Pacemaker failure during transurethral resection of the prostate

Abstract

SummaryA case is described of the intra-operative failure of an implanted pacemaker during transurethral prostatic resection caused by a diathermy-related increase in capture threshold which coincided with massive haemorrhage from the operative site. Key wordsEquipment; pacemakers, diathermy. Complications; pacemaker failure. Surgery; prostatectomy. Haemorrhage.There are more than 25000 patients in the United Kingdom with an implanted permanent pacemaker [I]. It is likely that this number will steadily increase, so that pacemaker-dependent patients will present for surgery more frequently. Although it is generally assumed that modern pacemakers are immune from the effects of surgical diathermy, problems may still occur. This report describes a patient in whom the use of unipolar diathermy for transurethral resection of the prostate (TURP) was associated with pacemaker failure. Case historyA 70-year-old man with a history of benign prostatic hypertrophy was admitted for elective transurethral prostatic resection. Three years prior to surgery he had developed complete heart block resulting in syncopal episodes for which a Biotronik Diplos 05 pacemaker had been implanted. This is a modern programmable device designed for atrial and ventricular pacing and it was programmed accordingly in the D D D mode (dual chamber sensing and pacing). It had been checked 6 months before surgery when it had been noticed that the ventricular capture threshold was higher than the lower output setting of the pulse generator (2.5 volts) so that, in order to achieve ventricular stimulation, the device had to be set on its maximum output of 5.0 volts. The threshold of the atrial lead was not elevated.The patient was taking enalapril 5 mg once daily for hypertension and was otherwise well. He was seen preoperatively by the cardiologists, who changed his pacemaker from D D D mode to VVI (on-demand ventricular pacing). His pre-operative electrocardiogram (ECG) showed pacemaker-generated potentials before each ventricular complex, implying that ventricular contractions were pacemaker-dependent. Two years previously he had undergone an uneventful T U R P under spinal anaesthesia with the existing pacemaker in place and he was keen to have the same anaesthetic technique on this occasion.He was premedicated with temazepam 10 mg and on arrival in the anaesthetic room a 14-G cannula was inserted under local anaesthesia, after which his circulation was volume preloaded with 1 I of Ringer lactate solution. He was monitored with continuous ECG, pulse oximetry and automatic noninvasive sphygmomanometry. A 26-G spinal needle was inserted into the L,, interspace, after infiltration with local anaesthetic, and isobaric 0.5% bupivacaine 3.5 ml was injected into the subarachnoid space. This produced a dense sensory and motor block to T, in 10 min and a decrease in blood pressure from 110/70 mmHg to 98/65 mmHg. He was then moved into the operating theatre where he was given oxygen 5 1.min-I by face mask and sedated with midazolam 2.5 mg, which produced no ...

Comparative randomized study on the efficaciousness of endoscopic bipolar prostate resection versus monopolar resection technique. 3 year follow-up

“…Contemporary TURP uses a monopolar electrocautery system in which the current passes through the patient' s body: from the active electrode, placed on the resectoscope, towards the return plate, normally placed on the patient' s leg. This has several disadvantages such as heating of deeper tissue, nervous or muscle stimulation and possible malfunction of cardiac pace-maker (6). Resectoscopes using bipolar electrocautery offer an alternative with active and return electrode placed on the same axis on the resectoscope using high current locally but with limited negative effects at distance.…”

Bipolar electrosurgery for benign prostatic hyperplasia: transurethral electrovaporization and resection of the prostate

“…Twelve had prostates larger than 50 cm 3 cohort of large glands was 73 min (25-120 min) and median dry resection weight was 36 g (20-62 g), giving a median tissue removal rate of 0.49 g/min. We have found that the visualization of endoscopic landmarks such as the capsule, bladder neck and apex are excellent, and although the gap between the double loop was best seen with a 308 lens, the extremes of electrode excursion were better seen using a 128 lens.…”

“…Finally, there is the issue of possible malfunction of certain types of pacemaker [3]. Prostate size and vascularity are perceived to be the two most important factors that have impact on the morbidity of monopolar TURP.…”

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