What are the steps and techniques involved in a Transurethral Resection of the Prostate (TURP) procedure?

Transurethral Resection of the Prostate (TURP): Techniques, Steps, and Tips

TURP remains the gold standard surgical procedure for benign prostatic hyperplasia (BPH) due to its proven efficacy from randomized clinical trials with long-term follow-up, despite the development of newer surgical technologies. 1

Indications for TURP

• TURP is appropriate for patients with moderate-to-severe lower urinary tract symptoms (LUTS) and those who have developed acute urinary retention or other BPH-related complications 1
• While medical therapy is generally tried first, patients may appropriately select surgical treatment as initial therapy if symptoms are particularly bothersome 1
• Patients who have developed complications of BPH are best treated surgically 1

Pre-Procedure Considerations

• Discontinuation of anticoagulants before TURP is recommended to reduce the significant risk of bleeding complications 2
• Either general or spinal anesthesia can be used, with spinal anesthesia potentially offering advantages for outpatient procedures 3
• Low-dose lidocaine (≤35 mg) spinal anesthesia may be preferred for shorter PACU stays and faster block regression compared to bupivacaine 4

TURP Procedure Steps

1. Patient Positioning and Preparation

   • Position patient in lithotomy position 5
   • Perform sterile preparation and draping of the surgical field 5
   • Insert a resectoscope through the urethra under direct vision 1

2. Initial Cystoscopy and Orientation

   • Perform initial cystoscopy to assess the bladder, ureteral orifices, and prostate anatomy 5
   • Identify anatomical landmarks: verumontanum, bladder neck, and ureteral orifices 5

3. Resection Technique

   • Begin resection at the 6 o'clock position near the bladder neck 5
   • Use an electrified loop to systematically resect prostatic tissue in strips 1
   • Work from the bladder neck toward the verumontanum 5
   • Maintain adequate irrigation throughout the procedure to ensure good visibility 6

4. Hemostasis

   • Achieve meticulous hemostasis during and after resection using the cautery loop 1
   • Pay special attention to bleeding vessels at the bladder neck and prostatic capsule 5

5. Completion and Catheter Placement

   • Evacuate all resected tissue fragments from the bladder 5
   • Place a large-caliber urethral catheter (20-24 Fr) with continuous irrigation 7
   • Maintain catheter traction if needed for hemostasis 5

Tips and Tricks

• Irrigation Management: Maintain crystalloid administration at 1-4 ml/kg/hr as maintenance fluid during TURP procedures to prevent TURP syndrome 6
• Capsule Identification: Look for the characteristic "white fibers" of the prostatic capsule to avoid perforation 5
• Resection Depth: Resect until prostatic capsule is visualized but avoid deep penetration to prevent perforation and excessive bleeding 5
• Bladder Neck Preservation: Preserve enough tissue at the bladder neck to prevent bladder neck contracture 2
• Apical Dissection: Exercise extra caution near the apex to avoid urethral sphincter damage and subsequent incontinence 2
• Monitoring: Regularly monitor vital signs, urine output, and fluid balance during the procedure 6

Potential Complications and Prevention

• TURP Syndrome: This unique and potentially life-threatening complication occurs when irrigant solution is absorbed into the bloodstream, causing dilutional hyponatremia (<1% of cases) 2

  • Prevention: Limit resection time to under 90 minutes and use bipolar TURP when available 6
  • Management: Immediate recognition, cessation of the procedure, and correction of hyponatremia 2

• Bleeding: Occurs in approximately 8% of cases requiring transfusion 2

  • Prevention: Meticulous hemostasis and careful capsule identification 2
  • Management: May require transfusion or transurethral fulguration 2

• Sexual Dysfunction: Retrograde ejaculation occurs in approximately 65% of patients 2

  • Prevention: Consider alternative procedures like TUIP for smaller prostates if ejaculatory function is a priority 2

• Bladder Perforation: Requires immediate recognition and management 7

  • Prevention: Careful resection technique and avoiding excessive depth 7
  • Management: Place large-caliber urethral catheter and consider surgical repair if needed 7

• Urethral Stricture/Bladder Neck Contracture: Occurs in approximately 7% of cases 2

  • Prevention: Avoid traumatic instrumentation and excessive resection at the bladder neck 2

Post-Procedure Care

• Maintain continuous bladder irrigation until hematuria clears 5
• Monitor for signs of TURP syndrome, including confusion, nausea, hypertension, and visual disturbances 2
• Remove catheter when urine is clear, typically within 1-3 days 5
• Avoid strenuous activity and straining for 2-4 weeks post-procedure 5