Transurethral resection of the prostate is a urological operation. It is used to treat benign prostatic hyperplasia. As the name indicates, it is performed by visualising the prostate through the urethra and removing tissue by electrocautery or sharp dissection. It has been the standard treatment for BPH for many years, but recently alternative, minimally invasive techniques have become available. This procedure is done with spinal or general anaesthetic. A triple lumen catheter is inserted through the urethra to irrigate and drain the bladder after the surgical procedure is complete. Outcome is considered excellent for 80–90% of BPH patients. The procedure carries minimal risk for erectile dysfunction, moderate risk for bleeding, and a large risk for retrograde ejaculation.
Indications
BPH is normally initially treated medically. This is done through alphaantagonists such as tamsulosin or 5-alpha-reductase inhibitors such as finasteride and dutasteride. If medical treatment does not reduce a patient's urinary symptoms, a TURP may be considered following a careful examination of the prostate/bladder through a cystoscope. If TURP is contraindicated a urologist may consider a simple prostatectomy, in and out catheters, or a supra-pubic catheter to help a patient void urine effectively. As medical management of BPH improves, the numbers of TURPs have been decreasing.
Types of TURP
Traditionally, a cystoscope has been used to perform TURP. The scope is passed through the urethra to the prostate where surrounding prostate tissue can then be excised. A monopolar device utilizing a wire loop with electric current flowing in one direction can be used to excise tissue via the resectoscope. A grounding ESU pad and irrigation by a nonconducting fluid is required to prevent this current from disturbing surrounding tissues. This fluid can cause damage to surrounding tissue after prolonged exposure, resulting in TUR syndrome, so surgery time is limited. TURP using a bipolar device is a newer technique that uses bipolar current to remove the tissue. Bipolar TURP allows saline irrigation and eliminates the need for an ESU grounding pad thus preventing post-TURP hyponatremia and reducing other complications. As a result, bipolar TURP is also not subject to the same surgical time constraints of conventional TURP. Another transurethral method utilizes laser energy to remove tissue. With laser prostate surgery a fiber optic cable pushed through the urethra is used to transmit lasers such as holmium-Nd:YAG high powered "red" or potassium titanyl phosphate "green" to vaporize the adenoma. More recently the KTP laser has been supplanted by a higher power laser source based on a lithium triborate crystal, though it is still commonly referred to as a "Greenlight" or KTP procedure. The specific advantages of utilizing laser energy rather than a traditional electrosurgical TURP is a decrease in the relative blood loss, elimination of the risk of post-TURP hyponatremia, the ability to treat larger glands, as well as treating patients who are actively being treated with anti-coagulation therapy for unrelated diagnoses.
Risks
Because of bleeding risks associated with the surgery, TURP is not considered safe for many patients with cardiac problems. Postoperative complications include
Acute complications
Bleeding. Bleeding may be reduced by pre-treatment with an anti-androgen such as finasteride or flutamide.
Clot retention and clot colic. The blood released from the resected prostate may be stuck in the urethra and can cause pain and urine retention.
Bladder wall injury such as perforation. Intraperitoneal bladder rupture will present with upper abdominal pain and referred pain to the shoulder. Extraperitoneal bladder rupture may present with inguinal, peri-umbilical pain.
TURP Syndrome: Hyponatremia and water intoxication caused by an overload of fluid absorption length of the procedure is limited to less than one hour in many centers, and 2) the height of the container of irrigating solution above the surgical table determining the hydrostatic pressure driving fluid into the prostatic veins and sinuses is kept to a minimum. The classic triad of TURP syndrome includes elevated systolic and diastolic blood pressures with increased pulse pressure, bradycardia, and mental status changes.
In most cases, urinary incontinence and erectile dysfunction resolve on their own within 6 to 12 months post TURP. Therefore, many doctors will postpone invasive treatment till after a year passes. Some people also report an improved erectile function after TURP.
Retrograde ejaculation due to injury of the prostatic urethra. This is one of the most frequent complications of the procedure, which occurs in about 65% of patients.
