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TURP: Transurethral Resection of the Prostate (1/2)

Transurethral Resection of the Prostate (1/2): Indications, Contraindications, Technique
Transurethral Resection of the Prostate (2/2): Complications

Review literature: (Alschibaja et al, 2005).

Indications for transurethral resection of the prostate (TURP)

Benign prostatic hyperplasia with symptoms should be treated with medication, until complications make surgery necessary:

Recurrent urinary retention
Recurrent urinary tract infection
Recurrent hematuria
Bladder stones
Renal insufficiency due to insufficient bladder emptying
Large diverticula of the bladder

The most common indication for TURP are moderate to severe symptoms of prostatic hyperplasia, which cannot be alleviated with medication (see section medical treatment of BPH and Alpha-blockers).

Contraindications for Transurethral Resection of the Prostate (TURP)

Large prostate adenomas (> 75 ml) should be treated with suprapubic simple prostatectomy
Need for bladder diverticula surgery: consider open prostatectomy at lower prostate gland volumes
Bladder stones: consider open prostatectomy depending on prostate volume and stone burden
Complex urethral disease like repaired hypospadia or repaired urethral stricture disease
Inguinal hernia: consider open prostatectomy and hernia repair at the same time
Contraindications for a lithotomy position
Low life expectancy
Coagulopathy
Untreated urinary tract infection

Surgical Technique of the Transurethral Resection of the Prostate (TURP)

Reducing the risk of bleeding

The bleeding during TURP may be reduced by a medication with finasteride or dutasteride. The effect is based on the reduction of vessel density, but can only be expected after several months lasting therapy.

Anesthesia for TURP

Spinal anesthesia or general anesthesia is recommended. The spinal anesthesia offers theoretical advantages in the initial postoperative period: the patient is immobilized, manipulations with the catheter are possible without pain and there is less pressing and coughing after surgery. Randomized studies have found no difference in bleeding volume.

Perioperative antibiotic prophylaxis

Several randomized studies have found benefits for the administration of a perioperative antibiotic prophylaxis. Dosage: e.g. ciprofloxacin 500 mg p.o. 1-0-1. Patients with risk factors for a urinary tract infection (diabetes, bladder stones and preoperative bladder catheter) benefit especially from an antibiotic prophylaxis. A perioperative antibiotic prophylaxis reduces postoperative urinary tract infections, fever and may reduce the likelihood for urethral strictures.

Preoperative Preparations

The patient is placed in lithotomy position. Suprapubic shaving. Disinfection of the external genitalia, the lower abdomen and the perineum. Sterile draping with rectal shield.

Cystoscopy

Check for the width of the urethra, prostate size and absence of bladder stones. A suprapubic bladder catheter with at least 14 CH size is inserted, to allow irrigation during the procedure.

Internal Urethrotomy

24 CH instruments normally can be inserted through the urethra without problems and should be used for resection of even large glands. Short distance urethral strictures are treated by internal urethrotomy with direct vision. However, if the anterior urethra is too narrow to accommodate the instrument, a perineal urethrostomy can be performed to insert the instrument. As an alternative, blind urethrotomy over the narrow segment of the urethra may be performed. With larger instruments (28 CH), prophylactic blind urethrotomy was recommended to prevent ischemic damage and consecutive urethral stricture.

Resectoscope:

A resectoscope is a combination of a cystoscope and electrosurgical instrument, which enables the resection of the prostate with an electrical activated wire loop [figure resectoscope]. Continuess irrigation is necessary due to the bleeding of the prostate during the procedure. In low pressure resection, the irrigation fluid is drained via a suprapubic trokar. Alternatively, a two-channel resectoscope can be used, one channel for irrigation and the other channel for the drainage. Disadvantages are however the diameter of the instrument and less reliable drainage of the irrigation fluid. .


Figure resectoscope: a resectoscope for TURP consists of an optik and working element with wire loop (upper left figure) und and the sheat with obturator (lower left figure). With the help of the working element, the wire loop can be moved (right figure).

Electrocautery

In standard TURP monopolar current is used, with different programs for cutting and coagulation, comparable to open surgery. The coagulation effect is produced by the current flow from the resection loop through the prostate tissue to the return electrode. The irrigation solution used in transurethral resection with monopolar current must be salt-free to prevent current flow through the irrigation fluid. The salt-free irrigation fluid harbors a risk for a TUR syndrome, if large amounts of fluid enters the circulation (see below).

It is important to avoid unnecessarily high current power, as collateral damage on the sphincter of the urethra and at the N. cavernous otherwise become possible. The padding of the patient must be kept dry to prevent burns. Bipolar resection is a good alternative to monopolar TURP, for which normal saline irrigation solution can be used.

Different wire loops and electrodes:

Various wire loops and electrodes have been developed to improve cutting, coagulation and vaporization. Technical variations are thicker loops (band loop), rollerballs, groved vaporization roller or Collins knife electrodes [figure different resection electrodes].


Different resection electrodes (from right to left): standard wire loop, rollerball electrode, vaporization roller electrode, thick look vor vaporization, Collins knife electrode for TUIP or bladder neck incision.

Resection Technique (Mauermayer, 1985)

First, the middle lobe is resected and an excavation between five and seven o'clock up to the surgical capsule is formed. After that, now with good irrigation speed made possible, the side lobes and ventral parts of the gland are resected. The apical parts of gland are resected last. [fig prostate resection (TURP)].

fig. TURP transurethral resection of the prostate in BPH

TURP:
Top left: View from the verumontanum to the bladder neck before the resection of a small obstructive prostate. The resection loop is positioned at six o'clock.
Top right: initial excavation between five and seven o'clock up to the surgical capsule.
Bottom left: resection of the left lobe.
Bottom right: View from the verumontanum to the bladder neck after resection.

Resection Technique (Nesbit, 1951)

The resection starts at twelve o'clock up to the surgical capsule. Next, the ventral portions of the prostate gland are resected until nine o'clock and three o'clock. The resection of the posterior quadrants are the next step, the apical parts of gland are resected last.

Apical Resection

The apical resection is the most important part for the success of the prostate resection. An insufficient apical resection does not remove the obstruction; on the other hand, the external sphincter of the bladder is in close anatomical proximity and is threatened by injury.

The anatomical land mark for the apical resection is the seminal colliculus (verumontanum). The adenoma is removed preserving the verumontanum. The resection starts at the six o'clock position (with the verumontanum in sight) and is carried out in a circular manner. An unintentional slippage of the resectoscope during resection has to be avoided or damage to the sphincter can easily occur. This is especially true for the resection at the twelve o'clock position, as the verumontanum cannot be seen.

Removal of the Resection Chips

Using a bladder syringe or Ellik-Evacuator, all resection chips should be removed from the bladder. This instrument should be raised (stand up!), so that the sheat moves in the direction of the trigone of the bladder. The cystoscopic control of the complete removal avoids postoperative problems like urinary retention or chronic infections.

Continuous Irrigation Catheter

After the resection and removal of all resection chips, a 20–24 CH irrigation catheter is introduced. The balloon is inflated with at least 20 ml and is positioned in the prostatic fossa. Venous bleeding can be controlled by increasing the balloon inflation (maximum additional 1 ml per 1 gram resected tissue) and/or by slight traction with the catheter.

Postoperative Management after transurethral resection of the prostate (TURP)

Continuous irrigation for 12–24 h
Removal of the catheter after 2–3 days
Control of micturition with help of the suprapubic catheter

Urologic Surgery

Index

TURP (2/2)

Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

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References

Alschibaja u.a. 2005 ALSCHIBAJA, M. ; MAY, F. ; TREIBER, U. ; PAUL, R. ; HARTUNG, R.:: [Transurethral resection for benign prostatic hyperplasia current developments].
In: Urologe A
44 (2005), Nr. 5, S. 499–504
Mauermayer 1985 MAUERMAYER, W.:: [Operative complications in transurethral operations: causes and prevention].
In: Urologe A
24 (1985), Nr. 4, S. 180–3
Nesbit 1951 NESBIT, R. M.:: Transurethral prostatic resection: a discussion of some principles and problems.
In: J Urol
66 (1951), Nr. 3, S. 362–72

Deutsche Version: Transurethrale Resektion der Prostata (TURP)

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