter because the incidence of urethritis is minimal and the incidence of epididymitis is much lower. Anecdotal evidence shows that the incidence of bacteriuria may be lower in patients with indwelling suprapubic catheters compared to patients with indwelling urethral Foley catheters. Chronic indwelling urethral Foley catheters cross the prostate as well as the ejaculatory ducts that drain into the prostate. A catheter is a foreign object and eventually will cause bacteria to colonize these areas. Bacteria can cause prostatitis that eventually can travel through the ejaculatory ducts, down the vas, and into the epididymis, creating epididymitis. The advantage of the suprapubic catheter is that it exits the lower abdominal wall and does not cross the prostate. The suprapubic catheter thus has less chance of causing infection. The disadvantages of using a suprapubic punch during surgery and a suprapubic catheter for postoperative care are few. There is some morbidity associated with improper placement of the catheter. Occasionally, transabdominal passage of the trocar causes intestinal injury and peritonitis. The surgeon can avoid this by completely distending the bladder and placing the patient in Trendelenburg’s position before probing for the bladder with the spinal needle. In patients who have had lower abdominal surgery, the surgeon should be careful to hug the symphysis pubis with the trocar system and point the trocar slightly inferiorly and posteriorly. A patient occasionally will have some extravasation of irrigating fluid around the trocar system with some additional suprapubic tenderness after the operation. This usually resolves in one to two days. In rare instances, if the suprapubic catheter remains left indwelling for some time, cellulitis and granuloma may form around the catheter.
AORN JOURNAL
Catheter infection can be controlled with appropriate antibiotic therapy. It is unnecessary to remove the suprapubic catheter because of this problem.
Conclusion
P
lacement of a suprapubic drainage system for both intraoperative and postoperative use does not put any additional burden on the operating room staff, the nursing staff in the PACU, or the nurses on the ward. This procedure actually facilitates postoperative care and makes for a frustration-free TURP. 0 Notes 1. H J Reuter, Atlas of Urologic Endoscopic Surgery, trans R J Kohen and M A Reuter (Philadelphia: W B Saunders Co, 1982); T A Stamey, Monographs in Urology, vol eight no 1 (Princeton, NJ: Custom Publishing Services, 1987); P N Bretan, Jr et al, “Improved continuous flow transurethral prostatectomy,” Journal of Urology (July 1985) 77-80. 2. Reuter, Atlas of Urologic Endoscopic Surgery.
311
AUGUST 1993, VOL 58, NO 2
Transurethra1 Prostate Resection A FRUSTRATION-FREE SURGICAL METHOD David M. Cumes, MD
A
transurethral resection of the prostate (TURP) is performed when patients, usually elderly men with enlarged, noncancerous prostate glands, find urination increasingly difficult as they age. The procedure is indicated if the patient believes that the symptoms (eg, multiple trips to the bathroom during the night, difficulty emptying the bladder) adversely affect his life-style. Surgery also is performed if a urologist discovers signs of upper urinary tract dilation or significant increase in residual urine (ie, above 100 mL). Combining the Reuter suprapubic trocar system and a single-fill bladder evacuator with a nonreturn valve eliminates many frustrations currently associated with TURP. Patients who otherwise would undergo open prostatectomy now can have surgery during which the prostate gland is resected quickly and safely under continuous, low-pressure irrigation.
Complications
S
everal problems can make resecting a large, vascular prostate technically challenging for the urologist and the operating room team. One problem is maintaining a clear field of vision and a low-pressure resection. When using a conventional resectoscope, the repeated filling and emptying of the bladder required to see and resect the prostate prolongs the procedure. If rapid bleeding occurs as the bladder fills and pressure increases, the visual field quickly becomes obscured by the lack of inflow. This is true especially if the 302
patient has a small-capacity bladder. Normal venous pressure usually is 10 to 15 cm of water. Using the conventional surgical method, however, intravesical pressure often reaches 60 to 100 cm of water as the bladder fills. This increases vascular absorption of irrigation fluid through the venous sinuses of the prostate and dilutes the total amount of sodium in the vascular space. This absorption can cause dilutional hyponatremia (ie, TURP syndrome), particularly if the resection time is lengthy. Resection time may increase if the size of the prostate is underestimated. When this happens, the surgeon must decide whether to complete the resection and risk postoperative dilutional hyponatremia or abort the procedure. The TURP syndrome can arise, although to a lesser extent, with continuous-flow resectoscopes. These instruments have been improved technologically and usually provide the surgeon with continuous, unimpeded vision; however, the system can become intermittently plugged with prostatic tissue. This obscures the surgeon’s visual field and increases the patient’s bladder pressure. The suction section of the continuous-flow system resectoscope loop occupies enough space that a 28 F instrument only can accommodate a 26 F resectoscope
David M . Cumes, MD,FACS, FRCS, FCS, is a urologist in private practice in Santa Barbara, Calif. He earned his medical degree from the University of the Witwatersrand Medical School, Johannesburg, South Africa.
AUGUST 194.1, VOL 58. NO 2
AORN JOURNAL
loop. This reduces the size of the cutting loop and decreases efficiency. Repeatedly irrigating the bladder using an Ellick evacuator or a Toomey syringe at the end of a long resection to evacuate prostate chips from the bladder also may prolong the procedure. Resection of a large prostate may require the bladder to be filled and drained several times to clear all the remaining chips. Using a bulb syringe to evacuate chips can allow chips to return to the bladder because of the pumping action of the bulb. The surgical team can overcome these problems, including TURP syndrome, by u s i n g a s u p r a p u b i c trocar system t o achieve unimpeded continuous-flow irrigation under low pressure and using a more efficient bladder evacuator that needs to be filled only once and will retrieve tissue efficiently.
pressure. An experienced surgeon, however, often knows when the holes of the trocar have been occluded with chips and bladder pressure is rising. The most important indication of this is a change in the configuration of the prostate as bladder volume and pressure increase and fill the prostatic urethra with irrigation fluid. The perioperative nurse also should monitor this vent, because fluid dripping out of it may indicate that intravesical pressure is rising. In this case, the surgeon can slide the inner cannula upward and away from the outer cannula. This strips off clinging prostate chips and restores flow when the cannula is reinserted. The top of this cannula is covered with a rubber hood with a hole in the center so that the surgeon can slide the trocar and the inner cannula in place to keep the system watertight.
Suprapubic Trocar
bladder evacuator with a nonreturn valve was developed to eliminate the problem .of evacuating prostate chips from the bladder. Figure 3 shows a single-fill evacuator with a flap valve that prevents chips from returning to the bladder when the rubber bulb is pumped. The reservoir is big enough to accommodate even the largest specimen. The device consists of a glass reservoir, a rubber bulb, and an inset valve system that allows the surgeon to empty the bladder chips after filling the reservoir only once and pumping several times. To fill the evacuator, it is immersed in a basin of sterile water, and all air is removed from it. The valve is inserted into the valve nozzle and the rubber bulb into the bulb nozzle. The evacuator is easier to assemble when all parts are wet. The outlet nozzle of the evacuator is connected by conventional latex tubing to thc appropriate adapter used for the resectoscope. To ensure that all chips are floating free in the bladder for evacuation, the outflow tubing exiting the inner suprapubic cannula needs to be occluded, and the inner cannula should be stripped away from the outer cannula. After surgery, prostate chips are removed from the evacuator by taking it apart. The Reuter system
T
he continuous-flow irrigation technique (ie, inflow irrigation through the resectoscope, outflow irrigation through the suprapubic trocar to speed resection) is not a new concept.' What is new is that the Reuter suprapubic trocar is used postoperatively for inflow irrigation to promote bladder drainage and prevent the formation of clots. The Reuter system uses a trocar and cannula designed in four parts (Fig 1). This system contains the following pieces: a sharp trocar that is removed from the cannula after placement in the bladder, an atraumatic, hollow inner cannula with multiple terminal side holes, through which fluid exits, that replaces the sharp trocar, an outer cannula, through which the trocar and hollow inner cannula pass, and 0 an outer sheath that surrounds the whole system and can be used to insert a Foley catheter into the bladder at the end of the case (Fig 2). The outer cannula of this system has a side vent designed by Reuter to monitor intravesical 304
Bladder Evacuation
A
AUGUST 1993, VOL 58, NO 2
AORN JOURNAL
Fig I . Reuter suprapubic trocar and cannulas.
Fig 2 . Placement of Foley catheter through outer sheath of Reuter system.
Fig 3. Single-fill bladder evacuator with oneway valve system. 305
AUGUST IY91, VOL 58,NO 2
AORN JOURNAL
and the evacuator are nondisposable and easily cleaned, assembled, and disassembled. They can be sterilized by autoclave or gas sterilization, or they can be high-level disinfected.
Preoperative Care
A
patient undergoing TURP usually is admitted to the hospital through the outpatient department. Hospital personnel complete laboratory studies (eg, uric acid test, urine culture, complete blood count, electrocardiogram if the patient is over 40 years of age). The nurse reviews the patient’s chart for consent, a list of allergies, and a medical history and checks the patient’s identification band. The nurse should explain to the patient that he will be put in a lithotomy position during surgery, that an IV will be inserted so that anesthesia personnel can administer antianxiety medications, and that he may receive nasal oxygen. The nurse also should assess the patient’s skin condition and range of hip motion for problems such as arthritis to ensure that the lithotomy position will not be uncomfortable during surgery. Because the genitals will be exposed during the procedure, the nurse should reassure the patient that every effort will be made to preserve privacy and dignity during the perioperative period. If the patient receives spinal anesthesia, the nurse should tell the patient that the surgeon, anesthesia personnel, and nurse will explain the procedure as it progresses and answer any questions the patient has. The surgeon counsels the patient about the possible complications of a TURP (eg, retrograde ejaculation, urethral stricture, total permanent incontinence, impotence). The surgeon also tells the patient that a small instrument known as a trocar cannula will be inserted above the pubic bone and into the bladder to expedite the surgery and that this instrument will be replaced by a catheter after the surgery for postoperative irrigation. Few patients are upset by the prospect of a minor additional procedure, especially after the surgeon explains that postoperative irrigation will prevent clot retention. 306
The setup for this procedure includes 0 the Reuter suprapubic punch cystostomy kit, 0 a 20-gauge spinal needle to locate the bladder after bladder distention, 0 additional latex tubing that attaches to the cannula for siphon or gravity drainage, a 14 F, 10 mL Foley catheter that can be placed through the outer sheath of the Reuter system, 0 3-0 silk on a Keith needle to suture the suprapubic catheter in place after it is inserted into the bladder, and irrigation fluid (eg, sorbitol, glycine) heated to body temperature. Because irrigation is continuous, the perioperative nurse should double the amount of irrigation fluid that is used for a conventional TURP. The additional cost of extra fluid is offset by the increased speed of the resection. This decreases the time the patient spends in the OR, and consequently, the cost of the procedure.
intruoperutive Care conferring with anesthesia personregarding the proposed anesthesia , spinal, general, caudal with suprapubic block), the nurse transports the patient to the cystoscopy room. He or she helps the patient into a comfortable position that permits the administration of anesthesia. After administration of anesthesia, the surgical team positions the patient in a lithotomy position, pads all potential pressure points, and covers the patient’s upper body with warm blankets. The nurse shaves the patient’s suprapubic area and preps this area and the genitals and perineum. The surgeon drapes the patient for a TURP and includes the suprapubic area within the surgical field.
Intruoperative Procedure
T
he surgeon uses a spinal needle to locate and confirm aspiration of irrigation fluid from the bladder before inserting the trocar into the patient’s full bladder through a
AUGUST 1993, VOL 5X, NO 2
AORN JOURNAL
small (ie, 1 cm) suprapubic incision. could cause voiding difficulties and less chance The Reuter system is preassembled for easy of perforation of the capsule. If a perforation bladder insertion. The resectoscope sheath is occurs, extravasation of irrigation fluid usually assembled with an obturator that has a slight is minimal because low-pressure irrigation is curve to it. Using a lubricant, the surgeon used. inserts it into the bladder in a fashion similar to The irrigation fluid should be kept at approximately 30 to 40 cm of water pressure. This a urethral sound. The surgeon also can insert the sheath into the bladder under direct vision pressure is measured by simple manometry, using a 12- to 30-degree lens that allows the and the surgeon uses a centimeter ruler to measurgeon to visually negotiate the sheath into the sure the height of the irrigation fluid bags bladder. He or she then connects the sheath to above the patient’s symphysis pubis. inflow tubing using a small stopcock that Continuous-flow irrigation is achieved by allows fluid to pass through the sheath. The hooking the Reuter inner cannula to convenobturator is removed and replaced by a resectotional latex tubing and allowing the fluid to scope. drain into a stainless steel kick bucket, which is The patient then is placed in Trendelenburg’s emptied as necessary, on the floor. The sound position to keep the puncture site extraperiof fluid dripping into the bucket is a sign that toneal. After the Reuter system is in place, the the surgeon’s continuous-flow irrigation is prosharp trocar is replaced by the blunt inner canceeding correctly. nula with multiple side holes for continuous The surgeon can elevate the outflow irrigation tubing a few inches above the patient’s irrigation (Fig 4). This continuous-flow reseclower abdomen to increase bladder pressure toscope system is very efficient because the and volume slightly. This is useful in cases in irrigation outlet through the Reuter inner canwhich the bladder wall collapses into the bladnula is slightly less than a 14 F, which is larger der neck region and around the cannula as the than what can be used by any self-contained, bladder empties. There is no advantage to concontinuous-flow instrument. necting the outflow irrigation tubing to a sucA continuous, low-pressure resection of the tion device because simple siphon or gravity prostate using this system is possible with little drainage works as well. absorption of irrigation fluid into prostatic At the end of the procedure, the inner three venous sinuses, and clarity of vision is excelcomponents of the Reuter system are removed, lent. In patients with very large glands, addileaving behind the outer sheath. A 14 F Foley tional time may be required to complete the catheter can then be placed through the suprapuresection. The low-pressure system offers bic tract via the outer sheath for postoperative increased safety for these patients. Reuter has reported resecting glands as large as 200 g with this technique.2 Resecting a 100-g gland is well within the range of most experienced urologists and operating room teams. Because the configuration of the prostatic fossa does not vary much during the procedure, anatomical landmarks remain constant (especially in the area of the external sphincter), and this makes resection safer. Using this procedure, there is less Fig 4. Reuter trocar and cannula are placed into the bladder. possibility of leaving an excessive The trocar is removed and the inner cannula inserted in its amount of apical tissue that later place. 307
AORN JOURNAL
continuous-flow irrigation. The flow now is reversed, and irrigation is coming in through the suprapubic tube and exiting the urethral Foley catheter. This minimizes postoperative clot retention. If the urine is clear, the suprapubic catheter usually is removed the next day. It can remain in a patient who has an atonic or a reflexic bladder detrusor and is expected to have residual urine despite the TURP. This patient can monitor his residual urine at home using the suprapubic tube until the amount of urine is sufficiently low enough to have the tube removed.
Postoperative Care, Teaching
F
ollowing surgery, the patient is taken to the postanesthesia care unit (PACU), where irrigation fluid (ie, glycine, sorbitol, saline) is instilled through the suprapubic Foley catheter and drained out of the urethral Foley catheter. Manual irrigation can be done, but if a “continuous flow to keep clear” policy is used, clots rarely form, and a clear, patent catheter irrigation is assured. The rate of irrigation can vary according to the severity of the bleeding. A slow, steady drip is usual. It is important that the irrigation system is not allowed to run dry, because clots can form in the bladder, rendering the Reuter irrigation system useless. Irrigation fluid should not be hung more than 12 to 24 inches above the bed to ensure that bladder pressure is not too high if the urethral catheter becomes blocked. Depending on the surgeon’s orders and the color of the urine, the nurse can clamp or remove the suprapubic catheter the day after surgery. If the nurse clamps the catheter, he or she can leave the sterile irrigation system at the bedside for possible reuse. In some instances in which the patient is known to be retaining considerable residual urine and may possibly have an atonic bladder, the suprapubic catheter can be left in until after the urethral catheter is removed. This way, if the patient fails to void, he can be discharged from the hospital safely with a suprapubic catheter in place and with instructions on how to manage it.
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Postoperative teaching should begin in the PACU, where the nurse explains the irrigation procedure the patient is undergoing and the importance of it. Additional patient teaching in the unit should be given to any patient who is being discharged with a suprapubic catheter in place. The nurse explains to the patient how to manage his voiding regime at home using the suprapubic catheter. The patient should be shown how to unclamp the catheter for a period of five minutes after voiding to monitor the residual urine and how to chart the amount of urine voided. The nurse also should explain how the catheter can be repeatedly reclamped during the day or, if necessary, left undamped during the night. The patient should be taught how to change the suprapubic dressing every other day. For a patient incapable of understanding or perfoming the care required, a visiting nurse can see the patient daily to supervise dressing changes and ensure that the patient’s voiding regime is proceeding correctly. When the residual urine is 25% or less of the total volume voided, the suprapubic catheter can be removed. Patients usually remain hospitalized for two to three days following surgery. They do not routinely receive antibiotics, and they usually experience minimal pain that can be managed with oral analgesics.
Patient Outcomes
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atients with atonic bladders are uncommon, and discharging patients with suprapubic Foley catheters in place is unusual. On rare occasions, especially in elderly patients with severely atonic bladders, suprapubic catheters may have to be left in as long-term drainage systems. The catheters can be changed in the urologist’s office on a monthly basis. The urologist can easily increase the size of each catheter until a 24 F catheter is in place in the bladder. This provides elderly, debilitated patients who are unable to void despite the TURP with an excellent method of urine drainage. The advantage of a suprapubic catheter is
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twofold. It makes it unnecessary to remove and replace catheters in patients who are unable to void, especially following a TURP when urethral manipulation could lead to bleeding or distortion of the prostatic fossa. Additionally, long-term drainage of a suprapubic catheter is better than that of a urethral catheter because the incidence of urethritis is minimal and the incidence of epididymitis is much lower. Anecdotal evidence shows that the incidence of bacteriuria may be lower in patients with indwelling suprapubic catheters compared to patients with indwelling urethral Foley catheters. Chronic indwelling urethral Foley catheters cross the prostate as well as the ejaculatory ducts that drain into the prostate. A catheter is a foreign object and eventually will cause bacteria to colonize these areas. Bacteria can cause prostatitis that eventually can travel through the ejaculatory ducts, down the vas, and into the epididymis, creating epididymitis. The advantage of the suprapubic catheter is that it exits the lower abdominal wall and does not cross the prostate. The suprapubic catheter thus has less chance of causing infection. The disadvantages of using a suprapubic punch during surgery and a suprapubic catheter for postoperative care are few. There is some morbidity associated with improper placement of the catheter. Occasionally, transabdominal passage of the trocar causes intestinal injury and peritonitis. The surgeon can avoid this by completely distending the bladder and placing the patient in Trendelenburg’s position before probing for the bladder with the spinal needle. In patients who have had lower abdominal surgery, the surgeon should be careful to hug the symphysis pubis with the trocar system and point the trocar slightly inferiorly and posteriorly. A patient occasionally will have some extravasation of irrigating fluid around the trocar system with some additional suprapubic tenderness after the operation. This usually resolves in one to two days. In rare instances, if the suprapubic catheter remains left indwelling for some time, cellulitis and granuloma may form around the catheter.
AORN JOURNAL
Catheter infection can be controlled with appropriate antibiotic therapy. It is unnecessary to remove the suprapubic catheter because of this problem.
Conclusion
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lacement of a suprapubic drainage system for both intraoperative and postoperative use does not put any additional burden on the operating room staff, the nursing staff in the PACU, or the nurses on the ward. This procedure actually facilitates postoperative care and makes for a frustration-free TURP. 0 Notes 1. H J Reuter, Atlas of Urologic Endoscopic Surgery, trans R J Kohen and M A Reuter (Philadelphia: W B Saunders Co, 1982); T A Stamey, Monographs in Urology, vol eight no 1 (Princeton, NJ: Custom Publishing Services, 1987); P N Bretan, Jr et al, “Improved continuous flow transurethral prostatectomy,” Journal of Urology (July 1985) 77-80. 2. Reuter, Atlas of Urologic Endoscopic Surgery.
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