IAN SMITH, ANURAG GOLASH & CLARE HAMMOND

(This article was originally published in the Journal of One-Day Surgery Vol. 23 No. 2, 2013. It was Number 4 in the 'How i Do It' series, updated in 2020)

Patient Selection

• Benign prostatic hypertrophy or carcinoma of prostate

• Small to moderate prostate (<40 g)

• Contraindicated if known large middle lobe or raised PSA

• Typically quite an elderly population with significant co-morbidities, but most will be acceptable provided spinal anaesthesia is not contraindicated.

Anaesthetic Techniques

• Most patients are managed using a low dose spinal technique

• We use 6–7 mg hyperbaric bupivacaine with 10 μg fentanyl added made up to 3 ml with saline

• Patients listen to their choice of music. Sedation is rarely needed, propofol (10–20 mg) can be used for especially anxious patients. We only add oxygen if sedation is used

• All patients get 240 mg of gentamicin and 1 litre of Hartmann’s solution

• General anaesthesia with spontaneous ventilation through a LMA is an acceptable alternative where spinal anaesthesia is not possible

Surgical Technique

• A standard laser prostatectomy technique with saline irrigation is used, this is not modified for day surgery

• 16 French gauge 2 way catheter at the end of surgery (no irrigation)

• We remove the catheter at 2–4 hours when the spinal has worn off if the urine is clear

• If the urine is not clear or if trial without catheter (TWOC) fails, patients go home with a catheter for further TWOC at 2 days by district nurse

Peri-operative Analgesia

• Preoperative oral slow-release ibuprofen, 1600 mg

• Postoperative regular paracetamol and codeine, if needed

• With spinal anaesthesia, most patients have little postoperative pain

Take Home Medication

• Slow release ibuprofen for 3 days

• Co-amoxyclav for 3 days

Organisational issues

• Pre operative brief to include PACU staff member as anticipation of individual patient issues hugely valuable in this patient group

• Day Surgical Unit theatre team experienced in major gynaecological laparoscopic cases with skills that enable conversion to open procedures – staff rotate to main theatres if unfamiliar with open cases.

• Urinary catheter throughout procedure but removed in theatre prior to reversal of anaesthesia

Common Pitfalls

• Excessive talking (or laughing or singing!) by the patient can distort the surgical view

• Take great care to minimise intraoperative bleeding, especially at the start of the procedure. Avoid excessive movements of the resectoscope

• Postoperative dysuria is common, antibiotics probably do not prevent this but may deter the patient from troubling their GP!

Anticipated day case rates

• 90%