Transurethral Resection of the Prostate

Anatomy and Physiology

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 liquefies the ejaculate. These prostatic secretions make up approximately 30% of the ejaculate fluid. The prostate is derived from the urogenital sinus and becomes stimulated by androgens.[1]

The average prostate is approximately 33 grams in size.[2] It is composed of a capsule that surrounds the parenchyma, with three zones: central, peripheral, and transitional. The prostatic parenchyma is composed of stroma, ducts, and acini.[1] The transition zone is typically where obstructive enlargement occurs in benign prostate hyperplasia (BPH).[2][3] Fortunately, the transition zone is easily resected with a TURP. The peripheral zone is often the location of prostate cancer. 

The prostate enlarges due to testosterone exposure, and it continues to grow with age.[4] When the prostate enlarges, it is classified as benign prostatic hyperplasia (BPH), defined as an increase in the total number of prostatic stromal and epithelial cells causing nodular enlargement. (Prostatic hypertrophy refers to individual prostatic cellular enlargement.) When BPH causes urinary obstruction and either subjective or objective urinary difficulties, it may indicate the need for a TURP.

About 70% of men in their 60's and 80% of men 70 years or older have some level of benign prostatic hyperplasia.[5][6] Symptoms also vary with age, as 80% of men 80 years of age or more will have symptomatic BPH.

The primary arterial supply to the prostate is from the internal iliac artery. The third branch of the internal iliac artery is the inferior vesical artery, of which the terminal branch is the prostatic artery. The prostatic artery is only about 1 cm long as it then splits into the capsular branch (which has perforating branches and surrounds the capsule) and the urethral branch (which enters the prostate at the 5 o'clock and 7 o'clock positions), supplying the median lobe while another branch turns distally, and supplies the periurethral tissue. There may also be contributing arterial branches from the middle hemorrhoidal and/or pudendal arteries near the prostatic apex.[7]

The most critical anatomical landmark for TURP surgery is the verumontanum or "very," which represents the ejaculatory ducts. It is located posteriorly at 6 o'clock and is about 1 cm proximal to the external sphincter. The veru is the usual distal limit of resection except for very skilled surgeons due to its close proximity to the external sphincter muscle. 

The external sphincter muscle is critical to postoperative continence and must not be injured during surgery as the internal sphincter is removed when performing a TURP procedure. The external sphincter is slightly tilted with the anterior edge (at 12 o'clock) leaning proximally or inwards toward the patient. This means that when resecting the roof of the prostate, great care should be taken not to remove tissue more distal than the very, which is directly opposite. This can be challenging as the veru is not visible when resecting the roof. Also, the prostatic tissue is relatively thin here, and there is a significant venous complex (the periprostatic venous plexus or Santorini's plexus) covering the anterior prostatic capsule, which can cause very troublesome bleeding if violated.

Indications

Indications for a TURP include failure of medical management for lower urinary tract symptoms (LUTS) or bladder outlet obstruction (BOO), obstructive nephropathy, recurrent bladder stone formation, two or more episodes of urinary retention, prostate abscesses, difficulty with clean intermittent catheterization, recurrent gross hematuria, incomplete emptying, and obstructive azoospermia.[8][9] A bladder diverticulum by itself is not considered an adequate indication.[10]

Generally, men with BPH seek medical help when they experience bothersome lower urinary tract symptoms (LUTS). Patients presenting with LUTS are usually initially started on medical management, such as 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, it indicates that the patient is not completely emptying his bladder and may benefit from medical BPH treatment or a TURP to relieve the obstruction. Medical therapy is usually preferred initially.[10] Renal failure from obstructive uropathy with bilateral hydronephrosis, evidence of permanent bladder damage, and intractable or multiple episodes of acute retention are also indications for TURP surgery.[10]

The size of the prostate alone is not considered an indication for surgery. There should generally be a finding of real or potential permanent harm to the kidneys or bladder. Subjective or objective evidence of bothersome symptoms not adequately controlled by other means would also constitute a surgical indication.

A relative indication would be a sizeable intravesical median lobe, especially if it appears to be causing a ball-valve effect which is unlikely to be relieved by medications or alternate surgical procedures as transurethral resection is particularly effective in eliminating these types of obstructions that are resistant to medical therapy.[11]

A prostatic abscess that requires drainage, which is superficial and easily accessible via the urethra, can easily be unroofed with a TURP. Difficulty with catheterization in a patient with continuing retention or incomplete emptying can also be indications 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 transurethrally. 

Surgeons should not attempt a TURP in prostates larger than they can reasonably resect in 90 minutes of operating time to minimize postoperative complications. For most resectionists, this is typically about 75 to 80 grams, although particularly skilled and experienced surgeons can manage prostates of 100 to 150 grams in size. Very large prostates that require surgery and are deemed too big for TURP can generally be managed by simple open prostatectomy or laser enucleation (HoLEP).[12] 

Contraindications

An absolute contraindication would be a patient who could not medically tolerate the anesthesia or possible sequelae of the surgery. An active, untreated urinary tract infection would be another absolute contraindication.

Relative contraindications would be post-radiation therapy for prostate cancer, myasthenia gravis, multiple sclerosis, and Parkinson's, as these patient groups have a high likelihood of postoperative incontinence due to a dysfunctional external sphincter. Active anticoagulation is another relative contraindication to a traditional TURP, but a laser TURP can be performed on anticoagulated patients, or blood thinners can be appropriately withheld briefly to allow for the procedure. If a prostate is extremely large, greater than 100 grams, this is usually an indication to consider performing a simple prostatectomy or HoLEP, as most urologists do not possess the necessary skill or experience to perform a TURP of that size safely. A severely hyperactive bladder that is not easily controllable is also a relative contraindication. 

Equipment

• Antimicrobial prep 
• Preoperative antibiotics
• Resectoscope with at least two wire electrode loops
• Normal saline (bipolar), glycine, sorbitol-mannitol, or otherwise appropriate irrigation (monopolar)
• Large bore 3-way foley catheter (typically 22 or 24 French with a 30 cc balloon
• Continuous bladder irrigation (CBI) tubing and connectors
• Sterile lubricant
• Foley bag (large)
• Catheter tipped syringe
• Catheter guide
• Bladder evacuator (Ellik or similar)

Personnel

• Urologic surgeon – performs the TURP 
• Anesthesia – maintains anesthesia 
• Operating room nurse – supports the surgeon and anesthesia, replaces irrigation bags, obtains supplies as needed, etc. 
• Surgical technician – supports the surgeon, prepares instruments, empties the Ellik, etc.  

Preparation

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, urinary symptoms, frequency, urgency, flow rate, dysuria, nocturia, and incontinence., A review of what they have tried to manage their LUTS and medication history should be done. A physical exam should also be completed focusing on the genitalia, and a 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 assess the patient's voiding ability and rule out a UTI before the surgery.[13]   

Before TURP for urinary retention, some urologists will perform urodynamics on some or all of their preoperative patients to determine the functionality of the bladder. This testing provides more information about bladder functionality and may aid in the informed consent discussion before the surgery. This would be most reasonable in cases where detrusor muscular contractile ability is uncertain, such as in patients with an underlying neuropathy, persistently large bladder capacities, or urinary retention with >1,500 mL. However, there is little data on the benefit of urodynamics in the perioperative setting.[14] 

Other urologists believe that the best option is to perform the TURP, regardless, as it provides the patient with the best opportunity for spontaneous voiding post-operatively. In some of these questionable cases, placement of a suprapubic tube at the time of the TURP can be considered with the understanding that it will be removed if the patient demonstrates persistently low (<200 mL) postvoid residuals after surgery. This avoids the need to perform a separate suprapubic tube placement surgery later. Preoperative urodynamics is also recommended in patients with detrusor instability and poor bladder compliance who are more likely to develop post-operative urinary frequency and urgency issues which should be addressed prior to surgery.[15]

All the options for managing LUTS should be discussed and reviewed to ensure the patient fully understands the risks and benefits of all the reasonably available choices. After this in-depth discussion, an informed decision can be made to proceed to a TURP procedure.   

With advances in medical equipment, patients can have resection of a TURP with an electrical element or prostatic vaporization using a laser fiber. The TURP has been around for many years and allows quick resection of large prostates in patients with obstructive BPH that are not on active anticoagulation. This technique also allows for a pathologic review of the prostatic chips to look for possible prostate cancer. 

Cutting and coagulating currents require separate generators, usually packaged together inside one electrosurgical unit. Cutting current quickly achieves full voltage, while coagulating current is much slower to reach peak levels—this slower type of current results in charring and fulguration, which together produce the coagulating effect. The generators also greatly increase the electrical frequency from the standard 60 Hz current to avoid having any unexpected reaction with body tissue.

The preop evaluation generally includes a history and physical as well as baseline electrolytes, CBC, PSA, a post-void residual determination, and urinalysis, which are reasonable preoperative tests prior to urologic surgery. Coagulation studies are no longer considered necessary unless there is a history of unexplained or unusual bleeding. Renal imaging studies and urodynamics are also unnecessary in most cases.

The 2021 American Urological Association Guidelines on Management of Benign Prostatic Hyperplasia recommends the consideration of an evaluation of prostate size and shape before any surgery. This may be done by cystoscopy, transrectal ultrasonography, computed tomography (CT), or magnetic resonance imaging (MRI).[10] Uroflowmetry and post-void residual determinations are also recommended. Peak flow rates of <10 mL/sec are highly suggestive of bladder outflow obstruction.[16] Pressure-flow studies are suggested if there is diagnostic uncertainty.[10] The finding of an intravesical lobular extension, such as a ball-valving median lobe, is highly suggestive of the likely failure of medical BPH therapy.

Two weeks of finasteride therapy, a 5 alpha-reductase inhibitor, has been shown to reduce microvascular density and intraoperative blood loss; therefore, it is recommended, especially in larger prostates, prior to TURP.[17]

Preoperative antibiotics are recommended 1 hour before the expected start of surgery.[18] Patients with indwelling catheters should receive extended antibiotic coverage based on urine culture results.[19][20]

Due to the high risk of increased bleeding, venous thromboembolism prophylaxis is generally not recommended in TURP, except for early ambulation.[21][22] 

Monopolar vs. Bipolar

Transurethral resection of the prostate can be done with either a monopolar technique or bipolar. The original TURP procedure designed and developed in the 1930s and 40s used monopolar equipment where the electrical current passes from the wire loop through the tissue in direct contact with the electrode, through the patient to the grounding pad. For this to work, the irrigating fluid must be non-conducting such as water, 5% glucose, glycine, sorbitol, mannitol, or sorbitol/mannitol. (Water and 5% glucose are no longer used.) The use of these types of irrigation causes a possible chance of dilutional hyponatremia or TUR syndrome, especially in prolonged or high blood loss procedures.[23]

As there is constant irrigating fluid absorption during the resection, the patient will incorporate some of the irrigation during the procedure, which causes hyponatremia if excessive fluid is absorbed. A monopolar resection will not work using a conducting fluid such as normal saline. For this reason, many facilities have switched to bipolar equipment where both electrical poles are within the resectoscope instrument. This allows for using normal saline as the irrigation fluid and eliminates the possibility of TUR syndrome. However, the risk of TUR syndrome is somewhat overblown as the actual incidence is roughly only 20 cases/1,000 monopolar TURP surgeries.[24] Also, there are reports of hyperchloremic metabolic acidosis and complications of saline overload resulting in upper airway edema with bipolar resections.[25]

Bipolar equipment may not be available in many parts of the world; it requires completely changing sets of urologic instruments, a dedicated electrosurgical generator unit is needed, and it generally tends to be somewhat slower than monopolar resection, although overall results are comparable.[23][24]

The 2021 AUA Guidelines recommend both monopolar and bipolar transurethral resection depending on physician experience, expertise, and the available instrumentation. The overall outcomes and complication rates are essentially equivalent.[26]

The laser technique or photo vaporization of the prostate (sometimes called a laser TURP even though it's vaporization and not resection) can be safely utilized for men on anticoagulation. This technique is generally slower than the TURP and does not allow pathologic examination as the removed tissue is vaporized.

Technique or Treatment

General Principles, Tips, and Techniques for TURP

The Beginning - Getting Started

"A good beginning makes a good ending." Proverb

• The use of a thin plastic barrier sheath placed immediately before standard draping is recommended to maintain better sterility and protect the operative field. It also allows protected digital manipulation of the prostate through the rectum.
• The patient should be positioned with the buttocks flush with the end of the cystoscopy table. Resection of the anterior prostrate at the bladder neck can be impeded when the downward movement of the external portion of the resectoscope is restricted by the edge of the cystoscopy table.
• The table height should be adjusted to a comfortable position for the surgeon.
• If the patient has been catheterized, gentle irrigation of the urethra with a Toomey or bulb syringe should be performed to rinse mucus, blood clots, and other debris into the bladder, where they will not interfere with vision. This will be rinsed out as soon as the resectoscope is positioned inside the bladder.
• A cystoscopic examination of the urethra, prostate, and bladder is recommended immediately prior to inserting the resectoscope. This allows for optimal visualization and localization of important landmarks as well as identifying any previously unrecognized pathology. 
• Landmarks to be identified include the external urinary sphincter, prostatic urethra, median lobe, verumontanum, ureteral orifices, and trigone. Before starting the surgery, the surgeon should have a clear 3-dimensional mental image of the patient's specific anatomical features and relationships.
• The area between the veru and the external sphincter should be examined, and the precise distance noted.
• Care should be taken to avoid inadvertent resection of the very, as this is an important landmark that helps avoid injuries to the external sphincter.
• The external sphincter is identified by the red muscle bands directed centrally in the deep bulbous urethra, as well as the wrinkling and constricting action of the membranous urethra as the cystoscope is removed. There may also be a bunching up of the superficial mucosa just in front of the sphincter as the scopes are inserted.
• Confirm that the cutting wire loops fit perfectly into the resectoscope sheath without gaps. Otherwise, resection may be incomplete, leaving tags on tissue that interfere with vision and require a second cut that wastes valuable time.
• Check the instruments carefully before getting started. For example, some instruments may have a tip or beak that can come loose or break inside the bladder. Such pieces can be challenging to remove in the middle of a case.
• A spare set of instruments, including extra cutting loops, connectors, and a backup electrosurgical generator, should be immediately available if necessary.
• Make sure there are more than sufficient irrigation bags to complete the surgery. In the unlikely event that the irrigating fluid runs out, be prepared to use an alternative such as 1-liter bags instead of the usual 3 liters.
• The irrigation should ideally be heated to body temperature prior to use to avoid chilling the patient. If core body temperature drops below 95 F (35 C), this can induce shivering and increases the risk for angina, cardiac arrhythmias, and myocardial infarctions.
• Maintain the irrigation fluid at the minimum height necessary to provide adequate visualization; 60 cm above the height of the surgical table is generally sufficient.
• A perineal urethrostomy may occasionally be necessary for patients with severe contractures of the lower extremities or similar deformities that could otherwise interfere with positioning for the resection.
• Insertion of the resectoscope should optimally be done with a visual obturator to avoid false passages and inadvertent injury to the prostate, urethra, or bladder. Blind obturators should be avoided, if possible.
• Prepare the urethra by dilating with urethral sounds prior to insertion of the resectoscope sheath. If substantial resistance is encountered, use a smaller sheath or perform a perineal urethrostomy. 

The Middle - Performing the Resection

"The secret of getting ahead is getting started. The secret of getting started is breaking your complex overwhelming task into small manageable tasks and then starting on the first one." Mark Twain

• Always resect while pulling the cutting loop back or towards you; never by pushing it forward. This should cleanly separate one chip or slice of tissue from the rest of the prostate and prevent tunneling, perforation, bladder injury, and extravasation.
• If the resected chip is not separating cleanly from the prostate with one cut, readjust the wire loop until it works efficiently. This will save a lot of time.
• If there is a large and obstructing median lobe, resect this first, regardless of the technique used for the rest of the procedure.
• Follow an orderly resection plan regardless of which technique is used.
• Once the surgery has started in a particular area, that portion of the resection should be finished completely before moving to another location. 
• Performing partial or incomplete resections in multiple sites is discouraged, leading to additional bleeding and greater irrigation fluid absorption. It also makes it far more difficult to terminate the procedure quickly if it becomes necessary.
• Always be prepared to terminate the surgery quickly. Surprisingly good results occur if even only one lateral lobe is completely resected.
• Always have sufficient fluid in the bladder to keep the posterior wall away from the surgical area, especially when resecting the bladder neck. Typically, 100 mL or more is sufficient for this.
• Once the bladder neck area has been resected, be careful not to return there too often for more resection. It is very easy to continue resecting and end up well into the trigone and bladder.
• Visually check the ureteral orifices periodically when resecting near the bladder neck and the veru when cutting in the distal prostate.
• Never hesitate to recheck the landmarks for reorientation.
• Try to resect using long, smooth strokes. This avoids chippiness, minimizes perforations, and minimizes bleeding.
• The lateral lobes should generally be resected with curving strokes while the floor is less concave, and the roof should be resected straight.
• As the resection gets laterally deeper, the nature of the prostate tissue changes from an irregular off-white/yellowish color to the smooth, white, glistening, vertically striated surface of the surgical capsule, which is the lateral surgical margin.
• If one or both ureters are accidentally resected, avoid using cautery near the cut ends to minimize scarring. They will usually heal just fine.
• Resection of the lateral and posterior lobes should be somewhat curved or concave. Resection of the roof at 12 o'clock should be straight to avoid inadvertent perforation. The prostate is very thin here, and there is a large plexus of veins on the other side. 
• Try to remove as much bulk tissue as reasonably possible without perforating the capsule or overly extending the operating time. 
• Do not waste time cauterizing areas where the capsule may be perforated, as this can only be controlled by hemostasis from the Foley catheter at the end.
• If priapism is encountered during surgery, ask the anesthesiologist to change the level of anesthesia or consider an intracorporal injection of diluted phenylephrine, just as would be used for pathological priapisms.
• When resecting at an angle where the veru is not visible, be especially careful to hold the resectoscope steady without any distal migration. If unsure, stop and recheck the position of the veru.
• Avoid cutting off a large block of tissue as it will tend to float freely inside the bladder. This can be difficult to extract from the bladder lumen and usually requires chopping or resecting the tissue, which is highly mobile and unstable. This wastes valuable time and risks a possible bladder injury.
• When resecting the median lobe, a flap of bladder neck tissue may fall or collapse into the bladder. To resect this tissue, get behind and below the flap of tissue with the loop, gently lift it off the bladder surface, and only then apply the cutting current to free it.
• Check the surgical time periodically and when finished with one side. 
• Try to develop a rhythm, as this is the most efficient way to remove prostatic tissue quickly and safely.
• When resecting a larger prostate, try to make the chips full length from the bladder neck to the veru. Consider using a larger diameter resectoscope and loop for particularly large glands.
• Resection of the posterior lobe may uncover one or both seminal vesicles. This is harmless and requires no treatment. 
• An obturator reflex may occur during the surgery. This will cause the patient to jump suddenly. If this happens, stop the resection immediately and ask anesthesia to paralyze the patient if possible.
• Another technique is to inject a local anesthetic into the sidewall of the prostatic fossa near the point of resection where the reflex occurred.
• If the resectoscope is not held firmly by the sphincter, it will "wobble." If wobbling is noticed, stop the resection immediately and reposition the resectoscope to avoid possible permanent sphincteric damage and incontinence.
• Avoid unnecessary use of cautery as it damages normal tissue, increases postoperative irritative symptoms, and promotes scarring, especially at the bladder neck.
• Do not cauterize bleeding vessels until the surgical capsule is reached unless they interfere with vision. Otherwise, the same vessel will be cauterized multiple times instead of just once, wasting time.
• Do not cauterize the very, as it can cause painful ejaculation later.
• Do not cauterize or resect if visibility is not adequate. Try readjusting the resectoscope position or increasing the irrigation flow. Make sure there is adequate fluid, and the suction/drainage is working. Consider using an Ellik or similar evacuator to remove chips, clots, and debris.
• If still having trouble, place the end of the resectoscope near the lateral wall at the bladder neck and slowly move it back towards the very, looking for the bleeding vessel, usually just a small artery. If unsuccessful, rotate the resectoscope slightly and repeat the procedure.
• If totally unable to see due to hematuria, rotate the resectoscope 180 degrees and inspect the opposite wall. Often, a small bleeding artery will be found there or at the roof.
• A bleeding vessel at the bladder neck can best be visualized by filling the bladder, which rotates the inner bladder neck lip upwards and distally (towards the surgeon), where it can now be seen and cauterized.
• Do not proceed with surgery in other parts of the prostate if there is significant bleeding in previously resected areas.
• Arterial bleeders pointed directly at the lens can be difficult to identify. Change the angle of attack of the resectoscope or reposition it close to the bladder neck and slowly withdraw. 
• It is advisable to leave the apical tissue for the end of the procedure as this requires a slow, careful approach.
• If possible, consider leaving the roof resection until the end, as avoiding it to save time will tend to have a minimal clinical effect on the final result.

End of the Surgery - Finishing it Up

"It's not how you start that counts; it's how you finish." Proverb

• Do not attempt a TURP on a prostate that is clearly too large to be completed within 90 minutes. While not as critical with bipolar compared to monopolar instruments, it's still a good general rule.
• Avoid the temptation to return to the bladder neck and resect additional tissue. Advancing the resection well into the trigone and bladder is likely.
• If the bladder neck still appears obstructing, use the Collings knife and make a vertical incision in the midline instead. This avoids any potential ureteral injury.
• Unless very skilled and experienced, hold the resectoscope very still when cutting. Experts can move the cutting loop and the resectoscope at the same time, but this is an acquired skill and much more challenging to master with video surgery compared to the old-fashioned direct vision.
• Save the riskiest parts of the surgery for the end, specifically the roof and the tissue around the veru. Leaving some extra tissue in these areas is far better than risking permanent incontinence through an injury to the external sphincter.
• When the resection is complete, slow the irrigation fluid to a minimum. This will allow additional bleeding sites to become visible, and "floating tags" will fall into view.
• Try filling the bladder, then shut the inflow and let the bladder fluid evacuate. This will permit any hanging tissue tags to become visible for resection.
• After the evacuation of the prostatic chips, always take a final look inside the bladder to make sure there are no remaining pieces inside the bladder. Also, inspect the instrument to ensure there are no missing pieces that could possibly still be in the patient!
• Investing a few extra minutes in checking bleeding sites is usually a good idea.
• Place the Foley catheter carefully and without undue pressure. It is very easy to inadvertently place the catheter in the retroperitoneum or under the trigone, which is why a wire catheter guide is suggested, as it elevates the tip of the Foley and minimizes subtrigonal positioning.
• In difficult cases, consider placing a guide wire through the scope and feeding the catheter over the guidewire using the Blitz technique.[27]
• If unsure about the final Foley position, obtain a cystogram.
• Irrigation should be absolutely clear at the end of the surgery with the Foley catheter in the proper position. The 30 mL balloon can be overinflated up to 60 mL if necessary to help control bleeding. Traction may also be used. If these techniques are not controlling the hematuria, remove the Foley and replace the resectoscope for an inspection to control bleeding.
• Placing a belladonna and opium (B & O) suppository just before taking the patient's legs down from the lithotomy position can significantly help reduce postoperative bladder spasms.
• Postoperative irrigation fluid should be with normal saline, particularly after monopolar surgery. There is no reason to use a hypotonic irrigation fluid once the resection is completed.

The Nesbit technique

The first practical, safe, and effective technique for transurethral prostate resection was originally described by Dr. Reed Nesbit in his landmark 1943 book "Transurethral Prostatectomy."

The surgery begins with the resectoscope positioned at the midpoint of the prostate. The resection starts by removing the intravesical prostate, bladder neck, and immediately adjacent prostatic tissue, starting at the 12 o'clock position and working clockwise. After this, further proximal resection is not recommended. 

The next step is to reposition the resectoscope to the very, and the resection is continued from the prior margin to just in front of the verumontanum again, starting at the 12 o'clock position creating a channel. The resection extends laterally to the 4 o'clock position of the patient's left lateral lobe, and then a similar extended channel is made on the patient's right side to the 8 o'clock position. The intention is to make a wide channel on the anterior aspect of the prostate, which will cause the bulk of the remaining lateral lobe tissue to fall posteriorly to the floor of the prostatic fossa. It also significantly devascularizes the remaining tissue to minimize further bleeding. This lateral lobe tissue can now be resected similarly, slowly rotating the resectoscope to remove all the bulk prostate remaining.

The final step is to carefully remove any apical tissue blockage around the veru.

Discussion

The Nesbit technique has several significant advantages. Starting at the roof allows the bulk tissue to fall down into the prostatic fossa making for an easier resection of that bulky portion of the prostate. There is also early control of the prostatic blood vessels, starting with the perforating urethral blood vessels.

There are also some disadvantages. There are essentially three distinct, separate stages to the surgery, and it would be difficult to quickly stop the procedure until all the surgical steps are completed. The initial groove made at the roof is done without any visual landmarks in an area where the prostate is the thinnest. Any early bleeding or perforation will significantly increase the complication rate and severity. The lateral lobes can easily overcrowd the prostatic fossa, hide bleeding sites, and not leave enough room for easy resection due to interference with the mobility of the resectoscope. Any early bleeding can be difficult to see or control with bulky lateral lobe tissue in the way.

The Milner Technique

Dr. William A. Milner was a highly skilled and respected urologist who was a contemporary of Dr. Nesbit. Dr. Milner received an early working resectoscope model from Joseph F. McCarthy in 1931 and then proceeded to develop his own technique for safe, rapid transurethral prostate resections on animal models until he had perfected the procedure. In 1941, he reported on his first 700 human cases in the Journal of Urology which achieved excellent success rates together with remarkably low mortality and few complications.[28] Widely regarded as the world's leading transurethral surgeon in his day, he became renowned for his innovative surgical technique, described below.

An initial groove is made at the 9 o'clock position from the bladder neck to a point parallel to the veru. This groove is deepened and extended until capsular fibers are visualized. The chips are cut, with the deepest portion being in the middle of the resection. This mirrors the concave shape of the prostatic capsule. The capsule is easily identified by the white, smooth vertical striations, which are clearly distinguishable from the heterogenous, bulky prostatic tissue. Coagulation is only used minimally until the resection is at the capsular level. The groove is then extended up to the 11 o'clock position and down to the 7 o'clock position by simply rotating the resectoscope slightly. No attempt is made to encircle the bulk lateral lobe tissue but rather to resect it quickly from the inside out and reach the surgical capsule expeditiously, at which point any perforating or bleeding vessels can be cauterized. The resectoscope can then be rotated slightly and the procedure repeated. When the patient's right lateral lobe has been resected, a similar procedure is done on the left side. 

The posterior and median lobes are resected similarly to the technique described by Dr. Nesbit.

The tissue around the veru is resected next, and the scope is inverted. The remaining tissue between 11 and 1 o'clock is resected with straight strokes, and care is being taken to keep the scope parallel or proximal to the level of the veru.

Discussion

The Milner technique offers several advantages over the Nesbit procedure. Immediate attention is given to the bulky lateral lobe tissue, removing it quickly, offering improved vision and better irrigation with increased resectoscope mobility. One entire side is completed before moving to the opposite side, which provides the opportunity to stop the procedure midway if necessary. Partially resected lateral lobes tend to bleed more than if only incompletely resected, as with the Nesbit technique. If the initial groove is made incorrectly or too deeply, there is minimal harm if it is done at the extreme lateral position of 9 or 3 o'clock, where the tissue is thickest, and any inadvertent capsular perforation will have a minimal clinical effect. The full-length prostatic groove provides its own distal and proximal landmarks, which then only have to be extended by rotating the resectoscope and repeating the linear resection. Leaving the anterior prostatic tissue for last minimizes the risk of any accidental perforation in this risky area.

There are many variations of these surgeries (including separate techniques described by Barnes, Alcock, Flocks, and Mauermayer). Still, as long as the general principles are followed, they are all likely to give good results.

Transurethral resection of the prostate is an art that requires substantial practice to master. Since urologists are performing fewer of these procedures now than in the past, it is more difficult for most to develop very high skill levels.

"The actual technique is probably not as important as planning it carefully and executing it precisely so that the operation is complete and the surgeon remains oriented throughout the procedure." Winston Mebust

Postoperative Care 

After transurethral prostate surgery, patients are typically admitted at least overnight. The continuous bladder irrigation is titrated to a "light pink" or "pink lemonade" color. If possible, the irrigation is stopped early the next morning to determine if it is clear enough for either a voiding trial or discharge. If significant hematuria remains, then the irrigation needs to be continued, and the hospital stay may need to be extended. Most patients go home with the Foley catheter and instructions to "take it easy" for the next few days. A stool softener is often recommended to avoid straining and Valsalva, which can increase prostatic bleeding. 

Most patients will return to the clinic or office about one week after the surgery for catheter removal and a voiding trial. Pathology results can also be reviewed with the patient at that time. Finasteride is usually continued for an additional 2 to 4 weeks to help with hemostasis and minimize hematuria. Anticoagulation is typically resumed 24 hours after all visual bleeding has stopped. Some experts will recommend using 2 to 4 weeks of a low-dose antibiotic such as trimethoprim-sulfa or nitrofurantoin as prophylaxis immediately after Foley catheter removal based on the premise that there will be necrotic or devascularized prostatic tissue fragments remaining in the prostatic fossa which could become infected. This appears reasonable, at least in higher-risk patients.

There is minimal pain after surgery. Pelvic floor and Kegel exercises may help restore continence quicker and are generally recommended. Full urinary control, continence, and hemostasis may take 4 to 6 weeks after the procedure to fully normalize.

Special Situations

Controlling bleeding can be one of the more challenging aspects of transurethral prostate surgery. Here is a summary of some tips:

• Start patients on a 5 alpha-reductase inhibitor (finasteride or dutasteride) at least two weeks before the surgery.
• Stick with one area or lobe until it is completely finished. Partially resected lobes tend to bleed more.
• If a capsular perforation exists, do not waste time trying to cauterize it, as a Foley is usually necessary for bleeding control.
• Arterial bleeders should be cauterized but try to wait until the surgical capsule is reached.
• Do not use cautery if you cannot see the bleeding site. Instead, readjust the scope or increase the irrigation.
• If significant bleeding is encountered and a bleeding site cannot be seen, place the scope at the bladder neck and slowly withdraw it along the prostatic sidewall to the veru.
• If not successful, repeat the process after rotating the scope slightly.
• If still unable to find the bleeding site, check the opposite side and the roof.
• Bleeding sites at the bladder neck can be just inside the lip and bleed into the bladder. To identify, partially fill the bladder so the bladder neck lip will be pushed forward and into view. 
• When bleeding is well controlled, stop or reduce the irrigation rate to visualize more bleeding sites for cautery. 
• Ensure there are always more than enough bags of irrigation so you don't run out at a critical moment.
• Check for coagulopathy, especially in patients with known prostate cancer who are at increased risk for fibrinolysis. If confirmed, treatment of fibrinolysis would be aminocaproic acid or tranexamic acid.[29][30][31]
• Prostatic artery embolization by interventional radiology and limited radiation therapy can each help control otherwise intractable prostatic bleeding not amenable to surgical correction.

Prostate cancer may be discovered incidentally after a TURP, or patients with prostate cancer may develop urinary symptoms that are potentially amenable to transurethral surgery. TURP is not considered a definitive treatment for prostate cancer. For untreated prostate cancer patients, there is a higher incidence of postoperative incontinence and bleeding after TURP surgery. This is due to entrapment of the sphincter muscle by cancerous tissue, the reduced ability of small arteries to contract normally in malignant tissues, and the potential release of fibrinolysis from cancerous tissue during active resection.

Anti-fibrinolysis medications, such as aminocaproic acid, should be available in case of significant or life-threatening hematuria. Therefore, it is prudent and reasonable to perform only a "limited or channel" type TURP in patients with known prostate cancer. In these situations, only a central channel is made, and there is no attempt to extend out to the capsule. The immediate area around the veru is avoided to minimize postoperative incontinence. Prostate cancer patients who have undergone radiation therapy are at even higher risk of intractable, postoperative incontinence. TURP should not be done in patients considering brachytherapy or cryotherapy. Prostate cancer patients considering radiation therapy who have significant LUTS and are considering a TURP should have the surgery performed at least 30 days prior to starting definitive radiation therapy to minimize incontinence. 

Radical transurethral resection of the prostate (radical TURP) constitutes an attempt at complete prostatic adenoma removal by transurethral surgery. While similar to a standard transurethral resection, the radical TURP involves extending the limits of resection to the prostatic capsule until all visible tissue has been removed. It is used as a last-ditch treatment for intractable prostatitis, where success rates of up to 70% have been reported.[32][33][34] However, performing a radical TURP requires superior transurethral surgical skill, takes more time, is more difficult to perform, and carries higher risks of capsular perforation, hematuria, extravasation, incontinence, erectile dysfunction, and dilutional hyponatremia. Radical TURP has also been used successfully in highly selected cases of incidentally found focal prostate cancer.[35]

Pearls: Summary of Tips for Performing Large Prostates by TURP

• Do not attempt a larger prostate than you can reasonably handle within 90 minutes of operating time.
• Have everything ready and prepared, so you don't have to stop for supplies, instruments, or catheters.
• Be prepared to stop after just completing one side if it's taking too long. It is always possible to return another day to finish if necessary.
• Establish a regular rhythm.
• Make full-length slices from the bladder neck to the veru.
• Do not waste time cauterizing bleeding sites unless vision is seriously impaired or the capsule is reached.
• The resection does not have to be perfect; just good enough.
• Try to leave some extra time at the end to search for bleeders. 
• Using video can slow you down. Consider using just direct vision. The position of the surgeon's head will prevent inadvertent distal repositioning of the scope.
• It is a good idea to learn how to do the TURP both with video guidance and direct vision in case there is a problem with the video in the middle of the case.

Complications

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 the case due to excessive bleeding or poor visualization, extravasation, and subtrigonal or retroperitoneal placement of the Foley catheter.[36]  

It is expected that most, if not all, post-TURP patients will develop retrograde ejaculation and have no ejaculate, but erectile function is otherwise preserved in 90% of patients.[37]

Postoperative complications include transurethral resection syndrome (TUR syndrome), continuing urinary symptoms (which typically improve over time but may never resolve completely), retrograde ejaculation, infection including UTI and ongoing prostatitis, urethral strictures, bladder neck contractures, incontinence, urinary retention due to either obstruction or a poorly functioning bladder requiring intermittent self-catheterization or a catheter, and prostatic regrowth (which typically takes at least ten years).[38]

Incontinence after TURP surgery typically resolves within three months of the procedure. Kegel exercises and behavioral/pelvic floor modification treatments can be helpful. Complete or intractable incontinence is, fortunately, quite rare. 

Postoperative bladder neck contractures are more common after surgery on smaller prostates. It is suggested that more active management of postoperative urinary infections may help reduce the risk of bladder neck contractures.[39] 

Urethral strictures and the most common late complication of TURP surgeries. The overall risk of a urethral stricture or bladder neck contracture after TURP is 3.7%. Urethral trauma due to overly aggressive passage of the resectoscope, inadequate lubrication, or using an overly large resectoscope sheath without adequate dilation first is the most likely cause. 

Severe postoperative bleeding should be treated with a return to surgery for cystoscopic re-examination with the resectoscope. Most of the time, a single arterial vessel will be found to be bleeding. If this is not successful, interventional radiology may be able to embolize the prostatic artery, and a check should be made to look for a coagulation disorder.[40] Limited short-course radiation therapy (9 Gy per 3 fractions) may also be useful in controlling prostatic bleeding unresponsive to other measures.

An unrecognized bladder perforation can lead to abdominal distension, bradycardia (as an efferent vagal response), and hypotension with abdominal or shoulder pain. Such symptoms suggest an immediate cystogram. The procedure should be terminated as quickly as possible, and any significant bladder perforation surgically repaired.

Dilutional hyponatremia or "TUR syndrome" is a potentially dangerous complication of transurethral prostate surgery. This condition arises due to high volumes of hypotonic irrigation fluid used during the resection being absorbed intravascularly, causing dilutional hyponatremia and various neurologic symptoms, such as confusion, nervousness, nausea, hemolysis, visual disturbances, coma, shock, and even death. Early patient-reported symptoms include a  burning or prickly sensation of the face and neck, lethargy, and fearful ideations.

Patients at high risk include those with pre-existing hyponatremia, renal failure, increased irrigation fluid pressure (>60 cm of water), prolonged surgical operating time, unrecognized bladder perforation, and excessive bleeding.

Roughly 20 mL of fluid is absorbed per minute during TURP surgery, with about one-third entering directly into the venous system. Symptoms do not generally appear until the serum sodium is 125 mEq or less and are likely at 120 mEq/L, and >115 mEq/L is considered critical. The risk is essentially eliminated in TURP surgeries that utilize bipolar technology with normal saline irrigation, compared to monopolar instrumentation, where hypotonic solutions are required.[41] 

Initial treatment of mild to moderate cases of dilutional hyponatremia is with IV furosemide and normal saline. Correction of the hyponatremia should be done gradually.

Hypertonic saline 3% may be used cautiously in severe or symptomatic cases. The dosage is usually 150 to 200 mL at a time, administered over 1 to 2 hours. No more than roughly half the estimated sodium deficit should be corrected with 3% hypertonic saline. Correction of more than 20 mEq/L of serum sodium in 24 hours is not recommended. Estimated sodium deficit = (140-current serum sodium) x (body weight in kg) x (0.6). For example, a 70 kg man with serum sodium of 120 mEq would have an estimated sodium deficit of 840 mEq. (Normal saline contains 154 mEq/L of sodium, and 3% hypertonic saline has 513 mEq/L). Increasing the serum sodium by 4 to 6 mEq/L is usually sufficient to relieve symptoms and mitigate risks.[42] Overcorrection of the hyponatremia can be reversed with desmopressin.[43]

Prophylactic doses of hypertonic saline have been given in high-risk situations successfully.[44]

Trace amounts of ethanol (1%) can be added to the irrigation fluid, which allows for a reliable estimate of the total absorbed fluid to be made from a simple determination of alcohol in the breath.[45] 

If monopolar instrumentation is used, a postoperative sodium level should be checked if the surgical time is over 60 minutes, the pre-operative sodium is low, if the drainage for the continuous flow becomes inoperative, or if there is excessive bleeding. Severe or symptomatic hyponatremia is unlikely, with surgical operating times of 90 minutes or less. The overall risk of significant "TUR syndrome" in monopolar TURP procedures is estimated at only about 2%.[24]

While bipolar instrumentation minimizes hyponatremia, there may still be a substantial increase in intravascular fluid volume due to absorbed irrigation fluid from the procedure, and hyperchloremic metabolic acidosis has been reported.[25][46]

Clinical Significance

The clinical significance of a TURP is typically to relieve blockage due to obstructive enlargement of the prostate, but it can also unroof prostatic abscesses and relieve ejaculatory duct obstructions. The importance of a TURP for bladder outlet obstruction is to prevent obstructive nephropathy and bladder damage, LUTS, and UTIs due to incomplete emptying. If a patient utilizes CIC to empty the bladder, a TURP can allow for easier catheterization and less hematuria. Abscess management requires drainage, as it is difficult for antibiotics to penetrate the abscess cavities, especially in protected organs like the prostate. When patients have obstructive azoospermia due to ejaculatory duct obstruction, a transurethral incision or resection of the intraurethral portion of the duct can relieve the blockage and restore normal male fertility.  

Roughly 90% of patients indicate resolution or significant improvement in their urinary symptoms after TURP. The average reported degree of improvement is 85%. Men with the greatest degree of bother from their urinary symptoms generally reported the best outcomes. Urinary peak flow rates typically increase more than 100% after TURP, with an average increase in peak flow rate of an additional 10 mL/sec. Effective bladder capacity increases an average of 45% by six months post-TURP, and bladder instability is decreased by 50%.

Enhancing Healthcare Team Outcomes

TURP is typically an elective procedure used to treat prostatic enlargement resulting in symptomatic bladder outlet obstruction. 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 and family have appropriate expectations. This approach will ensure that patients are adequately prepared for their procedure and what to expect. Patients who are better informed are more invested in their decision and are happier with their outcomes. The procedure is elective and irreversible, so some extra review and discussion with the patient and family are reasonable.

Collaboration, shared decision-making, and communication are critical 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 evaluating all joint activities. The earlier the signs and symptoms of a complication are identified, the better the prognosis and outcome of the procedure. [Level 4]