Transurethral resection of the prostate or TURP is a procedure where the prostate is resected from an endoscopic approach. This procedure has been in use for many years and is still the surgical gold standard for bladder outlet obstruction (BOO), with some minor changes. A TURP can also be used to unroof prostatic abscesses, as well as open ejaculatory ducts in obstructive azoospermia.
The prostate is an organ that functions in male fertility. It provides prostatic secretions to the ejaculate, composed of an alkaline solution and prostate-specific antigen, which functions to liquify the ejaculate. These prostatic secretions make up approximately 30% of ejaculate fluid. The prostate is derived from the urogenital sinus and becomes stimulated by androgens.
The average prostate is approximately 33 grams. It is composed of a capsule that surrounds the parenchyma, with three zones: central, peripheral, and transition. The transition zone is typically where hypertrophy exists in benign prostate hypertrophy or BPH . Fortunately, the transition zone is easily resected with a TURP. The peripheral zone is often the location of prostate cancer. The prostate parenchyma is composed of stroma, ducts, and acini.
The prostate enlarges due to testosterone and age. When the prostate enlarges, it classifies as BPH. When BPH causes urinary obstruction, it may indicate the need for a TURP procedure.
Indications for a TURP include failure of medical management for LUTS or BOO, obstructive nephropathy, bladder stone formation, 2+ episodes of urinary retention, prostate abscess, difficulty with clean intermittent catheterization and obstructive azoospermia.
Generally, men with BPH experience lower urinary tract symptoms (LUTS). Patients presenting with LUTS are initially started on medical management, an alpha-adrenergic blocker, and/or 5 alpha-reductase inhibitors. Should they fail medical management, they can then proceed with a TURP. If a patient is found to have a bladder stone this is an indication that the patient is not completely emptying his bladder and may benefit from a TURP to relieve BOO. Multiple episodes of acute retention is also an indication for a TURP.
A prostate abscess that requires drainage and are superficial and easily accessible via the urethra can be unroofed with a TURP. Difficulty with catheterization in a patient that requires catheterization can also be an indication for a TURP, as this may decrease the difficulty in placing a catheter. If a patient is found to have obstructive azoospermia at the level of the ejaculatory ducts, these can be resected in a technique very similar to a TURP.
A TURP should be forgone if the patient will not tolerate the risks or the possible sequelae.
Anticoagulation is a relative contraindication in a traditional TURP, but one can perform a laser TURP on anticoagulation or with the appropriate holding of anticoagulation. If a prostate is extremely large, greater than 100 g, this is an indication to perform a simple prostatectomy. But as with anything in medicine, discussing the options with the patient is the most appropriate decision prior to performing an irreversible surgery.
Before performing a TURP, patients must understand the expectations before, during, and after the case. Initially, a thorough history needs to be performed, focusing on their voiding history, ensuring documentation of symptoms, frequency, urgency, dysuria, nocturia, incontinence—a discussion of what they have tried for management of their LUTS and medication history. A physical exam should also be completed focusing on the genitalia and digital rectal exam, which is utilized to evaluate for other pathology that describes symptoms and to estimate the size of the prostate. A post-void residual and urine analysis is preferred to understand patients voiding ability as well as ruling out UTI.
Some urologists, prior to TURP for urinary retention, will perform urodynamics to determine the functionality of the bladder. This testing provides more information and may aid in informed consent before the TURP. Other urologists believe that the best option is to perform the TURP, providing the patient with the best voiding parameters post-operatively. However, there is little data on the benefit of urodynamics in the perioperative setting.
One needs to discuss all options for the management of LUTS and ensure the patient understands the risks and benefits of all the choices. After this in-depth discussion, an informed decision can be made to proceed to TURP.
With advances in medical equipment, patients can have resection of a TURP with a bipolar element or a laser fiber. The bipolar TURP has been around for many years and allows quick resection of large prostates on select patients that are not on anticoagulation. This technique also allows for pathologic review of the prostatic chips to look for incidentally found prostate cancer.
The laser technique, or photo vaporization of the prostate, can be utilized safely for men on anticoagulation. This technique is generally slower than the bipolar TURP and does not allow for pathologic evaluation as the prostatic tissue is vaporized and not resected. Monopolar TURP is also an option, and instead of using saline irrigation, this procedure uses non-conducting irrigation such as water, glycine, sorbitol, mannitol. The uses of these types of irrigation cause a greater chance of TUR syndrome.
The patient arrives in the preoperative area. The surgeon and staff should answer all questions, review the risks and benefits, and consent is signed. The patient is taken back to the operating room and anesthetized. The patient is placed in the lithotomy position and prepped and draped in a sterile fashion.
The resectoscope is inserted through the urethra into the bladder using a visual obturator. The entire bladder will be visualized with particular attention to the ureteral orifices, as these need to be spared in the resection. The location of the verumontanum or veru is also noted, as this makes up our distal resection edge. The visual obturator is then removed, and the working element with the resection loop or laser fiber inserted.
A channel is made at the 5 and 7 o’clock position down to the veru using the cut feature; this allows better continuous irrigation during resection, improving visualization. Resection then continues between the two channels down to the prostatic capsule. Then the resection is continued laterally up to the 3 and 9 o’clock positions, working to keep the same depth and not violate the prostate capsule. During the resection and at the completion of resection, hemostasis is maintained using the coagulation setting. This process should occur with little to no irrigation running to evaluate for venous bleeding. All of the prostate chips are removed from the bladder using either the Ellik, catheter tipped syringe, or breaking the resectoscope. Finally, a large-bore 3-way catheter is placed with 30 ml of water put into the balloon. CBI is started in the OR to allow for observation of the urine color. The CBI should be titrated to light pink.
Patients are typically admitted one night. If the urine has remained clear, a voiding trial is performed the next morning. If a patient is unable to void, a foley will be placed, and follow up with the patient will be conducted in about one week for a voiding trial in the clinic.
It is easiest to split complications into intraoperative and postoperative complications, to manage patient expectations as well as ensure the discussion of all complications.
Intraoperative complications include general anesthesia risks, bladder perforation, ureteral orifice injury, bladder neck undermining, prostatic capsule perforation, inability to complete case due to bleeding, or poor visualization.
Postoperative complications include transurethral resection syndrome (TUR syndrome), LUTS but these typically improve as the patient is further from surgery, but they may never completely resolve, retrograde ejaculation, infection including UTI and prostatitis, urethral stricture, bladder neck contracture, incontinence, urinary retention due to either obstruction or poorly functional bladder requiring CIC or catheter, and recurrence.
TUR syndrome is very concerning. This condition arises due to the irrigation fluid used during the resection being pushed intra-vascularly, causing hyponatremia and neurologic symptoms, such as confusion. The risk of this is low, as modern-day TURPs utilizing bipolar technology and saline as irrigation, as compared to a monopolar TURP.
The clinical significance of a TURP is typically to relieve obstruction due to the prostate, but it can also unroof prostatic abscesses and to open ejaculatory duct obstructions. The importance of a TURP for bladder outlet obstruction is to prevent obstructive nephropathy, LUTS due to incomplete emptying, and UTI due to incomplete emptying. If a patient utilizes CIC to empty the bladder, a TURP can allow for easier catheter placement. Abscess management requires drainage, as it is difficult for antibiotics to penetrate the abscess cavity. When patients have obstructive azoospermia due to ejaculatory duct obstruction, an incision of this structure can relieve the obstruction and allow patients to father children.
TURP is typically an elective procedure used in the treatment of BOO. Because of this, appropriate indications and discussion of the complications associated with the procedure require an integrated interprofessional team to communicate effectively and initiate treatment plans, so the patient has proper expectations. This approach will ensure that patients are prepared for their procedure and what to expect. When patients are better informed, they are more invested in their decision and are happier with their outcome.
Collaboration shared decision making and communication are key elements for a good outcome. The interprofessional care provided to the patient must use an integrated care pathway combined with an evidence-based approach to planning and evaluation of all joint activities. The earlier signs and symptoms of a complication are identified, the better is the prognosis and outcome of the procedure. [Level 4]
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