Transurethral resection of the prostate

BPH is normally initially treated medically. This is done through alpha antagonists such as tamsulosin or 5-alpha-reductase inhibitors such as finasteride and dutasteride. If medical treatment does not reduce a patient's urinary symptoms, a TURP may be considered following a careful examination of the prostate/bladder through a cystoscope. If TURP is contraindicated a urologist may consider a simple prostatectomy, in and out catheters, or a supra-pubic catheter to help a patient void urine effectively.[1] As medical management of BPH improves, the numbers of TURPs have been decreasing.

Traditionally, a cystoscope [a resectoscope which has a 30-degree viewing angle, along with resectoscopy sheath & working element] has been used to perform TURP. The scope is passed through the urethra to the prostate where surrounding prostate tissue can then be excised.

A monopolar device utilizing a wire loop with electric current flowing in one direction (thus monopolar) can be used to excise tissue via the resectoscope. A grounding ESU pad and irrigation by a nonconducting fluid is required to prevent this current from disturbing surrounding tissues. This fluid (usually glycine) can cause damage to surrounding tissue after prolonged exposure, resulting in TUR syndrome, so surgery time is limited.

TURP using a bipolar device is a newer technique that uses bipolar current to remove the tissue.[6] [7] Bipolar TURP allows saline irrigation and eliminates the need for an ESU grounding pad thus preventing post-TURP hyponatremia (TUR syndrome) and reducing other complications. As a result, bipolar TURP is also not subject to the same surgical time constraints of conventional TURP.

Another transurethral method utilizes laser energy to remove tissue. With laser prostate surgery a fiber optic cable pushed through the urethra is used to transmit lasers such as holmium-Nd:YAG high powered "red" or potassium titanyl phosphate (KTP) "green" to vaporize the adenoma. More recently the KTP laser has been supplanted by a higher power laser source based on a lithium triborate crystal, though it is still commonly referred to as a "Greenlight" or KTP procedure. The specific advantages of utilizing laser energy rather than a traditional electrosurgical TURP is a decrease in the relative blood loss, elimination of the risk of post-TURP hyponatremia (TUR syndrome), the ability to treat larger glands, as well as treating patients who are actively being treated with anti-coagulation therapy for unrelated diagnoses.

Because of bleeding risks associated with the surgery, TURP is not considered safe for many patients with cardiac problems.

Postoperative complications include [2]

• Bleeding (most common). Bleeding may be reduced by pre-treatment with an anti-androgen such as finasteride[3][4][5] or flutamide.
• Clot retention and clot colic
• Bladder wall injury such as perforation (rare). Intraperitoneal bladder rupture will present with upper abdominal pain and referred pain to the shoulder. Extraperitoneal bladder rupture may present with inguinal, peri-umbilical pain.
• TURP Syndrome: Hyponatremia and water intoxication (symptoms resembling brain stroke in an elderly presenting patient) caused by an overload of fluid absorption (e.g. 3 to 4 Litres) from the open prostatic sinusiods during the procedure. This complication can lead to confusion, changes in mental status, vomiting, nausea, and even coma. To prevent TURP syndrome the 1) length of the procedure is limited to less than one hour in many centers, and 2) the height of the container of irrigating solution above the surgical table determining the hydrostatic pressure driving fluid into the prostatic veins and sinuses is kept to a minimum.[6] The classic triad of TURP syndrome includes elevated systolic and diastolic blood pressures with increased pulse pressure, bradycardia, and mental status changes (assuming an awake patient under regional anesthesia).[7]
• Bladder neck stenosis
• Urinary incontinence due to injury of external sphincter system which may be prevented by taking the Verumontanum of the prostate as a distal limiting boundary during TURP
• Retrograde ejaculation due to injury of the prostatic urethra. This is one of the most frequent complications of the procedure, which occurs in about 65 % of patients.[8]
• The different types of irrigation fluids used for TURP each have specific disadvantages. [7] Glycine irrigating solution may cause transient blindness.  Distilled water has the highest risk for intravascular hemolysis, hypervolemia, and dilutional hyponatremia.  Balanced salt solutions (such as normal saline) cause electrical current dispersion during TURP but significantly reduce the risk of TURP syndrome.  Sorbitol and mannitol solutions may lead to hyperglycemia (sorbitol), intravascular fluid expansion with absorption (mannitol) and an osmotic diuresis (sorbitol and mannitol).[7]

Additionally, transurethral resection of the prostate is associated with a low risk of mortality.

• Transurethral incision of the prostate
• Transurethral greenlight laser therapy
• Transurethral steam treatment (Rezum)

• Medscape: Transurethral Resection of the Prostate