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

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

Review literature: (Alschibaja et al, 2005).

Intraoperative Complications of TURP

Bleeding

Arterial bleeding should be stopped using electrocautery by the end of the operation. New arterial bleedings in the postoperative course require repeated endoscopic hemostasis.

Venous bleeding is often difficult to be stopped by electrocautery. Venous bleedings can be controlled with the catheter: 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. Alternatively, the catheter balloon is positioned in the bladder, inflated to 50–100 ml and pulled against the bladder neck with slight traction.

Bleeding requiring transfusion should occur very rarely, transfusion rates around 4%.

Perforation of the Prostatic Capsule

A too deep resection can result in perforation of the prostate capsule. Extravasation of the irrigation fluid causes nausea, vomiting, tense abdomen, lower abdomen and back pain despite intraoperative spinal anesthesia. The development of a TUR syndrome is likely (see below).

TUR Syndrome

The intrusion of salt-free irrigation fluid in open veins or perforation of the prostate capsule can cause a volume overload and dilutional hyponatremia (<125 mmol/l) of the patient.

Signs and symptoms of the TUR syndrome:

Signs and symptoms of a TUR syndrome are confusion, nausea and vomiting, arterial hypertension, bradycardia, pulmonary edema and impaired vision. Risk factors for a TUR syndrome are a prostate volume over 45 ml, resection time over 90 min, height of the irrigation fluid by the patient over 70 cm.

Diagnosis and therapy of the TUR syndrome:

Early detection of the TUR syndrome is possible with intraoperative sodium controls (venous blood gas analysis). In case of clinical suspicion of a TUR syndrome, furosemide is given (20–40 mg i.v.). It is important to quickly end the operation and to reduce the height of the irrigation fluid by the patient during coagulation. With proven hyponatremia, additionally hypertonic NaCl solution is infused slowly. Depending on the severity of the TUR syndrome, intensive care monitoring is necessary.

Injury to Adjacent Organs

• Injury to the external sphincter of the bladder resulting in stress urinary incontinence
• Excessive resection at six o'clock, especially with a large middle lobe, can result in undermining of the bladder neck
• Injury to the trigone of the bladder and ureter ostium
• Very rarely perforation into the rectum

Postoperative Complications of TURP

Retrograde Ejaculation

Retrograde Ejaculation occurs in 60–90% after transurethral resection of the prostate.

Urinary Tract Infections

The cause for postoperative urinary tract infections is not only an ascending catheter infection, but also the (already existing) bacterial colonization of the prostate. A perioperative antibiotic prophylaxis reduces the likelihood of infectious complications. An epididymitis occurs in 2%.

Micturition

Urinary incontinence (up to 10%), mostly mild and self limiting. Persistent urinary retention, 2.5% are discharged from the hospital with catheter.

Bladder Neck Stricture

Bladder Neck Stricture in 2–10%. Risk factors are a prostate volume, missing incision of the bladder neck, blood transfusions and poor micturition after resection.

Urethral Stricture

Urethral stricture in up to 10%; they can be avoided with a thin resection sheat (24 CH), limiting the time of the transurethral catheter and applying prophylactic antibiotics.

Cardiac Complications

Myocardial infarction in 1%, perioperative mortality in 0.2%.

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)