Overview of Transurethral Resection of the Prostate
Transurethral resection of the prostate, or TURP, is a medical procedure where doctors use a minimally invasive technique to remove part of the prostate. It’s been hailed as one of the first major modern medical procedures that require little to no incisions. Since its introduction in 1943, it has remained the standard treatment for a condition called bladder outlet obstruction (BOO), which is when the flow of urine is blocked. Although the procedure has stayed largely the same for many years, there have been some minor changes.
Besides treating BOO, TURP can also be used for other medical issues. For example, it can help treat prostatic abscesses, which are pockets of pus within the prostate, by removing the top layer of these abscesses. It’s also used to open ejaculatory ducts (the tubes that carry sperm from the testicles to the urethra) in situations where they’re blocked, which is a condition known as obstructive azoospermia.
Anatomy and Physiology of Transurethral Resection of the Prostate
The prostate is a small organ in males that plays a crucial role in fertility. It produces a fluid that makes up around 30% of the semen, aiding in the fertility process. The fluid it secretes has a slight alkaline nature and contains a substance called prostate-specific antigen that thins the semen. The prostate’s growth is stimulated by hormones known as androgens.
Typically, a healthy prostate weighs around 33 grams. It is made up of three sections: the central, transitional and peripheral zones surrounded by a capsule. When the prostate grows larger – a condition known as benign prostatic hyperplasia (BPH), the enlargement usually occurs in the transitional zone. This condition is common in men as they age, with around 70% of men in their 60s and 80% in their 70s experiencing some degree of BPH. If BPH leads to difficulty in urinating, a surgical procedure known as a Transurethral Resection of the Prostate (TURP) may be required.
The blood supply to the prostate comes mainly from the internal iliac artery, specifically its branch called the inferior vesical artery, which further divides into the prostatic artery. Then it separates into two branches: one surrounds the outer layer of the prostate and the other provides blood to the middle lobe of the prostate. Other arteries close to the prostate apex may also contribute to its blood supply.
When performing TURP, a notable anatomical landmark is the verumontanum, which represents the tube-like structures that carry sperm. It is located fairly close to the external sphincter muscle, which controls the flow of urine. During the TURP procedure, surgeons need to very carefully avoid injuring the external sphincter muscle, as it is essential for maintaining continence post-operation. During the operation, it is important not to remove tissue beyond the verumontanum or risk damaging a network of veins that covers the front of the prostate, as this can lead to significant bleeding.
Why do People Need Transurethral Resection of the Prostate
A TURP, or transurethral resection of the prostate, is a procedure that may be recommended if someone has urinary problems due to a condition like an enlarged prostate, which can block the flow of urine. Some situations that might call for this treatment option include not finding relief from medications for urinary symptoms or bladder obstruction, kidney damage due to a blocked urinary tract, repeated instances of bladder stones, at least two episodes of not being able to pee, abscesses or pus-filled pockets in the prostate, continued discomfort with a clean intermittent catheterization routine (a method to empty the bladder by inserting a tube), consistent blood in the urine, not completely emptying the bladder, or fertility issues due to blockage of sperm.
However, it should be noted that a bladder pouch or diverticulum alone does not warrant this procedure. Men usually consider this treatment when they are experiencing urinary tract symptoms that are bothersome, and medication is not helping. Also, having prostate stones may indicate that the bladder is not emptying completely, which might make this procedure a necessary consideration. It’s good to remember that the size of the prostate itself is not a reason for this surgery. There generally should be signs of existing or likely damage to the kidneys or bladder, or symptoms not controlled by medication before TURP is considered.
In some cases, a large middle lobe in the bladder may result in a ball-valve effect, which impedes proper urine flow – this can make TURP a viable option, especially if other treatments are not effective. When there is a prostate abscess that is close to the surface and easily accessible, a TURP could help in draining it. For those experiencing difficulty in the process of inserting a catheter or have problems with complete bladder emptying, this procedure might be helpful. If a person has fertility issues due to blockage of the sperm pathway, a TURP could help address the issue.
Surgeons usually avoid performing a TURP when the prostate is too large to safely and effectively remove within an approximate 90-minute surgery time. Typically, this is around 75 to 80 grams, although highly experienced surgeons can deal with prostates of 100 to 150 grams in size. For large prostates that require treatment and are unsuitable for TURP, alternative procedures like simple open prostate surgery or laser enucleation might be more appropriate options.
When a Person Should Avoid Transurethral Resection of the Prostate
A surgery may not be possible for a patient who cannot medically handle the anesthesia or the possible aftereffects of the operation. An individual with an active, untreated urinary tract infection would also be such a case where the surgery is absolutely not recommended.
There are also some conditions where the surgery is not an outright ‘no’, but should be carefully weighed before proceeding. This includes patients who have had radiation therapy for prostate cancer, or those with conditions like myasthenia gravis (weakness and rapid fatigue of muscles), multiple sclerosis (a disease affecting nerves), and Parkinson’s disease (a disorder of the nervous system that affects movement). These groups of patients have a high chance of not being able to control urination after the operation because of a dysfunctional muscle controlling urination.
Being on blood-thinning medication can also be a concern before surgery, though there is a version of the operation using lasers that could be done on such patients, or the medication can be temporarily stopped in some cases. Also, if a prostate is exceptionally large – more than 100 grams – it’s usually a sign to think about a different kind of operation, as many urologists may not possess the necessary skill or experience to perform the usual surgery safely. Having an overly active bladder that is hard to control can also be a reason to reconsider the surgery.
Equipment used for Transurethral Resection of the Prostate
During a medical procedure, doctors use several tools to ensure everything goes smoothly. Here’s a list of what might be used:
* Antimicrobial prep: This is a type of preparation that kills or slows down the growth of microbes, essentially serving as a defense against infections.
* Preoperative antibiotics: These are medicine given before surgery to prevent infections.
* Resectoscope: This is a special telescope-like instrument with a loop at the end. The loop is essentially an electric wire that can remove or vaporize tissue.
* Saline, glycine, sorbitol-mannitol, or other irrigation substances: These are various fluids used to wash and cleanse the area during surgery.
* Large bore 3-way foley catheter: A foley catheter is a thin, flexible tube that is inserted into the bladder to drain urine. A 3-way foley catheter has an extra channel for irrigation of the bladder.
* Continuous bladder irrigation (CBI) tubing and connectors: This equipment is used to continuously flush the bladder with a sterile solution.
* Sterile lubricant: This is a special substance used to reduce friction during medical procedures.
* Foley bag (large): This is the bag that collects urine from the catheter.
* Catheter tipped syringe: This is a syringe, a device used to inject or withdraw fluids, with a special tip that can connect to a catheter.
* Catheter guide: This is a device that helps in guiding the catheter into place.
* Bladder evacuator: This tool (like an Ellik evacuator) helps remove fluid or small pieces of tissue from the bladder after an operation.
Who is needed to perform Transurethral Resection of the Prostate?
A specially trained doctor known as a urologic surgeon is the one who carries out the TURP, which is a procedure to help with urination problems. While the surgeon is carrying out the operation, there’s another team member, an anesthetist, who makes sure you stay asleep throughout the process.
We also have a nurse right in the operating room. They work with the surgeon and the anesthetist during the operation. Their job often includes replenishing the irrigation bags, which help keep the area being operated on clean, and getting any supplies the surgical team might need during the procedure.
Lastly, a surgical technician is also part of the team. The surgical technician assists the surgeon by preparing the surgical instruments before the operation and taking care of tasks during the operation like emptying the Ellik – a device that collects tissue removed during the procedure. All these team members work together to make sure your procedure goes smoothly and safely.
Preparing for Transurethral Resection of the Prostate
Before undergoing a procedure called Transurethral Resection of the Prostate (TURP) to relieve issues with urination, it’s important for patients to understand what they should expect before, during, and after the procedure. Initially, your doctor will take a detailed account of your health history, focusing mainly on your urinary symptoms like how often you urinate, urgency, flow rate, pain during urination, waking up at night to urinate, and any incidents of incontinence or loss of bladder control.
They’ll also check the treatments you’ve tried before for your Lower Urinary Tract Symptoms (LUTS) and any medications you’ve been taking. A physical examination will be carried out which includes checking the genital area and conducting a rectal exam to check for any health concerns. This also helps estimate the size of the prostate. Certain tests will then be done to check how well your bladder is working and rule out any Urinary Tract Infections (UTIs) before the surgery.
In some cases, urologists (doctors specialized in urinary tract diseases) also perform a test called urodynamics to understand how well your bladder works. This helps them judge whether the patient can consent to the surgery, especially in cases where the bladder muscles’ contractions are in question. However, not all patients need this additional test.
If the urologist decides to go ahead with TURP, they may consider putting in a tube to drain urine from the bladder if there are concerns about how well you can urinate after the operation. This tube would be removed once it’s clear you don’t have much urine left in your bladder post-urination.
Before deciding to go ahead with TURP, patients are always informed about all treatment options for LUTS and the risks and benefits associated with each of them. Once this comprehensive discussion is done, an informed decision can be taken on undergoing TURP.
With new medical technologies, a TURP procedure can be done using either an electrical or a laser element. This procedure helps to quickly address large prostates. It also allows for any removed tissue to be checked for possible prostate cancer.
The procedure is done using electrical currents that can either cut tissue or halt bleeding. These currents are produced by special machines inside an electrosurgical unit.
Before surgery, the patient usually goes through checks like urine tests, tests for electrolytes and blood cells, a measure of how much urine is left after urinating, and a test to check prostate health. Imaging tests of the kidney are not usually necessary, unless there’s unusual or unexplained bleeding.
In 2021, the American Urological Association suggested evaluating prostate size and shape before the surgery either by looking inside the bladder with a cystoscope, a transrectal ultrasound, or scans like a CT or MRI. Other tests like determining how fast urine flows and measuring the urine left after urinating are also suggested.
It’s usually suggested that a certain medication called finasteride be taken two weeks before TURP, especially in those with larger prostates, to reduce the chances of excessive bleeding during surgery.
Another measure is giving antibiotics an hour before surgery to prevent infections. Patients with urinary catheters already in place are given longer antibiotic courses based on urine sample results. Although, TURP usually does not require protection against blood clots as it involves a higher risk of increased bleeding.
The TURP can be done using either a monopolar technique (original method) or a bipolar technique. The monopolar technique passes electrical current from the wire loop through tissue in contact with the electrode through the patient, ending at a grounding pad. Non-conducting fluids are used for this, but they increase the risk of too little sodium in the blood (hyponatremia).
Many hospitals have moved to the bipolar technique where the electrical poles are within the instrument used for surgery. This allows for normal saline to be used and reduces the risk of hyponatremia. However, risks include saline overload which may lead to swelling in the upper airway, and the occurrence of too much acid in the blood.
While bipolar equipment isn’t available in many parts of the world and requires completely changing sets of urologic instruments, the overall results from monopolar and bipolar procedures are similar. The type of TURP method used will depend on the urologist’s experience and preference.
How is Transurethral Resection of the Prostate performed
In order to effectively perform a Transurethral resection of the prostate (TURP) surgery, proper preparation and planning is essential. A TURP surgery is a procedure used to treat urinary problems that are caused by an enlarged prostate. Here, we’ll go over the things the surgeon does to make sure that the procedure goes as smooth as possible.
Before the operation starts, the surgeon dresses the patient and themselves to maintain absolute cleanliness and minimize the chances of infections during the surgery. It’s important to properly position the patient on the surgical table to provide the best access to the prostate. The surgeon makes sure to provide a clear field of vision by delicately washing the urethra to remove any substances that could impact vision. The bladder will be flushed out as soon as the resectoscope, a surgical instrument used for the operation, is in place.
Next, the surgeon examines the patient’s inner organs using a tiny camera to locate important landmarks and detect any unexpected issues. They take note of the anatomical features of the patient’s body. This is critical for the surgery, as it helps them avoid injuries to important parts of the prostate, urethra, or bladder.
The surgeon then checks the surgical instruments to make sure all are working correctly and are ready for the operation. A failure could complicate the procedure, so it’s better to be prepared for every situation. They also prepare a sufficient amount of irrigation or cleaning fluids that will be used during the operation. This fluid helps to rinse away tissue and blood from the operation area, allowing for a clearer view. It is important to keep the patient’s body temperature stable, as fluctuations can cause complications.
Now that preparation is done, the surgeon will start with the actual prostate resection. This means removing parts of the prostate to help ease the patient’s urinary difficulties. The goal here is to do so in a careful, organized way. This is achieved by making long, smooth cuts to separate one slice of tissue from the rest of the prostate. This technique helps avoid complications like tunnelling, perforation, bladder injury, and extravasation, which means leakage of fluids into areas where they should not be.
Visual checkpoints are regularly made during the operation to make sure the right areas are being targeted and the resection is going as planned. The goal is to remove as much unnecessary tissue from the prostate as possible without overstepping boundaries or running into complications. The outcome of this procedure will lead to relief from the urinary difficulties faced by the patient due to an enlarged prostate.
Possible Complications of Transurethral Resection of the Prostate
It’s helpful to separate complications into those that can occur during surgery (intraoperative) and those that might happen after surgery (postoperative). This helps patients know what to expect and allows for a thorough discussion of possible issues.
During prostate surgery (also known as TURP), complications can include risks from anesthesia, accidental injury to the bladder or urethral opening, excessive bleeding or poor visibility during surgery, and improper placement of a Foley catheter, which is a tube put into the bladder to drain urine.
After TURP surgery, almost all patients may have retrograde ejaculation, where semen goes into the bladder instead of out through the penis during orgasm. However, the ability to have erections is usually maintained in 90% of patients. Other possible post-surgery complications can include ongoing urinary symptoms, urinary tract infection, a narrowed urethra or bladder neck, urine leakage (incontinence), and the need for a catheter due to urinary retention or a poorly functioning bladder. In some cases, the prostate may regrow, but this usually takes at least ten years.
Leakage of urine after TURP surgery usually gets better within three months. Doing Kegel exercises and changing habits related to the pelvic floor can help. Fortunately, complete or unmanageable urine leakage is quite rare.
Narrowing of the bladder neck after surgery is more common with smaller prostates. It’s suggested that more aggressive treatment of urinary infections after surgery may help reduce this risk.
Narrowing of the urethra is the most common late complication of surgery. Urethral damage due to rough insertion of the surgical tool, inadequate lubrication, or using an overly large surgical tool without enough dilation can most likely cause this.
Severe bleeding after the operation should be treated with another surgical examination. Most of the time, a single blood vessel will be found to be bleeding. If this doesn’t solve the problem, there are other options such as embolizing the prostatic artery, which is like putting a plug to stop the bleeding.
If the bladder gets punctured during surgery and isn’t noticed, this can cause the belly to swell up, slow heart rate, low blood pressure, and abdominal or shoulder pain. These symptoms suggest an immediate screening test called a cystogram. If there’s a significant bladder tear, it should be surgically repaired.
TUR syndrome is a potentially dangerous condition that can arise due to the absorption of large volumes of the irrigation fluid used during surgery. This can cause water intoxication and various symptoms such as confusion, nervousness, nausea, vision problems, and in extreme cases, coma, shock, and death. Patients who are at high risk include those with pre-existing low sodium levels, kidney failure, high irrigation fluid pressure, prolonged surgery, unnoticed bladder tear, and excessive bleeding.
Roughly 20 mL of the fluid is absorbed per minute during surgery, with about one-third dissolving directly into the blood vessels. Symptoms usually appear when the sodium levels drop below 125 mEq or less.
If mild to moderate symptoms of water intoxication occur, it is treated with furosemide and normal saline. For severe cases, a solution with a high concentration of sodium (hypertonic saline 3%) is used. This should be done gradually to avoid complications due to a rapid rise of sodium levels in the blood. Severe overcorrection of low sodium levels can be treated with a drug called desmopressin.
In some situations, hypertonic saline is administered before surgery to prevent low sodium levels following surgery. Another way to prevent water intoxication is to mix a small amount of alcohol (1%) in the irrigation fluid used during surgery. This allows doctors to estimate the total fluid the patient has absorbed just by testing for alcohol in the breath.
If surgery takes longer than 60 minutes, or there’s excessive bleeding, a post-surgery sodium level should be checked. Surgical technologies that use saline are less likely to cause low sodium levels. Still, there may be a significant increase in the fluid levels in the blood vessels due to absorbed irrigation fluid from the procedure, which could potentially lead to other complications.
What Else Should I Know About Transurethral Resection of the Prostate?
A TURP, or transurethral resection of the prostate, is a procedure usually done to relieve a blockage in the prostate. This blockage can cause problems like difficulty urinating, UTIs (urinary tract infections) due to the bladder not completely emptying, and potential damage to the kidneys and bladder. If a patient has to use a catheter to empty their bladder, a TURP can make this process easier and cause less bleeding.
In some cases, the prostate can develop abscesses, which are pockets of infection. Since it can be hard for antibiotics to reach these abscesses, a TURP could be used to drain them.
For men experiencing fertility problems due to a blockage in the duct responsible for ejaculation, a TURP can help by making a cut or removing the blocked section of the duct.
Rough statistics show that about 90% of patients see their urinary symptoms significantly improve or completely go away following a TURP. On average, the improvement in symptoms is around 85%. Men who were particularly bothered by their urinary symptoms usually report the best results. After the prostate surgery, the flow rate of urine typically increases more than 100%, with the average rate increase being 10 mL/sec. The capacity of the bladder to hold urine also improves, being about 45% greater six months after the procedure, and any unstable bladder issues are reduced by around 50%.