Dr. med. Dirk Manski

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TURP: Indications and Technique of Transurethral Resection of the Prostate

Transurethral resection of the prostate (TURP) is the endoscopic removal of prostate tissue using an electrified wire loop (Alschibaja et al., 2005). TURP is used for a maximum prostate gland size of 75–120 ml. Despite many endoscopic alternatives, TURP is the most commonly performed procedure for the treatment of benign prostatic hyperplasia (BPH)

Technique of transurethral resection of the prostate: with kind permission, Dr. J. Schönebeck, Ljungby, Sweden.
figure technique of TURP transurethral resection of the prostate

Indications for transurethral resection of the prostate (TURP)

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

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

Principle of TURP: transurethral resection of the prostate adenoma while sparing the prostate capsule, verumontanum, and external sphincter.
figure Principle of TURP

Contraindications for Transurethral Resection of the Prostate (TURP)

Low life expectancy, coagulation disorders, urinary tract infection. Consider simple prostatectomy for very large adenomas (> 75–120 ml), urinary bladder diverticula requiring surgery, urinary bladder stones, complex urethral disease (after hypospadias surgery), and contraindication for lithotomy position.

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

Reducing the risk of bleeding

The bleeding during TURP may be reduced by medication with finasteride or dutasteride. The effect is based on lowering microvessel density; the result will become significant after one to several months of 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 trials found benefits for perioperative antibiotic prophylaxis using cephalosporins or aminopenicillins with penicillinase inhibitors. In particular, patients with risk factors for urinary tract infection benefit (diabetes, urinary bladder stones, urinary retention with catheter). Perioperative antibiotics reduce the rate of postoperative urinary tract infections and fever and may reduce the risk of urethral strictures.

Intraoperative preparations:

Lithotomy positioning, suprapubic shaving if necessary, disinfection of external genitals, lower abdomen, and perineum, sterile draping with rectal shield, provision of body-warm irrigation solution.


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 usually fit through the urethra without problems and should be used to resect 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.

figure resectoscope for TURP
Resectoscope: a resectoscope for TURP consists of an optic and working element with a wire loop (upper instrument) and the sheath with an obturator (lower instrument).

figure resectoscope for TURP
Resectoscope: with the help of the working element, the wire loop can be moved.


A resectoscope is a combination of a cystoscope and an electrosurgical instrument, which enables the resection of the prostate with an electrically activated wire loop [figure resectoscope]. Continuous irrigation is necessary for endoscopic vision impaired by the bleeding of the prostate during the procedure. In low-pressure resection, the irrigation fluid is drained via a suprapubic trocar. A two-channel resectoscope is an alternative, with one channel for irrigation and the other for drainage. Disadvantages are, however, the diameter of the instrument and less reliable drainage of the irrigation fluid.


Monopolar current is used in standard TURP, with different cutting and coagulation programs 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 TUR syndrome if large amounts of fluid enter the circulation (see below).

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

It is essential to avoid unnecessarily high current power, as collateral damage to the sphincter of the urethra and the cavernous nerve is possible. The padding of the patient must be kept dry to prevent burns. Bipolar resection with isotonic saline irrigation is an excellent alternative to monopolar TURP.

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, grooved vaporization roller, or Collins knife electrodes [figure different resection electrodes].

Mauermayer Resection Technique

The middle lobe is resected, and a channel between the five and seven o'clock positions is formed at the prostatic floor. After that, now, with good irrigation conditions, the side lobes and ventral parts of the gland are resected. The apical region of the gland is resected last [fig prostate resection (TURP)] (Mauermayer, 1985).

figure TURP schematic view from the surgeon's perspective
Transurethral resection of the prostate, schematic view from the surgeon's perspective.

Nesbit Resection Technique

The resection starts at the twelve o'clock position until the surgical capsule. Next, the ventral portions of the prostate gland are resected until nine o'clock and three o'clock positions. The resection of the posterior quadrants is the next step, and the apical parts of the gland are resected last (Nesbit, 1951).

Apical Resection

The apical resection is the most critical step for the success of 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 may be injured by excessive apical resection.

The anatomical landmark 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 circularly. An unintentional slippage of the resectoscope during resection has to be avoided, or damage to the sphincter can quickly occur. This is especially true for the resection at the twelve o'clock position, as the verumontanum is not in sight.

Ejaculation-preserving TURP:

The preservation of para-collicular tissue (minimum 10 mm laterally and proximally of the colliculus seminalis) is essential to avoid post-operative retrograde ejaculation. The resection of the middle and lateral lobes is comparable to standard TURP. Still, a deep resection between the bladder neck and para-collicular tissue between the 5 and 7 o'clock position should be avoided to spare the posterior longitudinal musculature of the urethra (Musculus ejaculatorius).

Removal of the Resection Chips

Using a bladder syringe or Ellik-Evacuator, all resection chips should be removed from the bladder. The instrument should be raised (stand up!) so that the shaft moves in the direction of the trigone of the bladder. The cystoscopic control of the complete removal avoids postoperative problems like catheter blockage, urinary retention or 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. Increased balloon inflation can control venous bleeding (maximum additional 1 ml per 1 gram resected tissue). The bladder is an alternative position for the catheter balloon (50--80 ml balloon inflation). Bleeding is controlled with a slight traction on the catheter, which pulls the catheter balloon against the bladder neck.

Postoperative Management after transurethral resection of the prostate (TURP)

Intraoperative Complications of TURP


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; it is better managed with the irrigation catheter balloon positioned in the prostatic fossa or bladder (see above the placement of the catheter). Bleeding requiring transfusion should rarely occur, with transfusion rates around 4%.

Perforation of the Prostatic Capsule

Deep resection can result in perforation of the prostate capsule with extravasation of the irrigation fluid. If not noted, perforation and extravasation lead to nausea, vomiting, tense abdomen, lower abdomen, and back pain despite intraoperative spinal anesthesia. The development of 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).

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. Frequency 2%, risk factors for a TUR syndrome are a prostate volume over 45 ml, resection time over 90 min, and height of the irrigation fluid over 70 cm.

Diagnosis and therapy of the TUR syndrome:

Early detection of 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 vital to end the operation quickly and to reduce the height of the irrigation fluid during coagulation. With proven hyponatremia, hypertonic NaCl solution is infused slowly. Depending on the severity of TUR syndrome, intensive care monitoring is necessary.

Injury to Adjacent Organs

Postoperative Complications of TURP


Postoperative Hematuria usually stops within three weeks after TURP. Recurrent hematuria, Clot retention and bladder tamponade is possible in up to 20%, physical rest is necessary for four weeks.

Retrograde Ejaculation

Retrograde Ejaculation is common after standard transurethral resection of the prostate (60%). The preservation of the peri-montanal tissue (around the colliculus seminalis) reduces the risk down to 10%.

Urinary Tract Infections

The cause for postoperative urinary tract infections is an ascending catheter infection and the (already existing) bacterial colonization of the prostate (risk factor urinary retention with bladder catheter). Perioperative antibiotic prophylaxis reduces the likelihood of infectious complications. An epididymitis occurs in 2%.


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

Bladder Neck Stricture

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

Urethral Stricture

Urethral strictures are reported in up to 10%. Urethral strictures can be avoided with a thin resection shaft (24 CH), limiting the time of the transurethral catheter and applying prophylactic antibiotics.

Cardiac Complications

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

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


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

N. Couteau, I. Duquesne, and Fr&eacute, “Ejaculations and Benign Prostatic Hyperplasia: An Impossible Compromise? A Comprehensive Review.,” J. Clin Med, vol. 10, no. 24, 2021.

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

M. Rieken, T. Antunes-Lopes, B. Geavlete, T. Marcelissen, E. Y. A. U. F. Urology, and B. Group, “What Is New with Sexual Side Effects After Transurethral Male Lower Urinary Tract Symptom Surgery?,” Eur. Urol. Focus, vol. 4, no. 1, pp. 43–45, 2018.

  Deutsche Version: Transurethrale Resektion der Prostata (TURP)