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.