Many anesthesiologists and urologists consider TURP to be a simpler and safer procedure than open prostatectomy; however, no differences have been reported in mortality rates between patients who have undergone monopolar TURP and those who have undergone retropubic or suprapubic prostatectomy. With recent advances in TURP, including bipolar and laser, the overall mortality has declined to 0.10%.

TURP patients often are elderly and suffer from cardiac, pulmonary, vascular, and endocrine disorders. The incidence of cardiac disease is 67%; cardiovascular disease, 50%; abnormal electrocardiogram (ECG), 77%; chronic obstructive pulmonary disease, 29%; and diabetes mellitus, 8%. Occasionally, these patients are dehydrated and depleted of essential electrolytes because of long-term diuretic therapy and restricted fluid intake.

Yes, a history of prior MI or ischemic heart disease is considered an intermediate predictor of perioperative cardiac morbidity. Unstable coronary syndrome, severe angina, or recent MI indicates major clinical risks. Also see Chapter 14, section A.1.

An acute MI (7 days or less), or a recent MI (more than 7 days but less than or equal to 1 month), is considered an event requiring evaluation to determine if there is residual myocardium at risk. The stratification is based on the presentation of the disease; patients with active ischemia are at highest risk. Therefore, it is advocated to wait at least 6 weeks after an MI before elective surgery is performed, although no evidence supports this precaution. Also see Chapter 14, section A.7.

The American College of Cardiology/American Heart Association guidelines suggest a stepwise approach that takes into account the clinical markers of cardiac risk, functional capacity, and surgery risk. The patient’s medical history should focus on information about previous cardiac evaluations and interventions (coronary stent and automatic implantable cardioverter-defibrillator [AICD] placement). During physical examination of all organ systems, attention should be paid to the circulatory functions, especially in the presence of active cardiac conditions such as unstable coronary syndromes, decompensated congestive heart failure (CHF), significant arrhythmias, or severe valvular disease. The functional capacity of the patient is best evaluated by the activity history. Minimally, a routine ECG and chest radiograph should be obtained. If the patient presents signs and symptoms of CHF, angina, syncope, or arrhythmia, further cardiac testing should be considered if the results would impact the patient’s management. Traditional indications for coronary angiography apply regardless of future surgical interventions. Also see Chapter 14, section B.1.

Studies suggest that patients who survive a non-Q-wave infarction are at greater risk of reinfarction than those who survive a Q-wave infarction.

Antianginal agents and β-blockers should be continued until the day of the surgery to prevent rebound hypertension and tachycardia that may result from sudden withdrawal of these drugs. Patients taking ACE inhibitors or angiotensin II receptor antagonists might present intraoperative hypotension due to a decrease of intravascular volume. It has been suggested that ACE inhibitors or angiotensin II receptor antagonists be withheld on the day before surgery and restarted after adequate intravascular volume has been established in order to avoid renal dysfunction.

Patients undergoing surgery with an ICD need to have the device interrogated prior to surgery. Recent and accurate information should be collected about the device’s features, the date of insertion, and the indication for placement. On the day of surgery, the device should be assessed for settings, pacer dependency, baseline rhythm and rate, tachyarrhythmia history, effect of magnet, and battery status.

In the event of potential electromagnetic interference, the antitachycardia algorithm of the ICD should be turned off and external cardioversion paddles should be placed until the device is reset to its initial functions after the procedure. Also see Chapter 8, sections B and C.

PCI is a common procedure in the United States. Coronary stent placement was introduced in order to reduce the risk of thrombosis, dissection, and restenosis after angioplasty. Two types of coronary stents have been used: bare metal stents (BMS) and drug-eluting stents (DES). Two types of DES—sirolimus and paclitaxel-eluting stents—have been used extensively to reduce the neointimal hyperplasic reaction seen with the use of BMS, which is the main cause of restenosis. Evidence suggests that DES delay the endothelialization of coronary stent struts. Patients with DES are at risk for late thrombosis if the antiplatelet therapy is prematurely interrupted.

Therapy with thienopyridines (ticlopidine or clopidogrel) and aspirin is recommended for 2 to 4 weeks after dilatation without stenting; elective surgery should be postponed for 2 to 4 weeks. After BMS, antiplatelet therapy for 4 to 6 weeks is recommended; elective surgery should be postponed for 4 to 6 weeks. After the implantation of DES, at least 12 months of antiplatelet therapy is required; elective surgery should be delayed for 12 months. Of note, newer DES may not require the same duration of dual therapy, and in these cases, consultation with the patient’s cardiologist can help guide the timing of discontinuation. In patients with an indication for PCI and a projected need for surgery within the next 12 months, a balloon angioplasty or BMS may be considered. Daily aspirin should be continued during the
perioperative period. Continuation of aspirin is not a contraindication to neuraxial anesthesia. For more details, see Chapter 10, section A.5 and Figure 10.1 and Chapter 14, section A.8.

The results of studies on the risk of surgical bleeding with aspirin are inconsistent. In Burger’s review and meta-analysis (aspirin withdrawal vs. low-dose aspirin), the low-dose group’s relative risk of bleeding increased by a factor of 1.5, but there was no increase in bleeding complications or in perioperative mortality, with the possible exceptions of intracranial surgery and prostatectomy. Studies with ticlopidine or clopidogrel are also contradictory. Although some data support increased risk of major perioperative bleeding with dual-antiplatelet therapy (0.4% to 1%), there is no consensus regarding withholding thienopyridines. The risk of perioperative bleeding must be balanced against protection from a coronary event.

The preoperative evaluation of patients with coronary stents should include information regarding the date of stent placement, the coronary anatomy before the intervention, the type of coronary stent, the localization of the intervention, complications (if any) during the procedure, the residual anatomy after the intervention (e.g., possibility of incomplete revascularization), and the antiplatelet strategy. Multidisciplinary discussions regarding how the risk of bleeding compares with the risk of coronary stent thrombosis are strongly encouraged. The most recently published Practice Alert indicates, “Elective surgery with a significant risk of bleeding should be postponed until the recommended course of thienopyridine therapy has been completed.” If surgery must be performed and if thienopyridine therapy must be interrupted (surgery with high risk of perioperative bleeding), aspirin should be continued and thienopyridine should be readministered as soon as possible after the procedure. Bridge therapies have been proposed for patients who undergo surgical procedures, but this practice has not been shown to reduce the risk of thrombosis. Currently, continuing double antiplatelet therapy is recommended in patients with DES for surgery with minor or intermediate risk of perioperative bleeding. A careful “case-by-case” consideration is advisable. Discussion between the anesthesiologist, the surgeon, and the treating cardiologist is recommended. For more details, see Chapter 10, section A.5 and Figure 10.1.

The following monitors would be used for this patient:

Regional anesthesia has advantages for patients undergoing monopolar electrode TURP for the following reasons: