Anaesthetic technique

TURP is frequently performed in very elderly men. These patients have a high incidence of concomitant disease, especially of the respiratory tract and cardiovascular system. There is a risk of septicaemia in those patients with urinary tract infection, stones in the bladder or an indwelling catheter. These patients should have intravenous antibiotics, as should any patient with a joint prosthesis or valvular heart disease.

Spinal anaesthesia is useful particularly for patients with significant respiratory disease, although coughing during the procedure makes surgery difficult. An additional advantage of spinal anaesthesia is postoperative analgesia. Frequendy, the worst discomfort has settled by the time the anaesthesia has regressed.

One of the biggest concerns with spinal anaesthesia is hypotension caused by sympathetic blockade, as blood loss may result in precipitate decreases in arterial pressure because of lack of compensatory vasoconstriction. There is often additional hypotension when the legs are lowered at the end of surgery. Reductions in arterial pressure may be treated by fluid or vasoconstrictors; ephedrine is commonly used, but produces tachycardia.

Spinal anaesthesia has traditionally not been used for patients with ischaemic heart disease. However, the incidence of silent myocardial ischaemia is the same whether general anaesthesia or spinal anaesthesia is used. It appears to be related to the severity of the pre-existing cardiac disease. There is some evidence that the increase in cardiac pre- and afterload when the spinal anaesthetic regresses can induce ischaemia.

A dose of heavy bupivacaine 0.5%, sufficient to produce a block to the eighth thoracic nerve, is needed; this is generally about 2.7-3 ml. Postdural puncture headache is less common in elderly men than in other groups of patients. The incidence is least with the use of pencil-point needles. The choice between spinal and general anaesthesia depends on the patient's preoperative condition and the preferences of both the patient and the anaesthetist. The usual absolute contraindications to spinal analgesia (anticoagulants, clotting disorders and local sepsis) apply. Any method of general anaesthesia is suitable, depending on the patient's medical condition. A caudal injection of local anaesthetic may be useful for postoperative pain.

Careful monitoring of arterial pressure and drainage from the catheter is necessary after surgery and the possibility of TURP syndrome should be borne in mind for 12 h or so, especially if the resection was prolonged.

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