What is Transurethral Resection of the Prostate (TURP)?

Transurethral Resection of the Prostate (TURP)

Transurethral resection of the prostate (TURP) is a surgical procedure that involves removing the inner portion of the prostate gland through the urethra using an electrified loop to resect prostatic tissue and cauterize bleeding vessels, and remains the gold standard for surgical treatment of symptomatic benign prostatic hyperplasia (BPH). 1

Procedure Description and Technique

• TURP is performed endoscopically through the urethra without external skin incision, using a resectoscope with an electrified loop to remove obstructing prostatic tissue 1
• The procedure can be performed using either monopolar or bipolar energy systems:
  • Monopolar TURP (M-TURP): Traditional approach requiring non-conductive irrigation fluid 1
  • Bipolar TURP (B-TURP): Newer technology with more favorable perioperative safety profile due to reduced risk of hyponatremia and TUR syndrome 1, 2
• Usually performed under general or spinal anesthesia and requires hospitalization 1, 3
• Resection time varies based on prostate size, with larger prostates (>80g) requiring longer operative times compared to smaller prostates 4

Indications

• Primary treatment option for moderate-to-severe lower urinary tract symptoms (LUTS) due to BPH that are bothersome enough to warrant intervention 1, 3
• Specifically indicated for patients with: 3
  • Renal insufficiency secondary to BPH
  • Refractory urinary retention
  • Recurrent urinary tract infections
  • Recurrent bladder stones or gross hematuria due to BPH
  • LUTS/BPH refractory to or unwilling to use medical therapy
• Most appropriate for prostates between 30-80ml in size 1

Efficacy

• TURP is considered the benchmark for surgical therapies for BPH due to extensive evidence from randomized clinical trials with long-term follow-up 1
• Provides durable outcomes for symptom relief and improved urinary flow rates 1, 5
• Effective for immediate relief of bladder outlet obstruction 1
• For prostates <30ml, Transurethral Incision of the Prostate (TUIP) may provide similar efficacy with lower risk of retrograde ejaculation 1
• For prostates >80ml, open prostatectomy or newer techniques like Holmium Laser Enucleation of the Prostate (HoLEP) may be considered 1, 6

Complications and Risks

• Perioperative mortality is low (0.1-0.25%) 1, 7
• Complications occurring in >5% of patients include: 1, 3
  • Sexual dysfunction (including retrograde ejaculation)
  • Irritative voiding symptoms
  • Bladder neck contracture
  • Need for blood transfusion (0.4-7.1%)
  • Urinary tract infection (1.7-8.2%)
  • Hematuria
• TURP syndrome (dilutional hyponatremia) is a unique complication that occurs when irrigant solution is absorbed into the bloodstream (0-1.1%) 1, 7
• Risk of urinary incontinence is approximately 1% 1, 3
• Long-term complications include urethral strictures (2.2-9.8%) and bladder neck contractures (0.3-9.2%) 7
• Retreatment rates range from 3-14.5% after five years 7

Advantages Over Alternative Procedures

• Bipolar TURP has reduced risk of TUR syndrome compared to monopolar TURP 1, 2
• TURP provides tissue for histopathological examination, although this is no longer considered a major advantage due to PSA-based prostate cancer detection 1
• Despite technological advances and alternative procedures, TURP remains the gold standard for surgical management of BPH due to its proven efficacy and safety profile 5, 7
• Some emerging technologies like HoLEP may offer advantages for specific patient populations, particularly those with very large prostates 6

Preoperative Considerations

• Evaluation should include medical history, symptom assessment (AUA Symptom Index), urinalysis, and post-void residual measurement 3
• Prostate imaging (transrectal or transabdominal ultrasound) is appropriate when planning surgical intervention to determine prostate size and shape 3
• Patients on anticoagulants or antiplatelet medications may experience longer catheterization and hospitalization times, higher blood transfusion rates, and increased rehospitalization 1

Postoperative Care

• Catheterization is required postoperatively until bleeding subsides 4, 7
• Patients should be monitored for complications including bleeding, infection, and urinary retention 3, 7
• Patients should be counseled about potential sexual side effects, including ejaculatory dysfunction and possible changes in erectile function 3