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TURP

Pre-operatively:

  • Recent urine culture with treatment of UTI (+/- catheter change)
  • Optimisation of co-morbidities
  • Pre-operative bloods, anaesthetic assessment re spinal vs GA
  • Withhold anticoagulation in conjunction with physicians
  • Consider pre-operative 5ARIs

 

Risks for TURP:

  • General
    • Anaesthetic (GA or spinal) risks, DVT/PE, MI/CVA, neuropraxias
  • Early
    • Bleeding / clots / return to theatre
    • Infection
    • Bladder / ureteric / rectal injury
    • TURP syndrome
    • Failure to improve symptoms
  • Late
    • Retrograde ejaculation
    • Risk of worsening erectile function (?up to 10 %)
    • Incontinence (1% stress incontinence)
    • Stricture / bladder neck contracture / meatal stenosis

 

Technique:

  • Lithotomy position
  • DRE and cursory baseline abdominal palpation
  • 22 fr cystoscopy – assess urethra, prostate length, location of ureters, presences of tumours/stones/diverticula
  • I use a bipolar system with saline irrigation and a 26 Fr continuous flow sheath (Otis urethrotomy as needed)
  • Resect the middle lobe first if present, or floor first followed by lateral lobes
  • Evacuation of chips with “Uro-vac grenade” or glass Toomey
  • Haemostasis systematically at bladder neck and apical mucosal edges
  • 22 fr 3-way IDC with saline irrigation

 

No energy?:

  • Check leads are connected
  • Check appropriate fluids being used
  • If monopolar, check plate

 

Bleeding:

  • Check irrigation / raise height of irrigations
  • Identify bleeder – is it venous or arterial
    • Venous bleeding obscured by full bladder
    • Bladder neck bleeders best seen with empty bladder
    • Arterial bleeding may cause ‘red out’ – can advance scope and use it to compress prostate, then slowly withdraw scope to identify bleeder
    • Arterial bleeding must be controlled and cauterised, venous bleeding will stop with catheterisation and traction and irrigation
  • Alert anaesthetist to bleeding and ask for blood pressure lowering, cross match, coagulation studies
    • Is the patient haemodynamically stable
  • Ongoing venous:
    • Overinflate balloon 50 mL and traction for 3-5 minutes (manual, hypofix)
  • Open and pack

 

Open packing:

  • Lower midline. Headlight.
  • Open bladder between stays
  • Remove all clot
  • ?? Complete enucleation depending on patient stability
  • Obvious bleeders cauterised or oversewn with monocryl J needle
  • Pack with 2 x lengths of ribbon packing gauze, one each side, with tail going into bladder
  • Large catheter placed under vision between packing gauze
  • Separate x 2 stab incisions on either side abdominal wall on to Roberts, then separate stabs into bladder, then bring each tail of packing out through abdominal wall on either side
  • Remove packing in 48 hours under GA (or in ICU if still sedated)

 

Monopolar vs bipolar:

  • Comparable efficacy
  • Risk of TURP syndrome negated with bipolar and saline
  • Monopolar resection should be limited to less than 60 – 90 minutes
  • Bleeding complications may be less in bipolar, but significant heterogeneity in studies
  • Bipolar preferred to larger glands with presumed longer resection time

 

Other potential issues:

  • Urethral length too long / unable to reach bladder (obese, malleable prosthesis)
    • Extra-long resectoscope (“Texan”)
    • Perineal urethrostomy
  • Priapism
    • Time and patience
    • 100 – 200 ug phenylephrine intracavernosal
  • Ureteric injury
    • Prevention is key – ID UOs early
    • Stent if able
    • If can’t find UO – consider methylene blue – if can’t stent or find, elect for a period of observation with serial ultrasounds
  • Bladder injury
    • Cystogram if concerns
    • Extraperitoneal – achieve haemostasis, leave IDC for 2-4 weeks, and either trial of void or return and complete resection
    • Intraperitoneal – open repair of cystotomy (?+/- complete enucleation)
  • Rectal injury
    • General surgeon involvement
    • Abandon resection
    • IDC over guidewire +/- SPC
    • Diverting end colostomy
  • Undermining of bladder neck / trigone
    • Be wary of extravasation of fluid to extraperitoneal space
    • Catheter should be placed over wire or introducer
    • Clear documentation in case of needing catheter replacement on ward / fails TOV
  • Urethral injury
    • Usually with blind blunt obturator – avoid if any resistance, use visual Schmidt obturator
    • Leave catheter for a bit longer