eMedicine Specialties > Urology > Benign Prostatic Hypertrophy

Transurethral Resection of the Prostate: Treatment

Author: Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio
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Updated: Oct 3, 2006

Treatment

Medical Therapy

Approximately 25% of all candidates for TURP present with urinary retention and require preoperative catheter drainage. Some of these men may develop postobstructive diuresis and other electrolyte disturbances, which require appropriate management. An attempt should be made to lower elevated BUN and creatinine levels in patients who are thought to be azotemic due to urinary obstruction. For this, use continuous Foley catheter drainage for at least 2 weeks prior to any anticipated surgery.

Prolonged catheter drainage before a TURP may also be helpful in patients with decompensated hypotonic bladders to help them regain a more normal bladder capacity and muscle tone. Despite the severity of the obstruction, many of these patients respond well to medical management with alpha-blockade, 5-alpha reductase inhibitors, or both. After the creatinine level has normalized and the bladder has been given at least two weeks to regain muscle tone, a voiding trial should be attempted. If the patient is unable to void or is able to void but his creatinine level again begins to rise, the catheter should be replaced. Many surgeons give patients 2 or even 3 voiding trials before proceeding with surgery.

Preoperative urodynamic studies are only indicated in patients considered to have underlying neurologic disease or those who may have detrusor decompensation from chronic or recurrent urinary retention. Urodynamic testing results can help predict whether the chronically distended bladder has the capability to regain adequate muscle tone and capacity. One technique is to leave an indwelling catheter for a period of time (usually 2-4 wk) and then remeasure the bladder capacity and voluntary voiding pressure. A reduction in bladder capacity or an increase in voluntary voiding pressure suggests the potential for reasonably normal bladder function eventually.

Patients who do not regain bladder tone should be counseled that they are likely to continue to have difficulty voiding even after their prostate surgery. Long-term catheter drainage or intermittent self-catheterization should be offered to all patients with chronic retention as an alternative to TURP and especially to patients with poorly contractile or atonic bladders and those with exceptionally high medical risk factors for anesthesia and surgery.

Another option for patients with hypotonic bladders is to place a suprapubic tube at the time of the TURP. This tube can be left to gravity drainage and periodically clamped for voiding trials that typically start approximately one week after the procedure. If the patient voids well with low residual urine volumes, the suprapubic tube can be removed. If not, the suprapubic tube can be reconnected to the drainage bag and another voiding trial can be scheduled later. In many cases, the bladder eventually recovers enough to safely allow removal of the suprapubic catheter.

The use of preoperative finasteride (Proscar) has been demonstrated to help reduce bleeding during and after TURP surgery, although the optimal timing is unclear. A recent prospective study found that 2-4 months of pretreatment with finasteride significantly increased immediate postoperative hemoglobin levels, but only in patients whose resected prostatic weight was more than 30 grams, suggesting this may be most helpful in patients with larger prostates. Even 2 weeks of finasteride has been shown to have a beneficial effect on reducing blood loss during and after TURP surgery. Therefore, we generally recommend a minimum 2-week period of finasteride therapy preoperatively when possible because it appears to be effective in reducing operative and postoperative blood loss from TURP procedures.

Finasteride (Proscar) also reduces recurrent episodes of hematuria secondary to BPH. It may also help control excessive or prolonged hematuria after prostatic needle biopsy. Finasteride decreases suburethral prostatic microvessel density, inhibits prostate angiogenesis, and lowers prostatic vascular endothelial growth factor, which are the likely mechanisms by which it reduces prostatic bleeding.

Dutasteride (Avodart) is quite similar to finasteride and would be reasonably expected to have the same hemostatic effects. This is currently being studied, but at the present time, no hard data are available for confirmation.

Surgical Therapy

Electrosurgical TURP remains the standard for endoscopic removal of obstructive BPH tissue and is the primary focus of this review.

Open prostatectomy is more appropriate for larger prostates, in which endoscopic resection would be so lengthy that dangerous fluid shifts and other complications are more likely to occur. This is entirely dependent on the skill and experience of the operating surgeon. If the transurethral resection will take longer than 90 minutes of operating time to complete, then an open prostatectomy procedure or some alternative therapy is recommended. Surgeons need to know their own resecting capability and should not attempt a TURP in a prostate that is clearly too large.

Surgical alternatives to TURP

Surgical alternatives to TURP are designed to decrease blood loss, inpatient hospitalization, and fluid absorption, while still removing or destroying the obstructing prostatic tissue. These include the vaporization TURP (VaporTrode), bipolar TURP, photoselective vaporization of the prostate (PVP), and holmium laser enucleation.

Electrovaporization of the prostate

Electrovaporization of the prostate (ie, transurethral vaporization of the prostate [TUVP], electrical vaporization, or VaporTrode method) uses a ridged or pitted cylindrical metal roller electrode instead of the standard wire loop. This roller electrode conducts the electrical cutting current at very high energy levels, resulting in complete vaporization of the prostatic tissue it contacts. This method results in relatively good hemostasis with less bleeding and fluid absorption than the standard TURP.

Overall results are very similar to TURP, although flow rates are not quite as good and postoperative irritative symptoms are reported more frequently. Electrovaporization must be performed relatively slowly, which tends to limit the size of the gland that can be treated, and little or no tissue remains at the end of the procedure for pathological analysis. Newly developed modified vaporization/resection electrodes offer the opportunity to treat larger glands with electrovaporization and still retain sufficient tissue for pathological examination.

Bipolar TURP

Bipolar TURP uses electrosurgical resection, but cutting energy is delivered in a bipolar fashion rather than the straight monopolar current used in the traditional TURP. The instrumentation and surgical TURP technique are virtually identical except for the special bipolar electrical generator and the specially modified loops and resectoscopes. When the cutting current is applied, a plasma corona or field of ionization is formed between them, disrupting the molecular tissue bonds and effectively cutting the tissue. The original bipolar wire loops used two parallel wires spaced about 2 mm apart, but current models now use a single wire loop with the electrical ground return built into the shaft of the loop.

Collateral and penetrative tissue damage is reduced compared to standard monopolar TURP surgery. This is because the electrical energy is directed between the wire loop and its shaft within the resectoscope (bipolar method) rather than into the peripheral tissue from the active wire loop electrode to the grounding pad (monopolar TURP). This explains why less granulation tissue is formed with bipolar instrumentation. Additionally, less tissue charring occurs, which helps in identifying the surgical capsule and other landmarks.

Overall hemostasis is possibly slightly improved with the bipolar instrument, although rapid sweeping with the loop using coagulating current is less effective than with a monopolar system. Direct pressure on a bleeding site is the recommended technique while a coagulating current is used with bipolar technology while. The resected prostate chips are cleaner and have less coagulation or desiccation defects, which simplifies pathological examination.

The main advantage of bipolar TURP is increased patient safety because saline irrigation is used, which virtually eliminates TUR syndrome and dilutional hyponatremia. It also allows larger prostates to be resected without the usual time limitations. When used for bladder tumors, the bipolar instrumentation greatly reduces the risk of an obturator reflex because the electrical effect is directed superficially and away from any deep tissue or nerves.

The movement of the wire loop in the bipolar instrument is somewhat slower compared with standard TURP, but hemostasis is perhaps slightly better; consequently, the total surgical time is approximately the same. Overall intra-operative and postoperative bleeding, hospital stay, and late complications are essentially identical between the two technologies. A bipolar electrical generator is required, and the specially modified wire loops used are slightly more expensive than standard monopolar TURP loop electrodes. A fluid warmer is recommended, particularly with bipolar instrumention, not only because it increases patient safety by preventing hypothermia, which can occur with longer procedures, but also because warmed saline for irrigation decreases the lag time and allows for faster cutting.

Coagulating intermittent cutting device

A modified cutting system designed to decrease blood loss and hematuria has been developed for TURP. This new coagulating intermittent cutting (CIC) device uses a constant voltage pulse current with controlled pulse intervals to help reduce bleeding.

Photoselective vaporization of the prostate

Photoselective vaporization of the prostate (PVP) uses a high-power potassium-titanyl-phosphate (KTP) laser, also called the "greenlight" laser. KTP laser energy at 532 nm is highly absorbed by oxyhemoglobin and only penetrates 1-2 mm deep into the prostatic tissue, making it theoretically superior to other types of prostatic laser vaporization procedures. Modern KTP lasers produce 80 watts of average power and 240 watts of peak power, which vaporizes the prostatic tissue fairly rapidly. The limited tissue penetration, compared to Nd:YAG lasers, minimizes the adverse effects associated with other types of prostate laser vaporization. The PVP procedure has excellent hemostasis because the blood vessels are rapidly sealed by the KTP laser energy. No tissue is available for analysis, but the procedure can be performed relatively quickly. In the hands of skilled operators, typical operating times are less than 1 hour for glands up to 100 grams.

Holmium enucleation of the prostate

Holmium enucleation of the prostate uses holmium laser energy to carve out the two lateral lobes of the prostate in an endoscopic version of an open enucleation. The tissue removed is generally too large to be removed through the resectoscope; therefore, a tissue morcellator must be introduced and the tissue, floating free in the bladder, must be captured and fragmented, while avoiding contact between the morcellator and the bladder wall. This method offers good hemostasis and allows tissue to be saved for histological evaluation. However, this modality is very technically challenging and can be quite time-consuming.

Reports comparing these various prostatic ablative techniques by Van Melick et al, Eaton and Francis, and Gilling et al show that they all demonstrate improvement that is roughly equivalent to TURP in terms of urodynamics, symptom scores, and uroflowmetry parameters for at least 7 years.

Noble and colleagues compared these techniques in a randomized, controlled trial from a strictly economic point of view. They concluded that noncontact laser therapies tended to be the most costly surgical treatment option, while TURP was the most cost-effective.

Minimally invasive procedures for BPH

Minimally invasive surgical therapies for BPH, such as interstitial laser coagulation, free-beam laser therapy, radiofrequency ablation, transurethral needle ablation, prostatic urethral stents (UroLume), and alcohol injection, are relatively simple procedures that can usually be performed in an outpatient setting, often with decreased postoperative catheterization time.

For patients at very high medical risk who cannot safely undergo significant anesthesia or surgery, these minimally invasive treatments may offer some benefit. Prostatic urethral stents, for example, have been suggested as a reasonable BPH treatment alternative when medical therapy has failed and the medical risks of surgery are unacceptably high. Stent migration, dysuria, and pain are relatively common complications but are easily reversible with stent removal.

These minimally invasive methods do not allow tissue to be saved for pathological analysis and do not remove the entire adenomatous prostate; thus, retreatment and even TURP is sometimes required later. Up to 25% of patients who receive these minimally invasive treatment alternatives ultimately undergo a TURP within 2 years.

General principles of transurethral prostate resection

Many variations are described for the basic operative approach to TURP. Various regions of the country and specific teaching institutions use slightly different techniques to perform the procedure. However, a number of general principles are applicable to all variations of transurethral prostate resection.

The beginning

• Use of a plastic barrier sheath (eg, Lingeman sheath, O'Connor sheath) helps maintain sterility and protects the operative field, while allowing digital manipulation of the prostate through the rectum.
• Make sure the patient is positioned with the buttocks flush with the end of the cystoscopy table. Resection of the anterior prostate opposite the bladder neck can be impaired when deflection of the resectoscope is restricted by the edge of the cystoscopy table. Varying patient height to a comfortable level and using the Trendelenburg position appropriately should make the resection easier and more comfortable and can facilitate visualization.
• If the patient has been catheterized, gentle irrigation of the urethra with a Toomey or bulb syringe rinses mucus, blood clots, and other debris into the bladder, where these materials will not interfere with vision. This debris can then be easily rinsed out when the bladder is drained through the cystoscope.
• Importantly, the procedure always begins with a careful cystoscopic inspection of the anterior urethra, external urinary sphincter, verumontanum, prostatic urethra, bladder neck, prostatic median lobe, trigone, ureteral orifices, and the rest of the bladder using a small-caliber cystoscope (see Image 15). This inspection is important not only to verify the absence of associated pathologies (eg, bladder tumors, urethral strictures, vesical stones), but also to help the surgeon obtain a clear 3-dimensional mental image of the patient's specific anatomical features and relationships.
• The initial cystoscopy should be performed gently, avoiding contact with the superficial surface of the enlarged lateral and medial lobes of the prostatic urethra as much as possible. Their surface is often hyperemic and they bleed easily, which interferes with vision during the cystoscopy and resection.
• The relative distance between the ejaculatory ducts of the verumontanum and the proximal edge of the external sphincter muscle should be carefully noted in order to better judge the absolute distal limits of resection. Despite the fact that 10-20% of the prostate may extend distally beyond the verumontanum, especially in larger prostate glands, the verumontanum remains the distal margin of resection in most circumstances. In very large prostates, some expert and experienced resectionists remove apical and lateral lobe tissue located adjacent or slightly distal to the verumontanum, arguing that failure to remove this tissue results in an incomplete resection and postoperative voiding difficulties in some patients. However, the risk of inadvertent and permanent injury to the external sphincter muscle is quite high when resecting in this area, so caution is advised.
• Always know exactly where the verumontanum is located and do not resect it. Without this anatomical landmark, one can easily lose orientation and risk damaging the external sphincter muscle, causing the patient to be permanently incontinent. If, during the case you are not absolutely certain of your exact location, orientation, or position relative to the verumontanum, stop resecting immediately and reorient by finding a stable landmark such as the bladder neck or verumontanum.
• Avoid resecting or cauterizing the verumontanum. Besides removing an important landmark, this may also lead to painful ejaculation later.
• The external sphincter muscle is identified by (1) its wrinkling and constricting action as the resectoscope is withdrawn and (2) the bunching-up of the superficial mucosa just in front of the telescope as it is reinserted. The fibers of the external sphincter are imbedded within the urogenital diaphragm, which is relatively fixed in position, while the prostate has some limited mobility.
• Confirm that the cutting loop of the resectoscope fits perfectly into the sheath without any gaps. This helps avoid tags of tissue that interfere with vision and would have to be cut again, wasting valuable time.
• Instruments should be carefully checked before starting. In particular, check that any insulating pieces, attachments, parts, or tips are firmly secured. Some continuous flow systems use a plastic insulating beak at the end of the inner sheath, which can come loose and break off in the bladder during surgery. If this occurs, removal can be challenging. Meanwhile, the patient is most likely actively bleeding, absorbing additional irrigating fluid, and delaying the completion of the surgery.
• A spare telescope and sheath, extra cutting loops, a backup electrosurgical unit, instruments for a perineal urethrostomy, and a small (24F) resectoscope set should be immediately available in case they are needed. The smaller resectoscope set should be used if the urethra proves to be narrower than expected. A perineal urethrostomy is helpful in patients with severe contractures, if urethral strictures are encountered, or if the urethra is so long that it makes the resection difficult.
• An isotonic solution should be used for intraoperative irrigation to prevent intravascular hemolysis if hypotonic fluid, such as water, is absorbed into the large venous sinuses frequently exposed or unroofed during transurethral prostate surgery. Although isotonic, the electrolyte composition of normal saline dissipates the electrical current, preventing adequate cutting and coagulation of tissue. Isotonic irrigating solutions of glycine, sorbitol, or mannitol are used most often. Although they prevent hemolysis, these solutions can still cause hyponatremia, confusion, and visual disturbances if large volumes are absorbed.
• Irrigating fluid should be kept at the lowest height (pressure) level possible to maintain an adequate flow. Raising the irrigating fluid level from 60 cm to 70 cm height has been shown to dramatically affect fluid absorption. A starting fluid height of 60 cm is suggested and is usually sufficient.
• Irrigating fluid should be warmed to body temperature to avoid chilling the patient, and adequate fluid should be available. Surprisingly large volumes of fluid may be needed if continuous-flow instrumentation is used.
• The resectoscope sheath should be well-lubricated and placed with the aid of an obturator to prevent trauma to the urethral mucosa or false passage formation.
• A perineal urethrostomy may be necessary or advisable if the patient has severe medial contractures of his lower extremities that prevent adequate access to the penis, a penile prosthesis, or other significant penile or pelvic deformity. One of the most common mistakes made in TURP surgery is the failure to use a perineal urethrostomy appropriately (see Image 16).

The middle - Performing the resection

• Resect tissue only when pulling or withdrawing the cutting loop toward the resectoscope, never when pushing it forward. This cleanly separates the resected tissue from the rest of the prostate gland and prevents tunneling, perforation, bladder injury, and extravasation.
• If a very large and obstructing median lobe is present, resect this first regardless of the method chosen for the rest of the transurethral resection (see Image 17).
• Always keep in mind and follow an orderly resection plan, regardless of which technique is used. As Winston Mebust noted, "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."
• Once the resection has been started in a particular area, that portion of the resection should be finished completely before moving on to another location. Performing a partial or incomplete resection in several lobes at once is discouraged because of the resultant increased bleeding and fluid absorption. Also, terminating the procedure quickly, if necessary, is more difficult.
• The surgeon should always be prepared to terminate the procedure with relatively little notice if the patient develops complications. This is aided by finishing the resection completely in one area of the prostate at a time. In these cases, good results have generally been reported when at least one complete lobe has been resected. In some very high-risk patients, it may be reasonable to intentionally complete only the median lobe and one lateral lobe so as to reduce the total anesthesia and operating times.
• When resecting at the bladder neck, make sure enough fluid is present in the bladder to keep the posterior bladder wall away from the surgical area. Approximately 100 mL prevents accidental posterior bladder wall injury and perforation. Before resecting at the 4 to 5-o'clock and 7 to 8-o'clock positions at the bladder neck, visually check the position of the ureteral orifices to prevent their inadvertent resection. Once the inferior bladder neck area has been adequately resected, respect the margin as the proximal limit of resection. Resecting additional tissue from the bladder neck later during the procedure is often tempting, but this often results in undermining the trigone and inadvertent resection of one or both ureteral orifices.
• If one or both ureters are inadvertently resected, avoid using cautery near the cut end to prevent scarification and possible hydronephrosis. This usually heals without problems.
• When cutting the anterior tissue at the 12-o'clock position, making relatively shallow straight cuts is better, which leaves the surface fairly flat, rather than trying to make it concave or curved. The prostate is thinnest here; the external sphincter is at its most proximal position and the risk of perforation is relatively high, especially if this area is resected early in the case.
• Try to resect using long smooth strokes (see Image 18). This prevents chopping of the prostatic fossa, avoids capsular perforations, helps limit bleeding, and shortens the overall resection time.
• The adenomatous tissue of the hypertrophied prostatic adenoma is usually somewhat irregular, off-white to light-yellow in color, and appears slightly granular or nodular. This changes to the smooth, white, glistening, vertically striated surface of the compressed peripheral zone tissue when the surgical capsule is reached. This is the lateral limit of resection because going deeper causes perforations, with extravasation and increased bleeding.
• Try to resect all the prostatic tissue possible without perforating the capsule or unduly extending the operating time. Residual tissue can regrow, foster infection, increase fluid absorption, and tends to bleed. An old urology axion states "It is not how much is taken out that causes the postoperative problems, it is how much is left in."
• Priapism can be dealt with by changing the level of anesthesia or by direct corporal injection of an alpha-adrenergic vasoactive compound such as phenylephrine. We use a diluted solution of 10 mg phenylephrine (1 mL) mixed with 49 mL of isotonic sodium chloride solution to make a solution of 0.2 mg/mL. One to two mL at a time is injected into the corpora cavernosa every 10-15 minutes as needed.
• If resecting at an angle or in a location at which the verumontanum is not clearly visible, make sure the instrument is held very steady, without any distal migration of the resectoscope sheath. If unsure, check the relative position often by rotating or slowly withdrawing the resectoscope until the verumontanum is visible.
• Avoid cutting off a large block of tissue that will float freely in the bladder. This becomes very difficult to extract from the bladder and requires chopping or resecting the tissue, which is mobile and unstable. This wastes valuable time that is better spent elsewhere and risks a bladder injury.
• Avoid unnecessary use of cautery because it damages normal tissue, increases postoperative irritative symptoms, and promotes scarring, especially at the bladder neck. Cautery involving the verumontanum is discouraged because it can result in painful ejaculation.
• Immediately cauterize larger bleeding vessels that interfere with vision because another chance may not be available later. Do not cauterize vessels in areas where additional resecting will be performed, unless the tissue cannot otherwise be visualized. This prevents repeated cauterization of the same vessel. Waiting until the surgical capsule is reached before cauterizing the bleeding vessels is better.
• Do not try to cauterize bleeding venous sinuses because this is a waste of valuable time and may make the bleeding worse. This is one of the harder rules to follow.
• Do not do any resecting or cauterizing if visibility is not adequate. The danger of accidentally perforating the prostatic capsule, resecting the ureteral orifices, or injuring the external sphincter muscle is significant if visibility is not adequate.
• If bleeding is obscuring visibility, try increasing the irrigation fluid inflow rate or evacuating the clots and resected prostatic chips with an Ellik or other evacuator, then reexamine the last area of resection from a slightly different angle. If this fails, position the scope at the bladder neck and slowly pull the resectoscope out distally toward the verumontanum, while keeping the tip of the telescope close to the wall of the prostatic fossa and maintaining the same rotational angle. This can be repeated at a slightly altered angle until the bleeding source is found and cauterized. Make sure the irrigation fluid is flowing adequately. A bleeding vessel at the bladder neck may often be visualized best by filling the bladder. This rotates the inner lip of the bladder neck distally and makes it visible for cauterization (see Image 19).
• Keep a constant watch on the outflow irrigation fluid color to help monitor blood loss. Also, keep track of the elapsed resection time because the complication rate increases in direct proportion to the actual duration of surgery. Optimal resection time is less than 60 minutes. Complication rates increase dramatically when the resection time is prolonged beyond 90 minutes.

End of the surgery

• Do not attempt a TURP on a prostate that is too large for the procedure to be reasonably completed in 90 minutes of resecting time. Either do the case via an open technique, send the patient to a colleague with more experience in TURP surgery, or perform some alternative procedure. If in the middle of the case and unable to complete the entire resection in 90 minutes, at least finish one lateral lobe, the median lobe (if enlarged), and the bladder neck. This often results in very good clinical outcomes and offers essentially the same symptom relief as the completed TURP.
• Watch out for the tendency to extend the resection well beyond the bladder neck and into the trigone, which has been called "trigone creep." This is easily done, especially if one has not already performed a bladder neck resection and created the margins or border for the proximal resection. Once the anatomical landmarks have been identified and the borders have been established, do not resect beyond them.
• The raised edge of the resected posterior bladder neck often appears more obstructing than in actuality. If necessary, a midline incision through the bladder neck with a Collings knife can be made at the end of the case, which separates the bladder neck fibers and opens the passage, while avoiding injury to the ureteral orifices. It may also help prevent bladder neck contractures, especially in smaller prostates.
• Unless very skilled, keep the resectoscope relatively still while resecting so that orientation with regard to the verumontanum is never in doubt. Expert resectionists can move the cutting loop and the resectoscope at the same time to carve the prostatic fossa, which is basically a curved concave surface when the hypertrophied adenoma is removed. This lateral-to-medial carving motion is very useful in dealing with larger prostate glands; however, losing orientation and landmarks is easy, which can result in an unintentional extension of the resection distal to the verumontanum, thus risking incontinence if the surgeon is not extremely careful.
• Save the risky areas for the end of the case, especially the area around the verumontanum. It is often very tempting, especially in larger prostate glands, to continue the resection distal to the verumontanum when tissue is present that appears to be obstructing, but this should be discouraged except for very skilled and experienced resectionists. Leaving a small amount of nonobstructing prostate tissue near the verumontanum is much better than risking permanent incontinence through an injury to the external sphincter muscle.
• To help in resecting the tissue immediately around the verumontanum, inserting a finger in the rectum to raise the apical tissue is very useful. Another helpful technique is to stand and angle the scope downward toward the verumontanum, which exposes more apical tissue (see Image 20).
• When the resection is completed, reinspect the prostatic fossa from the verumontanum and then at the bladder neck. Significant hanging or retracted tissue tags that were previously hidden by the sheath may now fall into view (see Image 21). These are seen most easily with the scope inverted to look at the roof of the prostatic fossa. These remnants and tags should be resected only if they contain significant prostate tissue. The tags can be physically lifted from the inner bladder surface by the cutting loop before applying current and resecting them. This helps prevent bladder injuries. Mucosal flaps can be left alone because they will slough by themselves. Some tissue tags retract into the bladder from the vesical neck; look for these specifically. They can be seen most easily when the bladder is full, which will rotate the inner lip of the bladder neck outwards and make these tags more visible.
• A useful tip for finding small bleeding vessels at the end of the case is to slow down the flow of irrigation. This allows even a small bleeding vessel to become visible for cauterization.
• The most common area of injury to the external sphincter is at the 12-o'clock position, where direct visualization of the verumontanum is not possible. Therefore, be extremely careful at the distal surgical margins, particularly when resecting at the 12-o'clock position opposite the verumontanum, to avoid inadvertent damage to the external sphincter.
• When the case is completed, carefully place the Foley catheter and make sure it irrigates properly. When a catheter guide is used, the Foley catheter may perforate the prostatic capsule and end up in the retroperitoneum. If not recognized and corrected quickly, this causes considerable morbidity. If unsure of the catheter's position, replace the catheter or perform a quick cystogram to verify the location.
• Placement of a belladonna and opium (B&O) suppository just before taking the patient's legs down at the end of the case reduces immediate postoperative bladder spasms and provides some analgesic relief as the anesthetic wears off.
• Before removing the resectoscope at the end of the case, make absolutely certain that all significant bleeding vessels have been cauterized, the ureteral orifices and verumontanum are intact, the external sphincter has not been damaged, and all resected prostatic chips have been removed from the bladder. Be sure to check the interior of any bladder diverticula for resected chips that could clog and block the postoperative Foley catheter. A few extra minutes spent on hemostatic control at the end of the procedure is time well spent and may avoid an unplanned return to the operating room.

Preoperative Details

Anesthesia

Spinal anesthesia is generally preferred for transurethral resections for a number of reasons, not the least of which is the ability to converse with the patient and to evaluate him for symptoms of an early dilutional hyponatremia (ie, TUR syndrome) during surgery. Spinal anesthesia may make recovery a little easier with better pulmonary toilet. Patients recovering from a general anesthetic often cough heavily, which tends to increase hematuria.

A large national survey and cooperative study of 13 institutions by Mebust and colleagues confirmed that up to 79% of transurethral prostate resections are performed with the patient under spinal or epidural anesthesia.

A 1998 study by Fredman and colleagues compared general versus spinal anesthesia in patients older than 60 years undergoing short transurethral prostate surgery. The study demonstrated that general anesthesia with propofol and desflurane facilitated shorter induction and recovery times without adversely affecting patient comfort. In this study, these general anesthetic agents appeared to be preferable to spinal anesthesia for TURP, at least in this particular age group.

Several studies have failed to show any significant differences in complication rates, operative mortality and morbidity, or blood loss between regional and general anesthesia. Transurethral resections have even been performed with local anesthesia and sedation, although these have only been performed on relatively small prostates averaging just 11 grams of resected tissue.

The obturator nerve runs near the prostate and can be electrically stimulated during transurethral prostate surgery, causing a violent thrusting of the leg, which is called the obturator nerve reflex. This reflex can possibly lead to inadvertent intraoperative surgical complications. The problem of unintentional obturator nerve stimulation can be corrected under general anesthesia by paralyzing the patient. The obturator reflex most often occurs while resecting bladder tumors on the lateral walls of the bladder. In these cases, the reflex may be prevented by injecting a local anesthetic into the sensitive area through a special needle passed through the resectoscope.

Anticoagulants

Patients should be taken off anticoagulants at an appropriate time prior to surgery.

For most patients on warfarin (Coumadin), this is 3-4 days preoperatively. PT and aPTT should be checked just prior to the surgical procedure.

For patients on clopidogrel (Plavix), 14 days off the medication prior to TURP surgery is recommended, but 10 days may be sufficient. Unlike other surgeries, TURP relies more heavily on normal coagulation to help control postoperative bleeding. Only a bleeding time can help determine if any lingering anticoagulant effects from the clopidogrel are present. Platelet transfusion is the only way to correct the anticoagulant effects of clopidogrel but should be used only as a last resort when absolutely necessary.

In selected cases in which an unusually high medical risk exists for the patient, short-term heparinization can be used while other anticoagulants are discontinued. The heparin can then be reversed just before surgery. This technique requires careful monitoring and usually hospitalization. In such situations, careful consideration should be given to alternative treatments for BPH, such as medical therapy, interstitial laser coagulation, KTP laser vaporization (PVP), intermittent catheterization, suprapubic tube placement, permanent Foley catheterization, or a urethral stent.

A recent study by Dotan and associates compared patients on Coumadin who received either a standard protocol of anticoagulant discontinuation or low molecular weight heparin substitution. They found that the surgical blood loss was approximately equal between the 2 study groups and that neither received any additional blood transfusions. However, the heparinized group required more inpatient hospital days because of prolonged hematuria and a longer period of catheterization that averaged approximately 2 days more than the group who received the standard therapy. This study suggests that low molecular weight heparin substitution may be a reasonable alternative to oral anticoagulant discontinuation for selected patients.

Even low-dose aspirin has been shown to increase bleeding after transurethral prostate surgery. Nielsen and associates from Denmark reported a prospective, randomized, double-blind, placebo-controlled study on this subject. Patients were randomized to receive either a single-dose placebo or 150-mg aspirin tablet 10 days before surgery. No significant difference was noted in resected tissue weight, operative time, complications, or intraoperative blood loss, but postoperative bleeding was significantly higher in the group that received aspirin. Therefore, we recommend that aspirin be stopped at least 10 days prior to surgery and, preferably, 14 days before.

The issue of when to restart anticoagulants after transurethral prostate surgery is debatable. The timing is highly variable and depends on many factors, such as the original reason for anticoagulation, the patient's overall clinical situation, the size and difficulty of the transurethral surgery, and the degree and length of postoperative bleeding, among others. We generally wait until the urine is grossly clear for 24 hours before resuming warfarin (Coumadin), but having the urine grossly clear for 48 hours is recommended before restarting clopidogrel (Plavix) or aspirin because of the longer half life of these agents and the inability to easily reverse them, if needed.

Irrigating solutions

During the TURP procedure, one of a number of solutions may be used for irrigation. Saline cannot be used because it conducts electricity, which diffuses the current and prevents it from cutting or cauterizing tissue. Also, the current can possibly be transmitted down the shaft of the resectoscope and affect the surgeon. If the electrosurgery (cautery) unit does not appear to be functional, inadvertent use of normal saline (isotonic sodium chloride) irrigation is one of the first things to check besides the grounding pad, power switch, and cord connections. If normal saline is accidentally used, no cutting or coagulating will occur. It will appear as though the electrosurgical unit is not working.

Solutions that do not conduct electricity, such as sterile water, glycine, and sorbitol/mannitol, must be used instead of isotonic sodium chloride solution during transurethral prostate surgery. Sterile water is rarely used because, when absorbed in large quantities during the procedure, it causes hyponatremia, intravascular hemolysis, and hyperkalemia. Therefore, nonhemolyzing solutions of sorbitol/mannitol or glycine are used most often.

These relatively isotonic agents protect against hemolysis but cannot prevent dilutional hyponatremia because their intravascular absorption increases fluid volume without adding any sodium. The original nonhemolyzing irrigating solution recommended by Creevy in 1947 was 4% glucose, which is no longer used in modern transurethral surgery. However, as noted by Collins and associates, a 5% glucose solution may be a reasonable and economical substitute for the much more expensive glycine irrigation fluid in developing countries, where it would be less hemolyzing and safer than sterile water.

Glycine is probably the most popular irrigation media used for TURP surgery, with an osmolality of approximately 200 mOsm/kg compared to normal serum (290 mOsm/kg). While not truly isotonic, it is close enough to be essentially nonhemolyzing. The metabolism of glycine into glycolic acid and ammonia has been postulated as a contributing factor to TUR syndrome. Studies performed on rats given intravenous and retroperitoneal glycine found toxic effects from the glycine on the liver, kidneys, and pancreas.

Glycine inhibits neurotransmission and may rarely cause visual disturbances if absorbed in large amounts. Complaints of prickling sensations, increased nausea, hypotension, bradycardia, and confusion have been reported when more than 1000 mL of glycine has been absorbed. Progressively increasing adverse effects occur as the amount of absorbed glycine increases. This becomes potentially serious when 3000 mL or more is absorbed. However, most experts believe these effects are relatively insignificant during routine TURP procedures. Using sorbitol/mannitol (Cytal) solution helps avoid these problems. Glycine toxicity has been linked to the rare fatality, but this is considered an extremely rare event.

As mentioned earlier, a new bipolar resectoscope with a redesigned generator that can operate safely with normal saline (isotonic sodium chloride solution) irrigation is now available. Instead of a grounding pad on the patient, the ground electrode is placed inside the sheath of a modified continuous-flow resectoscope, allowing the cutting current to pass directly between the wire loop and the sheath, or is built into the electrode itself, where the more proximal of the dual adjacent, parallel wire loops acts as the ground.

The advantages of such a system include the total elimination of hyponatremia (TUR syndrome) because normal saline is used as the irrigant. The current generated by a bipolar instrument tends to remain superficial, which generally prevents the potentially dangerous obturator reflex often associated with transurethral resection of bladder tumors. The wire loop may be slightly smaller than a conventional resectoscope, but it otherwise looks and operates the same. No special or additional surgical skills are required. This type of technological improvement permits transurethral endoscopic surgeries to be performed more safely, especially in high-risk patients and those at particular risk for dilutional hyponatremia or iatrogenic trauma from an inadvertent obturator reflex. Overall surgical time and blood loss are comparable with those of the standard TURP.

Hypothermia

Room-temperature irrigation can result in a substantial decrease in the patient's core body temperature, particularly if continuous-flow irrigation is used. Other factors that may increase the risk of hypothermia include longer resection times, larger amounts of irrigating fluid absorbed, increased prostate size, small body habitus, and low body weight. Ambient temperature in the operating room is another important factor. Aside from postoperative chilling and shivering, bodily cooling produces a number of cardiovascular changes such as bradycardia, reduced cardiac output, higher mean arterial pressure, increased cardiac stress, and greater vascular resistance.

Hypothermia, defined as a core body temperature of 36°C or less, induces shivering, which has been shown to increase oxygen demands by as much as 500%. Hypothermia is particularly worrisome, as the core body temperature approaches 35°C or less, which is sufficient to induce angina, cardiac arrhythmias, and myocardial infarctions. Therefore, irrigating fluid warmed to body temperature is strongly recommended, along with the use of warming blankets and other appropriate thermal modalities. No significant increase in blood loss has been found with the use of irrigating fluid warmed to body temperature. Warmed saline may also improve the performance of bipolar TURP instrumentation. A high-flow, low-pressure fluid warmer specifically designed for TURP irrigation is commercially available from Smiths Medical. (For information on their Level 1 "NormoFlo" model H-1100 fluid warmer, call 1-800-553-8351 or go to www.smiths-level1com/fluid_warming_normo.htm.)

Preoperative antibiotics

Some controversy exists regarding the use of systemic antibiotics prior to the initiation of prostate surgery. The majority of studies have demonstrated a benefit, and most urologists use them routinely. A broad-spectrum cephalosporin or fluoroquinolone is usually preferred. Elderly patients with BPH often have moderate postvoid residual values, bacteriuria, and/or frank urinary infections. Preoperatively, up to 25% of patients with BPH have a documented urinary tract infection. With these issues in mind, administering a preoperative systemic antibiotic seems reasonable and prudent.

Patients with indwelling Foley catheters are presumed to be infected regardless of culture results and should be routinely given broad-spectrum antibiotic coverage before surgery. Culture-specific antibiotics are preferred.

The issue of how long to maintain the antibiotics and whether to use them postoperatively is even less clear, although some evidence indicates that 2 weeks of postoperative antibiotic coverage can help reduce urethral stricture formation. A recent meta-analysis by Berry and Barratt suggested that the type of antibiotic was relatively unimportant when used prophylactically in low-risk individuals. They found that prophylaxis significantly decreased bacteriuria and septicemia, even in men with sterile urine preoperatively. Effective agents included quinolones, aminoglycoside, sulfa-trimethoprim, and cephalosporins. Such prophylaxis reduced septicemia rates from 4.4% to 0.7% in these low-risk patients. Short-course therapy was found to be more effective than single-dose regimens, regardless of the agent chosen.

After postoperative catheter removal, we generally use doxycycline (Vibramycin), TMP/SMX (Bactrim, Septra) or a nonsystemic urinary antiseptic such as nitrofurantoin (Macrobid). The partially devascularized and necrotic prostatic tissue tags and any remaining tissue remnants are perfect breeding grounds for bacteria; therefore, some antibacterial prophylaxis should probably be maintained for at least the first 15 days after a TURP. This may also help reduce urethral stricture formation.

Continuous flow

• Coaxial continuous-flow instruments
  • Continuous-flow resectoscopes are designed to eliminate the need for intermittent bladder evacuations, which interrupt the resection and waste time while the surgeon needs to become reoriented. They also help maintain low fluid pressure in the prostatic fossa and bladder, which should reduce fluid absorption.
  • The main disadvantages are the tendency of the resected chips to sometimes flow toward the telescope and interfere with vision; the slightly reduced wire loop size available because of the coaxial nature of the instrument; and the lack of any definitive study that proves they actually save time, reduce blood loss, or decrease absorption of irrigation fluid intraoperatively. Nevertheless, most urologists find continuous-flow instrumentation convenient and beneficial.
• Suprapubic trocars
  • Suprapubic trocars can also be used to establish continuous-flow irrigation. These instruments require a small skin incision and create a small cystostomy wound in the bladder, but they offer several distinct advantages over the more popular single coaxial continuous-flow instruments. Chips and irrigation flow away from the telescope toward the drainage tube in the bladder, which improves visualization. A larger wire loop can be used with the same caliber resectoscope sheath. Finally, suprapubic trocar continuous-flow drainage has been shown to maintain bladder fluid pressure below pelvic venous pressure levels, which keeps fluid absorption down.
  • The suprapubic trocar can keep the bladder fluid pressure at or below only 8 cm of water, which is well below the 10-15 cm of water pressure of the pelvic veins and periprostatic venous system. When compared directly to a coaxial continuous-flow system, the suprapubic trocar technique has been found to allow shorter operating times with lower intravesical pressures and less fluid absorption.
  • We prefer to use a suprapubic trocar for establishing continuous-flow when trying to resect larger prostates (>80 g), following the technique of Paul O. Madsen of Madison, Wisconsin. Madsen extensively studied fluid absorption during transurethral prostate surgery and routinely used temporary suprapubic trocar cystostomies for continuous flow in his TURP procedures. The technique is especially useful in larger prostates, or even in prostates of moderate size when only a 24F sheath can be used. This way, a full-thickness cut of tissue can be made without compromising the flow of irrigation. Also, resected chips tend to flow away from the telescope toward the intravesical trocar site, improving visualization and making the procedure easier to perform.
  • We use the Wolf 14F suprapubic trocar because it rarely clogs and can be placed easily. The placement technique is to fill the bladder to capacity (or with at least 200-300 mL) while the resectoscope is in place and then make a small suprapubic stab wound approximately 1 cm above the pubic symphysis. The trocar is placed into the stab wound, with the sharpened obturator tip angling slightly superiorly toward the patient's head. This is performed in such a manner that the final intravesical trocar position is angled toward the posterior bladder wall and away from the resection site. Pressure is applied to the trocar to allow it to penetrate into the bladder. The sharpened obturator tip is then replaced with the fenestrated drainage insert attached to suction tubing. The other end of the suction tubing is in a floor drain. No mechanical suction is needed because gravity provides an adequate flow rate.
  • The key to placement of the suprapubic trocar is to have the bladder completely filled before attempting to place the trocar. This can be achieved safely even in patients with previous abdominal surgery. At the end of the case, when the Foley catheter is in place and the irrigation fluid is clear, the suprapubic trocar is removed and the stab wound site is covered with a small compression dressing using gauze pads and an elastic adhesive bandage (eg, large Band-Aid). No sutures are required.
  • No significant extravasation occurs unless the trocar is removed too early and the resectoscope needs to be reintroduced. Therefore, wait until just before the patient is ready to be transferred from the cystoscopy table before removing the suprapubic trocar. Only very rarely does any significant intravesical bleeding occur from the trocar site. This can be cauterized with the resectoscope before the case is completed and the trocar is removed.

Intraoperative Details

Getting started

The procedure begins with a cystoscopic inspection of the urethra, prostate, and bladder using a small-diameter cystoscope. If an indwelling catheter was present preoperatively, the urethra should first be thoroughly irrigated with a bulb or Toomey syringe to clean the urethra of mucus, clots, and debris.

After careful inspection and orientation, the bladder is distended with approximately 100 mL of fluid, which helps to improve anatomical identification and better visualize the prostate, bladder neck, median lobe, and bladder wall. The external urinary sphincter is located just distal to the verumontanum, which is specifically used as the distal resection border and landmark to prevent any injury to the sphincter.

A meatotomy may be needed in order to easily accommodate the resectoscope sheath through the penis. This is first evaluated by calibrating the urethra, if any doubt exists, to make sure it is of adequate size to easily accommodate the resectoscope sheath that will be used. Most adult male urethras allow a well-lubricated 28F sheath to pass easily. To prevent postoperative urethral strictures, do not to use a resectoscope that is much larger than the patient's urethra, fossa navicularis, or urethral meatus. If the patient has an extremely small urethra, an internal urethrotomy (preferred) or gentle dilation of the urethra with sequential Van Buren sounds may be needed. A meatotomy can also be performed if the urethral meatus is inadequate. While most surgeons normally perform a ventral meatotomy, Winston Mebust and others have suggested making a dorsal internal urethrotomy, arguing that large ventral meatotomies often result in a split or diverse stream with splattering and splaying.

Importantly, do not to force the resectoscope sheath into the urethra. This commonly results in a urethral stricture at the fossa navicularis and possibly elsewhere in the urethra (see Image 22). A perineal urethrostomy can be performed to create temporary access into the bulbous urethra to avoid any additional trauma to the rest of the urethra. The perineal urethrostomy is especially important if obtaining easy passage of the resectoscope sheath proves difficult, if patients have contractures or penile prostheses, or if the urethral length proves to be too long for the standard instruments. A smaller-sized resectoscope sheath (24F) should be used if the urethra appears too narrow for easy access with larger instruments; therefore, a 24F resectoscope sheath and appropriately sized cutting loops should always be immediately available. We use a 28F resectoscope sheath only on the largest prostates and prefer a 24-26F sheathforroutine use.

Intraoperative priapism occurs in approximately 4% of patients undergoing TURP surgery. It is less common with a spinal block than with other types of anesthesia. Occurrence varies according to patient age, with younger patients (<50 y) affected most often. Treatment is usually with intracavernosal phenylephrine injections. We prefer to use 1 mL phenylephrine at 10 mg/mL diluted in 49 mL of isotonic sodium chloride solution, which results in a concentration of 0.2 mg/mL. One to two mL is injected with a 25-gauge needle directly into the corpora cavernosa. In our experience, detumescence occurs 2-3 minutes after a single 1 mL injection in all patients receiving this therapy. Only a transitory mild increase in blood pressure has been noted, which occurs approximately 10 minutes after the injection and returns to normal within 30 minutes. We have not needed more than a single injection, but the process can be repeated every 10-15 minutes if necessary.

Median lobe resection

The median lobe resection should be performed first if the median lobe is sufficiently large enough to interfere with irrigation or prostatic chip passage into the bladder. An attempt should be made to identify the ureteral orifices, but this may be impossible in some cases until the markedly enlarged median lobe has been at least partially removed. Intravenous methylene blue dye can be used to help find the ureteral orifices and prevent their inadvertent resection.

A modification designed to reduce bleeding from an enlarged median lobe involves making several small, short cuts in the cleft between each lateral lobe and the median lobe. This resection cuts off much of the blood supply to the bulk of the median lobe, which comes from the penetrating periurethral prostatic branches of the inferior vesical artery at the bladder neck.

The bulk tissue of the median lobe is resected from the top down, while the end of the resectoscope is at the bladder neck to avoid subtrigonal tunneling and bladder neck injury, which can lead to extravasation and increased fluid absorption (see Image 17).

When the resection approaches the bladder floor, the cutting loop can be used, without any electrical current, to gently lift the lip of the remaining median lobe tissue up and away from the bladder floor and trigone (see Image 23). Once lifted free, current can be applied to the cutting loop and the elevated median lobe tissue can be resected. This portion of the median lobe resection requires relatively thin superficial cuts of tissue. The process is repeated until the entire median lobe has been resected.

The bladder should be reinspected to identify the ureteral orifices, which should be visible. Resected prostatic chips and blood clots may need to be evacuated to allow for visualization of the ureteral orifices, trigone, and bladder floor. Great care should be taken to avoid inadvertent resection of the trigone, especially laterally where the ureteral orifices may be directly underneath the enlarged median lobe (see Image 18). Once the median lobe has been resected, the rest of the TURP procedure can be performed in a routine manner (see Image 24).

Nesbit technique

The Nesbit technique is probably the best-known and most commonly performed TURP method. It was first described by Reed M. Nesbit (see Image 6) of Michigan in his landmark 1943 book on transurethral prostatectomy and is currently considered the standard approach to TURP surgery. As originally described by Nesbit, the procedure is divided into 3 stages: (1) intravesical or proximal, (2) extravesical, and (3) apical.

To begin the intravesical portion, the resectoscope is positioned with the tip between the bladder neck and the midpoint of the prostatic urethra proximal to the verumontanum. This point is determined by the relative size of the intravesical prostate. Resection begins by removing the intravesical portion of the prostate and bladder neck tissue. This is removed, along with the immediately adjacent prostatic adenoma, starting at the 12-o'clock position and working clockwise (see Image 25). The initial cut is on one side or the other of the actual midline. The length of the cut is proportionate to the size of the gland. After this stage, care must be taken to avoid resecting proximal to the established resected margin. During this initial intravesical stage of the resection, only the internal sphincter, ureteral orifices, bladder neck fibers, and the margin of resection are visible for use as landmarks.

To begin the extravesical phase of the procedure, the resectoscope is repositioned just in front of the verumontanum, and the resection is continued from the previous distal resected margin to just proximal to the verumontanum, starting again at the 12-o'clock position (see Image 26). This channel is continued from the 12-o'clock to the 4-o'clock position on the left side and to the 8-o'clock position on the right side. The intent is to create a channel between the surgical capsule and the bulk lateral lobe tissue (see Image 27). This encircling maneuver, combined with the intravesical and bladder neck resection performed earlier, results in the bulk of the 2 lateral lobes falling onto the floor of the prostatic fossa (see Image 24). In addition, they are essentially devascularized and canberesected easily with minimal bleeding. The bulk of the prostate tissue is resected during this part oftheprocedure.

The remaining tissue in the posterior lobe is then resected. Nesbit recommended the use of a finger in the rectum to aid in judging the relative thickness of the remaining tissue; this remains a good idea (see Image 28).

The final stage of the procedure is the apical stage, in which the remaining apical tissue around the verumontanum is carefully removed (see Image 20). Again, Nesbit starts the apical portion of the procedure with an anterior resection (12-o'clock position), using the verumontanum as the main landmark.

Discussion of the Nesbit technique

The Nesbit technique has a number of significant advantages. By beginning at the roof of the prostate (12-o'clock position) and proceeding laterally along the capsule, the lateral lobes are released to fall posteriorly, making for an easier resection as one moves in that direction. The main benefit of this technique is early control of the major prostatic blood vessels, starting with the perforating urethral vessels that enter posterolaterally at the bladder neck. This is followed by an encircling resection between the surgical capsule and the lateral lobes. This is intended to isolate and devascularize the bulk lateral lobe tissue, which allows even very large glands to be resected with relatively little blood loss.

Early resection of the bladder neck not only controls many of the blood vessels to the median and lateral lobes, it also helps clearly demarcate the proximal limits of resection and helps avoid subtrigonal tunneling and extravasation. Most of the resection is performed with the scope and the surgeon in a comfortable upright position, resecting from the top downwards. Finally, leaving the apical tissue for last allows the surgeon's full attention to be directed to this critical surgical area.

The Nesbit technique has a few disadvantages. The procedure involves 3 distinct surgeries, each performed separately. The initial groove at the anterior prostate is made without any real landmarks, at the point where the prostate is thinnest and the risk of perforation is highest. An early perforation at the start of the resection greatly increases fluid absorption, hyponatremia, bleeding, and extravasation, leading to early termination of the surgery and increased morbidity.

For cases in which the lateral lobes are particularly crowded in the prostatic urethra, sufficient room may not be present to accommodate the falling lobes, causing them to bunch together and making further resection more difficult. Resected grooves do not initially extend the full length of the prostate from the bladder neck to the verumontanum, which causes delays, mandates repositioning, interrupts the rhythm of the surgery, and leaves an incomplete resection of all lobes if the procedure needs to be terminated quickly. Finally, the lateral encircling grooves may uncover bleeders or venous sinuses, which can be awkward to control with interference from the large, bulky lateral lobes that are in the way medially.

Milner technique

William A. Milner (see Image 7) was a highly skilled and respected urologist who established the Department of Urology at Albany Medical Center in Albany, New York. He received a working model of the Stern-McCarthy resectoscope from Joseph F. McCarthy in 1931 and then returned to Albany, where he developed his technique of TURP. This occurred more than 10 years before Nesbit published his book on transurethral prostatectomy. In 1941, Milner reported on his first 700 cases, which had a combined mortality rate of only 2.6%. This rate was far superior to any alternate technique of prostate surgery then available. Milner became world-renowned for his exceptional surgical skill and TURP technique, particularly in transurethral resection of larger prostate glands (see Image 7).

Almost 50 years and thousands of TURPs later, Milner personally instructed this author in his method, which differs slightly from the Nesbit technique described earlier. To the author's knowledge, this is the first time his particular technique for transurethral prostatectomy has been published in the modern era, and it is offered here as a tribute to this highly skilled surgeon and teacher.

The initial resection groove is made at the 9-o'clock position and carried down to capsular fibers. This groove extends from the bladder neck to a point parallel to the verumontanum at the level of the ejaculatory ducts. Coagulation is not used, except for major bleeding sites when the resection has reached the surgical capsule. The groove is first extended upwards toward the 11-o'clock position and then downward toward the 7-o'clock position. No attempt is made to encircle the bulk tissue. Rather, the intent is to resect the lateral lobe tissue from the inside out quickly and to reach the surgical capsule expeditiously, at which point the perforating and bleeding vessels can be cauterized if necessary. The next section in line is resected until an entire lobe is finished. The process is repeated on the opposite side (see Image 29).

When both lateral lobes have been resected, the posterior and median lobes are removed in a manner similar to the Nesbit technique, with one exception. Because Dr. Milner always used a Stern-McCarthy resectoscope working element (a 2-handed instrument), he did not have a free hand available to place a finger in the rectum. Instead, he would resect the posterior lobe to a slightly concave surface, depending on the size and shape of the rest of the prostatic fossa. The apical tissue around the verumontanum is resected in a similar manner to that described previously. Prostatic tissue located distal to the verumontanum is carefully resected if it appears to be obstructing and if sufficient space is available to avoid injury to the external sphincter.

The final area of resection is the anterior tissue between the 11-o'clock and the 1-o'clock positions. The anterior resected surface is left relatively straight and flat to avoid perforation in this area. The risk of perforation when resecting the anterior tissue is relatively high because this is where the prostate is thinnest and no distal landmark is visible on the anterior surface, which risks possible inadvertent injury to the external sphincter. Also, the anterior tissue is rarely obstructing; therefore, this area is resected last in case the procedure needs to be terminated early for any reason.

Discussion of the Milner technique

At first glance, the Milner technique seems to violate the main principles of the Nesbit school. By directly attacking the bulk tissue of the lateral lobes without devascularization from the encirclement technique used by Nesbit, additional bleeding might be reasonably expected. However, when performed properly, very little blood loss actually occurs. The median lobe tissue has already been removed, if enlarged, which blocks the periurethral vessels. Perforating capsular vessels are cauterized directly. The key is the speed with which the tissue is resected directly perpendicular to the surgical capsule. This allows rapid access to the main bleeding vessels, which can then be easily cauterized and controlled.

The Milner technique has several key advantages. The initial groove is made at the point at which the prostatic adenoma is thickest, so the risk of perforation or ureteral injury early in the resection is minimal. The initial resected grooves are the full length of the prostate, which speeds the surgery, avoids incomplete resections, and provides a new lateral/distal landmark from the very beginning of the procedure. Identifying the full length of the surgical capsule early in the case makes visualizing how the rest of the surgery will proceed easier. It also helps avoid perforations of the surgical capsule by providing the surgeon with the full-length lateral border of the resection at the start of the case.

With this technique, completely finishing the resection of one prostatic lobe before starting on the opposite side is much easier. This allows for early termination of the surgery if necessary. Resecting the anterior portions of each lobe allows the remaining tissue to then fall into the posterior section, much like the Nesbit technique. This method avoids the problem of the bulk lateral lobe tissue impeding either the resection or the cauterization of surgical capsular bleeders.

Leaving the anterior prostatic tissue for last minimizes the risk of any anterior perforation. It also allows the distal margins of the resection to be established when working on the distal anterior tissue when the primary distal landmark, the verumontanum, is not visible. This margin is established by the distal anterior edge of the already resected adjacent lateral lobes. Finally, it essentially converts the resection into reasonable parts (right side, left side, floor, and roof) compared to Nesbit's somewhat arbitrary stages (proximal or intravesical, extravesical, and apical).

Other variations

As mentioned previously, the critical issue is having a plan for the resection and carrying it out in an orderly fashion. This is far more important than where the resection starts or the particulars of the specific technique involved. Still, some of the other methods that have been advocated for TURP surgery and the reasons for their development are notable.

Nathaniel Alcock described his method as starting with one lateral lobe and completely resecting the lower portion from the bladder neck to a point just proximal to the verumontanum. This is supposed to allow the lateral lobe tissue to fall toward the floor of the prostatic urethra. New grooves are then made in the cleft anteriorly, and the upper half of the lateral lobe is then removed. In practice, this technique works reasonably well only for larger prostates in which the lateral lobes are sufficiently heavy to allow them to fall after being undermined. In small prostates, this would cause the lateral lobes to rise superiorly and might make completing the resection more difficult.

Robert Barnes preferred to start his resection at the posterior lobe, which helps guarantee a good flow of irrigation into the bladder. It also allows for a good resection of the posterior lobe, which can be difficult later when the floor of the prostatic fossa is full of clots and resected debris.

Holtgrewe and others suggest a variation of the Nesbit technique, in which the resection begins at the 1-o'clock position with the resectoscope tip positioned in the middle of the prostatic fossa. This is extended clockwise to the 6-o'clock position. A similar maneuver is performed on the opposite side. Once this stage is complete, the resectoscope is repositioned just proximal to the verumontanum and the bulk tissue is resected in quadrants, beginning with the area between the 12-o'clock and the 3-o'clock positions. Apical tissue is removed last.

Other variations include starting the resection at the 4-to 5-o'clock positions and the 7- to 8-o'clock positions, with the intention of blocking the main blood vessels coming into the prostate from the bladder neck area at these points. These and other techniques have been used at some point, and each has their proponents. Most importantly, the surgeon should know how to perform at least one type of TURP well and stick to it.

Posterior lobe resection

Posterior lobe resection is considered important by some and unnecessary by others. A few have recommended starting with the posterior resection so that the surgeon has a clear view without debris, resected prostatic chips, or blood clots in the way. Advocates of this position point out that resection of the posterior lobe removes tissue with the potential for developing cancer and makes the TURP more complete. Others suggest that the posterior lobe is usually not sufficiently enlarged to cause any obstruction; therefore, extensive resection is not particularly important.

Adequate resection of the posterior lobe requires good visualization. This means that if not performed at the start of the case, any resection performed previously needs to be very hemostatic. All prostatic chips should be irrigated into the bladder and evacuated. An Iglesias working element is usually preferred to allow for digital monitoring of the posterior resection from a finger in the rectum inside an appropriate sheath, which provides tactile sensory feedback to avoid perforation. Performing this resection with the Stern-McCarthy working element is also possible, but this requires greater skill and experience.

The posterior lobe resection is performed in the standard fashion while sweeping the distal end of the resectoscope up and carving a shallow groove with the cutting loop, using a scooping motion to create a concave surface. Relatively thin cuts are made to avoid inadvertent perforation. Care must be taken to avoid any resection or cauterization of the verumontanum. Unroofing of the seminal vesicles may occur. This has no significant sequelae and may be considered proof of an adequate posterior resection. The depth of the resection is up to the operating surgeon. Certainly, in a difficult or prolonged case, spending too much time on a lengthy posterior resection is not prudent. A more extensive posterior resection is recommended only if visualization is good, the patient is tolerating the procedure without problems, and reasonable time is available. Otherwise, only bulky posterior tissue should be removed.

Finishing the resection

After the completion of the resection, the resectoscope is withdrawn into the bulbous urethra so that the sphincter, verumontanum, and prostatic fossa can be observed. Some additional resection of apical tissue may be necessary. Placing a finger in the rectum to elevate the apex is very useful when examining or resecting apical tissue. Also, standing up straightens the angle of attack on the apical tissue and is sometimes helpful (see Image 20). In very large prostates, the prostatic apical tissue bulges distal to the verumontanum before the inferior margin of the external sphincter curves proximally. Some consider the resection incomplete unless this tissue, located somewhat distal to the verumontanum, is removed. Any surgery in this area must be performed with great care to avoid injury to the external sphincter.

The resectoscope is then reintroduced into the bladder and prostatic fossa to be absolutely certain that all bleeding sites have been controlled. All arterial and venous bleeders of significance are electrocoagulated, except for the venous sinuses, which cannot be controlled by cautery. One can safely assume that adequate hemostasis has been obtained when the irrigant flowing out of the bladder is completely clear. An Ellik evacuator (see Image 30) or similar device is then used to remove all the prostatic chips and large blood clots from the bladder. This final irrigation and evacuation should be performed gently to avoid disrupting blood clots forming on bleeding sites.

The bladder is given a final inspection to make absolutely sure no residual prostatic chips are present, and the prostatic fossa is given one final look to be certain that no treatable bleeders remain. Any bladder diverticula should be carefully inspected to make sure no prostatic chips are hiding inside. The bladder is partially filled with fluid to facilitate introduction of the catheter. The resectoscope is then removed.

A Foley catheter is inserted over a catheter guide into the bladder. The catheter guide is used to elevate the tip of the Foley catheter during insertion to avoid accidental tunneling under the trigone, especially if a lip of fibrous tissue is left at the posterior bladder neck. If present, this tissue should be cut as originally recommended by Kulb, in the midline at the 6-o'clock position with a Collings knife at the conclusion of the resection immediately before removing the resectoscope. The insertion of the Foley catheter at the end of the case is often rushed, sometimes with little thought or care given to potential problems.

Perforation of the prostatic fossa is possible when the catheter is inserted and its tip is left in the retroperitoneum. This can be disastrous if not quickly identified and corrected. Poor hand irrigation or inability to easily extract the irrigated fluid through the newly placed catheter would suggest malposition and the catheter should be removed and reinserted. If the catheter placement is particularly difficult, a filiform tip or guide wire can be inserted directly into the bladder through a cystoscope and the catheter inserted over the guide wire.

A Foley catheter hole punch (available from Cook Urological) to quickly add a small hole in the tip of the catheter to facilitate placement over a guide wire should be readily available. A quick cystogram in the operating room should be considered in difficult or questionable cases to make absolutely certain the catheter is properly positioned in the bladder before the case is ended.

We usually prefer a 22F, 3-way, 30-mL balloon catheter for continuous bladder irrigation immediately postoperatively, although some experts prefer a 24F catheter especially if the bleeding is unusually heavy. We use continuous bladder irrigation with normal saline (isotonic sodium chloride) solution to keep the bladder clear of blood clots during the immediate postoperative period. Normal saline is used so that any irrigating fluid absorbed does not contribute further to any dilutional hyponatremia. Glycine solution use is not justified for continuous bladder irrigation once the TURP surgical procedure is over. Glycine is much more costly than normal saline and not as safe. It can cause glycine toxicity and contains no sodium or electrolytes so it does nothing to help correct hyponatremia if absorbed.

Continuous bladder irrigation is used most commonly for postoperative management of hematuria, but intermittent irrigation can also be used. Our preference is to fill the Foley catheter balloon with 30-60 mL of water and temporarily place it on gentle traction to be sure that it irrigates well and that all bleeding is completely controlled. Placing the catheter on mild traction for a few minutes seems to assist in early hemostasis. Some resectionists fill the Foley balloon with a volume equivalent to the weight of the resected prostate tissue plus 10 mL. This volume helps prevent the balloon from sliding into the prostatic fossa.

Irrigation outflow should become completely clear. If it cannot be made completely clear with Toomey syringe irrigation and adjustment of the fluid content of the Foley balloon, the resectoscope should be reinserted and the prostatic fossa reinspected for bleeding sites. If bleeding control cannot be achieved in the operating room, it will not be obtained later in the recovery room or on the floor.

A B&O suppository can be placed just before taking the patient's legs down from the cystoscopy table. These suppositories have long been used for analgesia and to suppress bladder spasms after prostate surgery. Placing one at the end of the case provides the patient with some symptomatic relief as the anesthetic wears off. However, some urologists prefer to not place anything in the rectum after TURP surgery.

Sometimes, continuous irrigation does not initially provide good control of postoperative bleeding, and the addition of traction to the balloon is needed to facilitate hemostasis. Many experts routinely use prolonged mild or moderate traction as an aid in controlling bleeding for 24 hours or longer, but others feel that traction increases patient discomfort and is unnecessary if surgical control of hemostasis is adequate. We prefer not to use long-term traction routinely, but to use it only if the bleeding is otherwise hard to control or if the prostate is very large (>100 g). If in doubt about the degree of bleeding, removing the Foley catheter, replacing the resectoscope, and rechecking the prostatic fossa for bleeding sites is strongly recommended before transferring or moving the patient from the cystoscopy table.

A summary of tips for resecting larger prostates

• Practice makes perfect. A relatively inexperienced resectionist may not be able to handle a 100-gram prostate by TURP, even after carefully reading this review. Only practice, good technique, and increasing confidence allow the eventual accomplishment of this skill.
• Be confident. Initially, performing transurethral resections on prostates substantially larger than 100 grams and completing the surgeries in less than 90 minutes of operating time may not seem possible; however, using the tips and suggestions listed here, it can be accomplished safely.
• Get comfortable. Use the table movements to present the patient and prostate at the most comfortable angle and position. While tilting the table too much initially is not a good idea, changing the table height and judicious use of the Trendelenburg position can be very helpful by bringing the resecting area close to the surgeon's comfort level. Elbow rests also help stabilize the instrument during the resection. Make sure the patient is at the very end of the cystoscopy table so that deflection of the resectoscope is not restricted by the edge of the table.
• Use every possible advantage. Finasteride (Proscar) has been shown to reduce bleeding, particularly in patients with larger prostates. This appears to take approximately 2 months, but even 2 weeks of finasteride therapy may help. If possible, a longer course of therapy is probably better.
• Use continuous-flow. Continuous-flow techniques have not been conclusively proven to be substantially better than standard, intermittent-flow TURP surgery, but most urologists feel that the clearer vision with fewer interruptions allows them to resect more efficiently. It also helps maintain a lower intravesical pressure, which should lessen fluid absorption and reduce the risk of TUR syndrome and hyponatremia. Continuous-flow resection techniques are particularly useful in patients with very large prostates and those with small or contracted bladders.
• Cut with confidence. Failure to perform a perineal urethrostomy when appropriate is one of the most common errors in clinical TURP practice. A perineal urethrostomy allows a larger resectoscope instrument (28F) to be used safely without risking stricture formation (see Image 16). It takes only a few minutes to perform and allows better movement of the resectoscope while reducing the risk of permanent urethral injury and strictures. Meatotomies should also be performed if any question exists about meatal adequacy.
• Use only the best equipment. Use equipment with which you are comfortable and experienced. A case involving a very large prostate is not the time to try out a new type of instrument.
• Have adequate spares and supplies. Make sure enough irrigating fluid is available to handle a longer than average case. Have spares of critical equipment, such as a light source and cables, electrosurgical unit, electrical cord, cutting loops, telescopes, and a complete spare resectoscope set, immediately available in case a problem arises in the middle of a case. Sooner or later, these supplies and spares will be needed. In addition, do not forget to check the instruments yourself just before you start the surgery to make sure all the parts are secure and there are no leaks.
• Bigger is better. If possible, use a larger, 28F resectoscope sheath for bigger prostates. While performing the surgery with a small sheath is possible and may help prevent strictures, it is easier to resect a markedly enlarged prostate gland with the larger instrument. If the urethra does not allow the sheath to pass with ease (see Image 22), perform a perineal urethrostomy. Make sure the entire resectoscope sheath is adequately lubricated, not just the tip.
• Smaller is easier. Avoid cutting off a large chunk of tissue by separating it from the capsule. These freely floating prostatic sections cannot be evacuated through the sheath and must be cut into smaller pieces for removal. This is much easier to do when they are fixed in place in the prostate rather than floating freely in the bladder.
• Always have a plan. Always have a plan for the procedure that involves completion of one area of resection at a time. This is even more important for larger glands than for average-sized or small-sized prostates.
• Stay focused on the goal. Try to spend most of the available resecting time on the bulk tissue of the median and lateral lobes. This is where the obstruction originates. Many novice resectionists waste time on small, nonobstructing tissue tags or small bleeders instead of concentrating on getting the main bulk tissue resected. This is not a beauty contest, and no prize exists for the most beautiful prostatic fossa. The goal is to remove the important bulk obstructing tissue in the least possible time. Relatively little adenomatous tissue is present in the anterior and posterior prostatic urethra; therefore, spending much time on the resection in these areas is not efficient unless it is necessary to the overall surgical plan. If things are going well and time remains at the end, these areas can be resected, but they should be considered optional.
• Be generous with hemostasis. While the emphasis on safely performing TURP on a large prostate is speed and efficiency, hemostasis is an area in which extra time and diligence are required and well-spent. Spend extra time checking for bleeding sites that can be cauterized, but try not to waste time on bleeders until the surgical capsule is reached. Avoid cauterizing venous sinuses because they usually cannot be stopped by cautery alone; this also wastes valuable time.
• Keep track of the time. An assistant should inform the surgeon when 30 minutes of operating time has elapsed and then should notify the surgeon every 15 minutes after that point. This allows the surgeon to judge his or her progress and adjust the surgery accordingly. If the entire prostate cannot be completely resected in the remaining time, concentrate on finishing at least the median lobe (if obstructive) and one lateral lobe. This often works quite well in relieving symptoms, even for patients with very large prostates.
• Prostate resection is an art. The secret to safely performing a TURP on a prostate larger than 100 grams is the ability to carve and sculpt the prostatic fossa to produce the typical concave cavity, which can only be accomplished by withdrawing the resectoscope as the cutting loop is activated and retracted. The external portion of the instrument must be moved simultaneously to the contralateral side. The movable length of the average cutting loop is only 2.3 cm, while some prostates extend 6-10 cm. For example, if the patient's right lobe is being resected, the operator activates the cutting loop while withdrawing the resectoscope and angling the external portion of the instrument to the patient's left side. This creates the internal, curved surface by moving the cutting loop from medial to lateral and back again as it is being withdrawn. This avoids the need to resect the same area 2-3 times to make a single groove. To do this safely, the operator must know the landmarks and borders of the resection and the resectoscope's exact location and orientation to those landmarks at all times.
• Know your landmarks. Never resect tissue if the exact location or surgical orientation with regard to the relevant landmarks is uncertain. Taking an extra minute for reorientation is much better than risking permanent incontinence from iatrogenic injury to the external sphincter.
• Get into a rhythm. Maintaining a regular rhythm is the most efficient way to perform a TURP. Working steadily with a clear plan and long, smooth strokes over the entire length of the prostate allows for better results and increased surgical capability.
• Take your time. This is the single most important rule. If attempts are made to rush or speed up, trouble is inevitable. If bleeding is encountered that is hard to control, remember hemorrhage control techniques.
• Know when to quit. Be prepared to quit the resection with very little notice if the patient gets into trouble. If possible, try to finish at least one obstructing lateral lobe.
• Check and double check. Intraoperatively, regularly check laboratory values for patients with very large prostates. Use intravenous furosemide (Lasix) early if extensive bleeding is present and presumed fluid absorption occurs, as noted by a rise in blood pressure or a decrease in the hemoglobin and/or serum sodium level. If the serum sodium level reaches 125 mg/dL or the patient becomes symptomatic from hyponatremia, consider early termination of the procedure even if not completed. Pay extra attention to hemostasis because a return visit to the operating room should be avoided if possible.
• Take extra care at the end. Be careful when placing the Foley catheter at the end of the case to avoid perforating the prostatic capsule. Make sure the catheter drains easily, with clear fluid return, before concluding the surgery.
• Practice still makes perfect. If first attempts at larger prostates are not totally successful, continue applying these principles to all prostates until sufficient skill is attained. All expert resectionists went through a similar period during which their skills needed to be improved to allow them to handle more demanding cases.

Postoperative Details

Ensuring that the Foley catheter irrigates easily and well at the end of the procedure is essential. Catheter blockage can occur from incorrect catheter placement, a small prostatic chip that was not evacuated, a kink in the tubing, or a blood clot. If any doubt remains about the function or position of the catheter, remove and replace it. In difficult situations, a guidewire can be placed first through the cystoscope. The catheter can then be placed over the guidewire once the cystoscope has been removed. A quick cystogram while the patient is still on the table can resolve any issues about placement and should be performed if any uncertainty remains.

A few experts recommend placement of the Foley catheter balloon into the prostatic fossa when bleeding is not controlled otherwise. Others believe the balloon should be in the bladder, with traction holding it against the bladder neck to control bleeding. The support for this theory is the fact that the prostate gland is a very muscular structure similar to the uterus, and, after TURP surgery, the walls of the prostatic fossa contract, helping control any lingering bleeding.

If the Foley balloon is located in the prostatic fossa, it may prevent normal contraction and aggravate bleeding. To prevent the balloon from entering the fossa, a large amount of fluid (eg, 30-60 mL) is placed into the balloon. After the balloon is inflated, if bleeding is present, the catheter is placed on traction for 1-4 hours to compress bleeding from the venous sinuses until the prostate capsule adequately retracts to stop blood loss. The incidence of bladder neck contractures rises with a longer duration of traction because this also compresses the arterial supply, causing ischemia and increased scar formation.

Closed catheter irrigation with either continuous-flow or intermittent irrigation can be used. A rate of 500 mL/h has been suggested for continuous-flow irrigation. Normal saline solution should be used, not Glycine or sterile water. Most urologists prefer to adjust the rate according to the degree of hematuria rather than specify any arbitrary volume. The irrigation rate can usually be reduced or the catheter removed on the first or second postoperative day.

Once the catheter has been removed, a serial urine collection can be obtained by keeping a small sample of each void in a numbered test tube or urine container. This allows for a quick visual check that any hematuria is resolving. Checking the postvoid residual volume noninvasively with an ultrasound can be useful to be absolutely sure the patient is emptying adequately, particularly in patients with decompensated bladders or a history of urinary retention.

If the outflow drainage does not appear to equal the inflow irrigation rate or if the patient becomes distended, hand irrigation of the catheter using a Toomey syringe is recommended. Usually, a variable amount of thick clots are found. Hand irrigation should be continued until no further clots can be evacuated. This may take some time. Use of a bulb syringe for this purpose is discouraged because it cannot generate enough suction to remove thick clots from the bladder.

Deflating the Foley balloon is occasionally necessary in order to remove all the clots. Once all the clots have been extracted from the bladder, the closed catheter irrigation can be restarted, and it should be maintained at a rate sufficient to keep the irrigant clear to pale pink in color. A single dose of an appropriate analgesic may be administered to keep the patient comfortable during this procedure. A few drops of surgical lubricant on the catheter at the urethral meatus can also reduce discomfort and irritation.

Follow-up

The early use of pelvic floor rehabilitation exercises after TURP surgery has been reported to improve outcomes, increase quality-of-life scores, and hasten recovery without any complications or adverse effects in cooperative patients. Recommending such exercises postoperatively to all patients who have undergone TURP seems reasonable.

For excellent patient education resources, visit eMedicine's Prostate Health Center, Cancer and Tumors Center, and Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Enlarged Prostate, Prostate Cancer, Bladder Control Problems, and Foley Catheter.

Radical TURP

A radical TURP is the complete removal by transurethral resection of all the prostatic tissue possible. While similar to a standard transurethral resection, a radical TURP requires superior transurethral surgical skill; takes more time; is more difficult to perform; and carries slightly greater risks of perforation, extravasation, dilutional hyponatremia, and bleeding.

The radical TURP is performed by extending the limits of resection laterally and circumferentially to the prostatic capsule until all visible prostatic tissue has been removed. The resection is continued posteriorly until no more prostatic tissue can be felt by the surgeon's guiding finger in the rectum. The use of continuous-flow irrigation and drainage, allowing an uninterrupted resection under low hydrostatic fluid pressure, is recommended for this surgery.

Radical TURP has been used with some success for treating chronic prostatitis, especially in otherwise intractable cases. An overall improvement has been reported in approximately 33% of patients treated, and the remainder are generally no worse. A success rate of up to 67% has been reported in patients with documented chronic bacterial prostatitis who underwent the procedure. However, the incidence of incontinence and impotence is significantly higher after radical TURP compared to standard TURP.

Prostate cancer

Theoretically, entirely removing all prostatic cancer tissue should be possible using a radical TURP if the procedure is skillfully and completely performed in selected cases in which the prostate cancer is well localized some distance from the prostatic capsule. While practiced by a few urologists, no published data are available regarding the efficacy of radical TURP as a potentially curative therapy for prostate cancer. Therefore, TURP is not currently considered a definitive therapy for prostate cancer, but only a palliative measure for relief of obstructive symptoms.

In patients with known prostate cancer, the risk of urinary incontinence and bleeding following a transurethral prostate resection is generally higher because of their underlying disease. During a TURP, arterial vessels in prostate cancers are not able to contract the way they normally do in patients with benign prostatic tissue. More fibrinolysins are released from cancerous tissue during surgery, which also increases bleeding. However, a review of more than 3000 cases by Crow et al failed to show any significant difference in overall complication rate or hospital stay after TURP in patients with prostate cancer compared to patients with benign disease. These findings may be due to patient selection bias, relatively minimal or clinically insignificant cancers, or alterations in the standard TURP technique in patients known to have prostatic malignancies.

Performing only a limited TURP in patients known to have extensive localized prostate cancer is judicious and prudent. A channel is made through the prostate but is not carried routinely all the way down to the surgical capsular fibers. Resection around or even near the verumontanum is not recommended because of the increased risk of postoperative urinary incontinence in these patients. In patients who have undergone previous radiation therapy to the prostate, the risks of postoperative incontinence and hematuria are substantially increased compared to the average patient undergoing TURP.

Because of the release of fibrinolysins and other chemicals by prostate cancer cells, a bleeding diathesis or coagulopathy is more likely in patients with prostate cancer who undergo transurethral surgery compared to the general population. Epsilon aminocaproic acid (Amicar) is often helpful in these patients, particularly in cases in which diffuse bleeding is present and no specific vessels can be identified. Pretreatment with hormonal agents may be helpful in reducing bleeding in this patient population.

Transurethral prostate surgery should be avoided immediately after definitive radiation therapy for prostate cancer because of the high incidence of intractable postoperative incontinence. At least 3 months should separate radiation completion and TURP, but 6 months or longer is preferred, especially after brachytherapy (radioactive seed implantation). Allowing time for prostate shrinkage following definitive radiation therapy often obviates the need for surgical intervention.

TURP should also be avoided prior to planned radiation therapy or cryotherapy. Hormone therapy can usually shrink the prostate adequately for voiding and improves the efficacy of the radiation. In cases in which the patient has undergone recent prior TURP and is planned for prostate/pelvic radiation, the radiation therapy should be delayed until at least 4 weeks after the TURP has been completed. Postponing the radiation therapy for 6-8 weeks may help to minimize bladder neck contractures and incontinence. TURP should not be performed in patients in whom brachytherapy (radioactive seed implantation) or cryotherapy is being considered. Hormone ablation therapy and alpha-adrenergic blockers may be sufficient in these patients to avoid the need for a TURP.

Clinically significant tumor dissemination does not appear to occur from TURP surgery, although the literature suggests that patients with prostate cancer and obstructive symptoms are more likely to have higher-stage disease. Disease progression and mortality rates are similar in patients treated with TURP compared to patients not treated with TURP who are matched for pathological stage and histological grade. Repeat TURP for staging appears to be unnecessary except in the rare circumstance in which a small, localized, high-grade tumor is found and substantial tissue is left behind after an incomplete initial TURP.

Complications

TUR syndrome and hyponatremia

Significant amounts of fluid may be absorbed during a TURP, especially if venous sinuses are opened early or when the operation is prolonged. On average during a TURP, approximately 20 mL of fluid per minute is absorbed, or approximately 1000-1200 mL in the first hour of resecting time. One third of this fluid is absorbed directly into the venous system. This may lead to dilutional hyponatremia (TUR syndrome), which causes mental confusion, nausea, vomiting, visual disturbances, hemolysis, hemoglobin nephropathy, coma, and shock. Hemodynamically, this is characterized initially by increased central venous pressures, hypertension, bradycardia, and other signs of early vascular overload, including restlessness, tachypnea, and sometimes dusky skin changes of the conjunctiva, mucous membranes, or fingernails. Symptoms of TUR syndrome generally do not occur until the serum sodium level has decreased to 125 mEq or less.

An estimated 2% of patients experience TUR syndrome to some degree. The risk is increased in patients with prostates larger than 45 grams, when the resection time is prolonged beyond 90 minutes, and when the patient has relative hyponatremia preoperatively. Therefore, a TURP is recommended only when the operating surgeon is reasonably convinced of being able to finish the procedure in no more than 90 minutes.

The risk is reduced by using nonhemolyzing fluid for irrigation during the case and keeping the inflow irrigating fluid pressure as low as possible. A study by Madsen and Naber found that fluid absorption was directly related to irrigation fluid pressure. Raising the height of the fluid from 60 cm to 70 cm doubled the irrigation fluid pressure. They also found that an irrigation rate of 300 mL/min was necessary to maintain good visualization and that this rate cannot be adequately maintained if the fluid height is less than 60 cm. Continuous-flow systems tend to keep the intravesical pressure low and help minimize fluid absorption. If not using a continuous-flow methodology, to minimize fluid absorption, the bladder should be emptied routinely before maximum bladder filling has occurred and visualization is lost.

In light or moderate hyponatremia, treatment with intravenous normal saline and furosemide (Lasix) may suffice. This causes a reduction in fluid overload through a diuretic effect, while maintaining the serum sodium concentration. Furosemide administration should be started while still in the operating room if the case is unusually bloody, prolonged beyond 90 minutes of resecting time, or if the patient's serum sodium level is dropping rapidly.

Severe cases are best treated with slow intravenous administration of a 3% hypertonic saline solution, usually 150-200 mL at a time administered over 1-2 hours. This treatment should always be accompanied by diuretics (intravenous furosemide), especially in patients at risk for developing congestive heart failure. Hypertonic saline therapy can be repeated as needed. Carefully monitor electrolytes every 2-4 hours to prevent overcorrection while patients are receiving 3% hypertonic saline solution.

Patients who are symptomatic from hyponatremia can generally be made asymptomatic by increasing the serum sodium just 4-6 mEq/L. Typically, no more than one half of the expected sodium deficit needs to be corrected in the first 12-24 hours and no more than half of this amount should be reversed with 3% hypertonic saline. Convert from 3% hypertonic saline to normal saline as soon as possible. Avoid an absolute increase in serum sodium of more than 20 mEq/L in a 24-hour period. Slower rates are usually recommended.

Since 3% hypertonic saline is generally used for no more than half of the expected total saline replacement required, a total of no more than 300-500 mL of 3% hypertonic saline is a reasonable dose in most patients even with severe hyponatremia. Once any hyponatremia-related symptoms have clearly disappeared and the serum sodium level is improving, switch from 3% hypertonic saline to normal saline.

The amount of the sodium deficit can be estimated from the following formula: Estimated sodium deficit = (140 - current serum sodium)(body weight in kilograms)(0.6). For example, a 70-kg patient with a serum sodium level of 120 would have an estimated sodium deficit of 840 mEq. The amount of saline fluid to completely normalize the serum sodium can be calculated easily by taking the estimated total sodium deficit and dividing it by the sodium content of the replacement saline solution. (Normal saline contains 154 mEq/L of sodium and 3% hypertonic saline has 513 mEq/L.) The goal of therapy is to correct the hyponatremia slowly but sufficiently to avoid hyponatremic symptoms.

In rare cases of very severe and symptomatic hyponatremia or in patients with end-stage renal failure who develop dilutional hyponatremia, hemodialysis has been successful and should be considered.

Absorption of irrigation fluid during TURP has been suggested to lead to oxidative stress, which might make some contribution to TUR syndrome. This oxidative stress can presumably be minimized by the use of free radical scavengers (antioxidants), although no studies have yet indicated any proven benefit.

According to a large Swedish study reported by Hahn that involved 1160 patients, a history of smoking may increase the risk and degree of fluid absorption during TURP. The difference in fluid absorption rates between those who smoked and those who did not was most pronounced when absorbed amounts of 1000 mL or more were examined. Almost twice as many persons who smoked had fluid absorption of more than 1000 mL compared with nonsmokers (15.5% vs 8.8%). Because persons who previously smoked but quit also had a somewhat increased risk, this extra fluid absorption is unlikely to result from parasympathetic receptor stimulation from the nicotine.

Smoking may also alter the vascular growth of the prostate, leading to additional potential blood loss and fluid absorption. Persons who smoke tend to have 22% higher average serum levels of vascular endothelial growth factor compared with nonsmokers. This is presumably because of the lower average blood oxygen levels in smokers. In addition, the tobacco may directly affect prostatic tissue and/or vasculature, resulting in increased irrigation fluid absorption.

Preoperative hyponatremia must be identified and corrected prior to TURP surgery if possible. Hyponatremia is usually due to impaired renal free water excretion. The normal response by the kidneys to hyponatremia is to excrete the extra free water. Various factors can interfere with this process, as follows:

• Renal failure and a reduced glomerular filtration rate result in less renal free water excretion.
• Increased proximal renal tubular reabsorption from decreased extracellular volume or edema reduce free water delivery to the diluting segment of the kidney.
• Thiazide diuretics directly interfere with the renal diluting mechanism.
• Inappropriate antidiuretic hormone (ADH) syndrome inhibits renal free water excretion and causes hyponatremia. It can be caused by head injury, adrenal insufficiency, hypothyroidism, psychotropic medications, and urinary tract infections, among other etiologies.

The basic treatment for correcting chronic hyponatremia is fluid restriction and elimination of the underlying cause. Demeclocycline, a tetracycline antibiotic that specifically inhibits the renal action of ADH and induces free water excretion by the kidneys, can be used when fluid restriction alone is inadequate. It is particularly useful in inappropriate ADH syndromes. The usual dosage of demeclocycline is 150 mg qid or 300 mg bid.

Hemorrhage

Postoperative bleeding after TURP usually stops within 3 weeks of the procedure. The degree and duration of hematuria is generally related to prostate size, duration of the procedure, and the care with which the surgeon inspects and treats bleeding points at the end of the case.

One useful method to help identify significant bleeding points is to slow the irrigation input to a trickle. This allows even small bleeding points to be seen that otherwise are too quickly rinsed away by the irrigation fluid to be visible.

Another helpful tip is to change the amount of fluid in the bladder. A bleeding vessel from the bladder neck may be pointing toward the posterior wall when the bladder is empty, but it becomes more visible if the bladder is relatively full. This occurs because of the difference in orientation and angulation of the bladder neck. The bladder neck tends to evert and turn into the prostatic fossa when the bladder is full (see Image 19).

Arterial bleeding

Arterial bleeding should be considered when bright-red blood that does not change during filling and bladder drainage is noted in the irrigating fluid. If the fluid does not clear rapidly, the resectoscope should be reinserted and bleeding points coagulated. Arterial bleeders can always be stopped by cauterization. Sometimes, bleeding sites are actually opposite from where the blood seems to be originating. An arterial bleeder can be directed against the opposite sidewall, which can create the illusion that the bleeding is coming from a different site. This is called the "ricochet effect." If the bleeding site cannot be initially identified, one should inspect the walls of the prostatic fossa 180° from the apparent bleeding site for a possible source of ricochet bleeding.

Additional resection is sometimes needed to expose the bleeder, such as when the bleeding point is located in a split tissue cleft (see Image 19). Perform this resection cautiously and superficially to avoid a perforation.

Extensive coagulation of large areas of the resected prostatic fossa is not advisable because it increases irritative symptoms, causes unnecessary damage to normal tissue, and increases scar tissue formation.

Arterial bleeders located at the bladder neck should be addressed first. They are best exposed by keeping the bladder empty. If this is unsuccessful, filling the bladder may tilt the bleeding site upward and make it visible. If the bleeding vessels are oriented toward the interior of the bladder, they may be very difficult to see directly. They may appear as a vague area of increased bleeding directly behind the bladder neck. Careful coagulation of the area under consideration often stops this bleeding. A finger in the rectum can be used to elevate the bladder neck and help identify bleeding sites (see Image 31). When the finger in the rectum is pressed directly and firmly on a bleeding site, the bleeding stops until the digital pressure is released.

Care should be taken to identify the ureteral orifices to prevent their inadvertent resection or cauterization when working around the bladder neck area. The most important blood vessels to the prostate tend to enter at the 4-o'clock and 8-o'clock positions near the bladder neck.

Arterial bleeders pointing directly at the lens can also be difficult to identify, but they can be easily seen in profile. Change the angle of the resectoscope, and look at the bleeding site from a slightly different angle. Another technique is to reposition the resectoscope at the bladder neck and then slowly withdraw it until the bleeding point becomes visible. If at some point visibility is obscured by the bleeding, this is the level at which to find a bleeding source by altering the angle of orientation of the telescope and repeating the procedure. Alternately, slowly advance the resectoscope until very close to the bleeding source.

If a significant arterial bleeder is encountered while resecting, the bleeding vessel should be cauterized immediately because it usually becomes much more difficult to localize the bleeding vessel later. Do not begin resecting a new region of the prostate without good hemostasis in previously resected areas. Avoid cauterizing smaller bleeders, not only because it wastes time, but also because it leads to cauterizing the same vessels multiple times as the resection proceeds. If possible, wait until the surgical capsule is reached before cauterizing bleeding sites.

Overly aggressive resection into the true prostatic capsule also causes unnecessary bleeding from small capsular vessels. These are harder to control because the cut ends of the arterioles are located between the capsular fibers and a significant risk of opening venous sinuses or perforating the prostatic capsule exists when using coagulating electrical current directly on the capsule.

In rare cases in which endoscopic control of significant or even massive hematuria is not possible, selective arterial embolization can be performed as reported by Michel and colleagues. Arteriography with selective embolization is quick and uses only local anesthesia, which makes it particularly useful in frail and elderly patients. It has also been used successfully to treat severe post-TURP hematuria due to rare vascular anomalies such as congenital arteriovenous malformations or arteriovenous fistula.

Venous bleeding

Venous bleeding usually manifests as relatively dark blood in the irrigation fluid. Further inflating the Foley balloon in the bladder after evacuating all clots and exerting gentle traction to compress the bladder neck can usually solve this problem.

Venous bleeding is easily differentiated from arterial bleeding because of the lack of pulsatile high-pressure flow, darker color, and cessation upon increasing intravesical pressure. Bleeding from large venous sinuses cannot be controlled by cauterization. Continuing cauterization can cause local tissue damage, increase blood loss, create or worsen extravasation, and exacerbate irrigation fluid absorption leading to hyponatremia and TUR syndrome. The best course is to lower the inflow pressure of the irrigating fluid to the minimum necessary to visualize the surgical field and finish the procedure as quickly as possible.

Other principles of hemorrhage control

Some patients maintain a lower blood pressure during the case. When their blood pressure returns to normal, additional bleeding occurs. Sites that were not actively bleeding earlier now start to lose blood. Having the anesthesiologist allow the patient's blood pressure to rise to his normal level and reinspecting the prostatic fossa for additional bleeding sites is useful before terminating the procedure.

The bladder should be carefully examined if no other source of bleeding can be discovered. A laceration or perforation may be located in the posterior bladder wall that is not easy to find unless specifically sought. If a suprapubic trocar or tube has been placed, this should also be routinely examined cystoscopically to make sure any bleeding is controlled.

The irrigation fluid from the Foley catheter should be absolutely clear before removing the patient from the cystoscopy table. Inability to control bleeding after the catheter is in place is a clear indication for a reinspection with the resectoscope for additional bleeding sites, usually arterial.

Urokinase can cause prolonged venous bleeding following TURP surgery. If bleeding persists, treatment with epsilon-aminocaproic acid (Amicar) may be warranted. The usual dose is 3 g/d for urokinase inactivation and 8 g/d for systemic coagulopathies such as fibrinolysis. Epsilon-aminocaproic acid can also be added to the irrigation fluid, although how much actual benefit it can provide remains unclear.

Significant persistent bleeding after 2 hours of traction is an indication for a second look into the prostatic fossa, and the patient should be returned to the operating room.

Limited short-course radiation therapy (9 Gy per 3 fractions) can be helpful in controlling hematuria from the prostate that is unresponsive to other methods, as noted by Rosenberg and colleagues. They reported cessation of bleeding in 94% of patients within 48 hours after completion of the radiation therapy. This should not be used as a substitute for adequate surgical hemostasis or a second look with the resectoscope if otherwise indicated.

Perforation of the prostatic capsule and extravasation

Significant extravasation with perforation of the prostatic capsule occurs in approximately 2% of patients. Minor levels of extravasation are probably very common but clinically insignificant. Excessive bleeding with large or deep capsular perforations during the resection is usually visible and should raise the suggestion of possible extravasation. Also possible is a perfectly normal TURP surgery but perforation of the prostatic fossa when placing the Foley catheter at the end of the case, leaving the end of the catheter with its continuous irrigation in the retroperitoneum. This last scenario can be difficult to diagnose because symptoms do not become apparent until some time after surgery. It should be considered when the catheter fails to drain adequately without apparent blockage and associated symptoms of fluid extravasation appear.

Symptoms of excessive extravasation and prostatic perforation include restlessness, nausea, vomiting, and abdominal pain, sometimes even in spite of a spinal anesthetic. The abdominal pain tends to be localized to the lower abdomen and back. The abdomen typically becomes hard and rigid. The bladder and bladder neck may appear narrower and longer as fluid accumulates in the retroperitoneum and eventually compresses these structures. Dilutional hyponatremia (TUR syndrome) also may be present.

If significant extravasation is likely, the procedure should be terminated as quickly as possible. Patients who have had their TURP procedures terminated after having a single lobe resected do remarkably well, with excellent long-term urinary symptom relief. Careful attention must be paid to removal of all resected prostatic chips from the bladder and strict hemostasis because continued bleeding can be very difficult to manage along with the complications of an extravasation. Patients should have their serum sodium level checked for possible hyponatremia. Hemoglobin and hematocrit levels should also be monitored because blood loss into the extravasated area cannot be easily detected clinically. Antibiotics should be administered.

Bladder perforation can be caused by iatrogenic injury from either the resectoscope or overdistension. This should be considered when the abdomen becomes rigid during the procedure, when bleeding is excessive with no bleeding source found in the prostate, or when a patient under a spinal anesthetic complains of shoulder pain. The shoulder pain could be caused by irritation of the diaphragm from irrigation fluid in the peritoneal cavity.

The diagnosis can be confirmed by performing a simple x-ray cystogram. The extent of the extravasation, laboratory test results, and the patient's clinical response ultimately determine whether an open cystostomy with perivesical drainage is necessary. The overwhelming majority of these patients, more than 90%, can be maintained just on catheter drainage. If the patient's clinical condition worsens, open surgical intervention should be reconsidered. If open surgery is required, adequately exposing the extravesical space both anteriorly and laterally is important so that drains can be placed.

If the Foley catheter has been inadvertently placed in the retroperitoneum, catheter replacement into the bladder may be all that is necessary. Fluoroscopic guidance is sometimes helpful in managing this task, especially if the patient is already in an operative suite with fluoroscopic capability. Without radiographs or fluoroscopy, ensuring that the catheter has been repositioned correctly can sometimes be difficult.

Venous air embolism during transurethral prostate resection is very rare. Although uncommon, the result of a venous air embolism can be catastrophic and result in a fatality. Incorrect assembly of the resectoscope-drainage system can lead to the rapid infusion of air into the open venous channels of the prostatic bed, causing the air embolism. This risk is increased when open venous sinus channels are present and continuous-flow or other high-bladder pressure-control systems are not operative.

Long-term complications

Incontinence

Urinary incontinence of any degree 3 months after a TURP is found in approximately 3% of patients. Three forms of incontinence may be observed after TURP:

• Urge incontinence, which is associated with the healing process of the bladder, prostate, and prostatic fossa
• Stress incontinence, which is related to excessive resection at the prostatic apex and around the verumontanum
• Total incontinence, which is the result of irreparable damage to the external sphincter muscle

Both urge incontinence and stress incontinence usually resolve within 3-6 months, and improvement may be observed up to a year after surgery. Kegel exercises can be useful in mild-to-moderate degrees of incontinence and should be used. Rates of total incontinence after TURP are estimated at approximately 1%. Treatment in these cases can be difficult, involving sphincteric collagen injection and artificial sphincter placement.

Urethral strictures and bladder neck contractures

Urethral strictures are the most common late complication of transurethral prostate surgery. They should be considered in any patient who underwent TURP who has symptoms of outlet obstruction or a peak flow rate of 10 mL/s or less. Urethral strictures or bladder neck contractures appear in 3.7% of patients. Strictures occur because of insertion of a resectoscope sheath that is too large (see Image 22), urethral trauma during the procedure, use of a large-caliber catheter, or infection. No difference in urethral stricture formation rate was noted when suprapubic tubes were used instead of Foley catheters post-TURP. Coaxial continuous-flow resectoscopes tend to create fewer urethral strictures, most likely because they require less intermittent handling for bladder emptying.

Stray radiofrequency electrical current has been suggested as a possible cause of urethral strictures following TURP. This is aggravated by the use of a cutting loop with faulty insulation and may vary according to the particular type of electrosurgical unit used. Most post-TURP urethral strictures are found at the fossa navicularis and the bulbous urethra.

Prevention of urethral strictures is key. Urethral calibration with a bougie-a-boules alerts the surgeon to a urethra that will not easily allow a large caliber resectoscope sheath. Most adult male urethras calibrate at 28F or more. If not, then either a perineal urethrostomy or a smaller resectoscope sheath should be used. If even a 24F sheath proves too large, then a perineal urethrostomy should be performed. A ventral meatotomy or dorsal internal urethrotomy may be needed if the urethral meatus is too tight to allow easy passage of the resectoscope sheath. Dorsal urethrotomies are less likely to produce postoperative splaying of the urinary stream compared to ventral meatotomies.

Prevention of urethral trauma during the procedure requires adequate lubrication of the sheath and careful handling. The outer sheath should be well-coated with a water-soluble lubricant so that lubrication lasts throughout the case without rinsing away. The sheath with obturator should be passed carefully into the bladder. If difficulties are encountered, the sheath can be passed over a red rubber catheter or under direct vision, but care must be taken to avoid unnecessary urethral injury. Accidental extraction of the sheath beyond the external sphincter muscle should be avoided to reduce trauma to the bulbous urethra.

The etiology of bladder neck contractures is less certain, although they definitely seem to be related to the size of the gland, with smaller prostates being more likely to produce a bladder neck stricture than larger glands. Bladder neck contractures are less common after open prostatectomy, probably because of the very large size of the prostates normally resected at open surgery. Bladder neck contractures typically start to occur 4-6 weeks after transurethral prostate surgery.

Various methods have been tried to help avoid this complication. A deep incision with a Collings knife at the 6-o'clock position, extending from the proximal prostatic urethra, through the bladder neck, and into the mid trigone, has been helpful in reducing the rate of bladder neck stricture formation. Leaving a portion of the bladder neck intact is another technique that has been proposed to help reduce the rate of stricture formation.

Retrograde ejaculation and sexual dysfunction

Retrograde ejaculation results from the destruction of the bladder neck during TURP. During normal ejaculation, the bladder neck closes under sympathomimetic influence, allowing the semen to flow forward. The bladder neck is unable to close after TURP, permitting semen to flow backwards into the bladder. This is a very common sequela after TURP, occurring in 70.4% of patients. This should be carefully discussed with the patient before surgery because many patients confuse ejaculation with potency and may incorrectly consider themselves to be sexually impotent. It also may be quite alarming to the patient to unexpectedly find that he has a dry ejaculate after a TURP.

Preservation of sexual function after TURP depends on potency status before surgery, patient age, the patient's relationship with his partner, and the couple's adjustment after surgery. Penetration of the prostatic capsule has been linked to an increased risk of erectile dysfunction. It may also be related to the degree of injury to the cavernosal nerves, which are located very close to the prostatic capsule and can potentially be injured by transmitted heat or electrical current from the resecting loop, especially when used at the 4- to 5-o'clock and 7- to 8-o'clock positions.

Impotence following TURP surgery is estimated to occur in as many as 21.5% of men, although significant erectile dysfunction probably occurs in fewer than 10%. The reported range is 3.3-34.8%. Most randomized studies that compared postoperative rates of erectile dysfunction to preoperative rates, such as the controlled trial reported by Brookes and associates comparing sexual function between surgical and nonsurgical patients, found no significant difference. A few reports, such as those by Mishviki et al and Brookes et al, have even indicated improved sexual performance after TURP surgery.

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