Overview

Definition:
-Transurethral resection of the prostate (TURP) is a minimally invasive surgical procedure to remove excess prostate tissue that is blocking urine flow
-It is the gold standard treatment for symptomatic benign prostatic hyperplasia (BPH)
-Perioperative management encompasses the care provided to the patient before, during, and immediately after the surgical procedure to optimize outcomes and minimize risks.
Epidemiology:
-BPH is extremely common, affecting over 50% of men aged 50-60 and up to 90% of men over 80
-TURP remains one of the most frequently performed urological procedures worldwide
-Patient demographics typically include older men with lower urinary tract symptoms (LUTS) secondary to BPH.
Clinical Significance:
-Effective perioperative management of TURP is crucial for patient safety, reducing morbidity and mortality associated with the procedure
-It directly impacts the patient's recovery, length of hospital stay, and overall satisfaction with the surgical outcome
-For residents preparing for DNB and NEET SS, a thorough understanding of this topic is essential for clinical practice and examination success.

Indications

Absolute Indications:
-Acute urinary retention secondary to BPH
-Recurrent urinary tract infections due to bladder outlet obstruction
-Bladder stones associated with BPH
-Gross hematuria from BPH, refractory to medical management
-Renal impairment secondary to bladder outlet obstruction.
Relative Indications:
-Patient preference for surgical intervention
-Failure of medical management to adequately control LUTS
-Significant impact of LUTS on quality of life
-Documented detrusor underactivity secondary to chronic obstruction.
Contraindications:
-Uncorrected coagulopathy
-Active urinary tract infection
-Patient unlikely to tolerate anesthesia or surgery
-Prostate cancer (requires definitive treatment)
-Stricture urethra which may preclude resectoscope passage
-Patient's inability to lie supine for the duration of the procedure.

Preoperative Preparation

Patient Assessment:
-Comprehensive medical history focusing on LUTS, comorbidities, and previous urological interventions
-Physical examination including digital rectal examination (DRE) to assess prostate size, consistency, and nodularity
-Assessment of renal function (serum creatinine, urea)
-Coagulation profile (PT/INR, aPTT)
-Urinalysis and urine culture to rule out infection.
Medications Management:
-Discontinuation of anticoagulant and antiplatelet agents as per established guidelines, with consideration for bridging therapy if necessary
-Optimization of comorbid conditions such as hypertension, diabetes, and cardiac disease
-Alpha-blockers (e.g., tamsulosin) may be continued to facilitate voiding post-operatively
-Prophylactic antibiotics are generally not recommended unless there is evidence of infection.
Patient Education:
-Detailed explanation of the TURP procedure, including the risks and benefits
-Discussion about the expected outcomes, potential complications (e.g., bleeding, infection, retrograde ejaculation, erectile dysfunction, TUR syndrome), and the importance of postoperative care
-Informed consent must be obtained.
Anesthesia Considerations:
-Choice of anesthesia (spinal, general, or epidural) depends on patient's comorbidities, surgeon's preference, and duration of surgery
-Spinal anesthesia is often preferred as it allows the patient to be awake and report symptoms of TUR syndrome
-Adequate venous access must be established for fluid administration and monitoring.

Procedure Steps And Intraoperative Management

Resectoscope Insertion:
-A resectoscope, a specialized endoscope with a cutting loop and irrigation channel, is inserted into the urethra
-The bladder neck and prostate are visualized
-The bladder is distended with sterile irrigating fluid (typically glycine 1.5% or sorbitol 3% solution).
Tissue Resection:
-Using the electrocautery loop, the surgeon systematically resects adenomatous prostatic tissue in small chips, working from the bladder neck towards the apex
-The goal is to remove tissue from the transitional zone of the prostate, preserving the surgical capsule
-Bleeding vessels are coagulated as encountered.
Hemostasis:
-Careful hemostasis is achieved by coagulating bleeding vessels using the resectoscope loop or a separate coagulation probe
-The operative field is continuously irrigated to maintain visibility
-Inadequate hemostasis is a major contributor to postoperative bleeding and TUR syndrome.
Post Resection Irrigation And Catheterization:
-After resection, the bladder is thoroughly irrigated to remove prostatic chips and blood clots
-A Foley catheter (e.g., 3-way 16-22 Fr) is inserted to provide continuous bladder irrigation and hemostasis
-The balloon is inflated with a sufficient volume of saline (e.g., 30 mL) to provide tamponade effect on the prostatic fossa
-The catheter is secured to the thigh.
Fluid Management And Tur Syndrome:
-Continuous monitoring of the volume of irrigating fluid used and the patient's serum electrolytes is essential
-Transurethral Resection (TUR) syndrome occurs due to absorption of large volumes of irrigating fluid into the systemic circulation, leading to hyponatremia, hypoosmolality, and potential fluid overload
-Symptoms include nausea, vomiting, hypertension, bradycardia, confusion, and visual disturbances
-Management involves stopping the procedure, administering hypertonic saline if hyponatremia is severe, and supportive care.

Postoperative Care

Bladder Irrigation:
-Continuous bladder irrigation (CBI) with normal saline is initiated postoperatively to maintain catheter patency and prevent clot formation
-The rate of irrigation is adjusted based on urine color and clarity, aiming for clear or pink-tinged urine
-Once urine is clear, CBI can be discontinued.
Catheter Management:
-The Foley catheter is typically kept in place for 1-3 days
-Urine output, catheter patency, and signs of bladder spasm are monitored closely
-Pain management is provided for bladder spasms
-Catheter removal is usually performed once the patient can void spontaneously and the urine is clear.
Pain Management:
-Analgesics are administered for post-operative pain, which can include incisional pain (if open approach) and bladder spasms
-Antispasmodics (e.g., oxybutynin) may be prescribed to manage bladder irritation and spasms
-Opioids may be used for severe pain.
Monitoring And Discharge Planning:
-Vital signs, urine output, hemoglobin levels, and electrolytes are monitored
-Patients are educated on post-operative instructions, including fluid intake, activity restrictions, signs of complications (e.g., bleeding, fever, difficulty voiding), and wound care if applicable
-Discharge typically occurs once the catheter is removed, the patient can void adequately, and there are no signs of significant complications.

Complications

Early Complications:
-Bleeding: Can range from mild to severe, requiring transfusion or re-operation
-Urinary tract infection: Typically treated with antibiotics
-TUR syndrome: Due to irrigant absorption, a medical emergency
-Bladder perforation: Rare, may require surgical repair
-Postoperative urinary retention: Due to edema or clots.
Late Complications:
-Retrograde ejaculation: Most common long-term side effect, semen enters the bladder during orgasm
-Urethral stricture: Scarring and narrowing of the urethra
-Erectile dysfunction: Less common than retrograde ejaculation
-Incontinence: Stress or urge incontinence, usually temporary
-Bladder neck contracture: Scarring at the bladder neck.
Prevention Strategies:
-Meticulous surgical technique with emphasis on hemostasis
-Careful selection of irrigating fluid and monitoring its absorption
-Prompt recognition and management of TUR syndrome
-Adequate bladder irrigation postoperatively to prevent clot formation
-Careful catheter management and timely removal
-Patient selection and pre-operative optimization of comorbidities.

Key Points

Exam Focus:
-Key aspects for DNB/NEET SS: Indications and contraindications of TURP
-Risks of TUR syndrome and its management
-Common early and late complications, and their prevention
-Postoperative care including bladder irrigation and catheter management
-Choice of irrigating fluid and its implications.
Clinical Pearls:
-Always consider TUR syndrome in a patient with unexplained hypotension, bradycardia, or altered mental status during or after TURP, especially with prolonged operative times and large volumes of irrigant used
-Adequate tamponade with the Foley balloon is crucial for hemostasis
-Urine color is a critical indicator of bleeding and the need for CBI adjustment.
Common Mistakes:
-Failure to adequately assess coagulopathy preoperatively
-Inadequate hemostasis during surgery, leading to excessive bleeding
-Prolonged operative time leading to increased risk of TUR syndrome
-Insufficient bladder irrigation postoperatively, resulting in clot retention
-Dismissing early symptoms of TUR syndrome as general postoperative malaise.