Trans Urethral Resection of Prostate (TURP)
Overview
The prostate gland is a tiny organ located directly below the bladder in men. Transurethral resection of the prostate (TURP) is a surgical procedure that is used to decrease or eliminate prostate tissue. It is performed when an enlarged prostate gland presses on the urethra, producing issues with a man's urine stream.
What is Trans Urethral Resection of Prostate (TURP)?
Transurethral resection of the prostate (TURP) is an endoscopic surgery used to remove the prostate. It was the modern era's first big, minimally invasive operation. In rare cases of obstructive azoospermia, a TURP can also be utilized to unroof prostatic abscesses and open the ejaculatory channels.
Transurethral excision of the prostate is a surgery used to treat bladder outlet blockage caused by prostatic enlargement as well as prostatic abscess. If the patient wishes to discontinue medical therapy for bladder outlet blockage or if medical management fails, this surgery should be performed.
Anatomy and Physiology
The prostate is an organ involved in male fertility. It delivers prostatic secretions to the ejaculate and liquefies it with an alkaline solution and prostate-specific antigen. Prostatic secretions account for roughly 30% of ejaculate fluid. Androgens activate the prostate, which is generated from the urogenital sinus.
The typical prostate weighs roughly 33 grams. It is made up of three zones: central, peripheral, and transitional, which surround the parenchyma. Stroma, ducts, and acini make up the prostatic parenchyma. In benign prostate hyperplasia (BPH), obstructive enlargement usually develops in the transition zone. Fortunately, a TURP can simply remove the transition zone. Prostate cancer is frequently seen in the periphery.
Because of testosterone exposure, the prostate enlarges and continues to develop with age. When the prostate enlarges, the condition is known as benign prostatic hyperplasia (BPH), which is described as a rise in the total number of prostatic stromal and epithelial cells resulting in nodular enlargement. Prostatic hypertrophy is the swelling of individual prostatic cells. When BPH produces urinary blockage and either subjective or objective urinary issues, a TURP may be indicated.
Around 70% of men in their 60s and 80% of men aged 70 and more have benign prostatic hyperplasia. Symptoms also vary with age, with 80% of men aged 80 and over having symptomatic BPH.
The internal iliac artery provides the principal arterial supply to the prostate. The inferior vesical artery is the third branch of the internal iliac artery, with the prostatic artery being its terminal branch. The prostatic artery is only about 1 cm long before splitting into the capsular branch (which has perforating branches and surrounds the capsule) and the urethral branch (which enters the prostate at the 5 and 7 o'clock positions and supplies the median lobe), while another branch turns distally and supplies the periurethral tissue. Near the prostatic apex, there may also be contributing arterial branches from the middle hemorrhoidal and/or pudendal arteries.
The verumontanum, or "very," which indicates the ejaculatory ducts, is the most important anatomical marker for TURP surgery. It is situated posteriorly at 6 o'clock, approximately 1 cm proximal to the external sphincter. Due to its near closeness to the external sphincter muscle, the veru is the conventional distal limit of resection unless for exceptionally skillful surgeons.
The external sphincter muscle is essential for postoperative continence and should not be harmed during surgery since the internal sphincter is removed during a TURP treatment. The front edge of the external sphincter (at 12 o'clock) is leaning proximally or inwards toward the patient. This implies that while resecting the prostate roof, extreme caution should be exercised to avoid removing tissue further distal than the very, which is directly opposite.
Because the veru is not visible when resecting the roof, this might be difficult. Furthermore, the prostatic tissue is quite thin here, and there is a substantial venous complex (the periprostatic venous plexus or Santorini's plexus) surrounding the anterior prostatic capsule, which can cause severe bleeding if ruptured.
Indications for TURP
Failure of medical management for lower urinary tract symptoms (LUTS) or bladder outlet obstruction (BOO), obstructive nephropathy, recurrent bladder stone formation, two or more episodes of urinary retention, prostate abscesses, difficulty with clean intermittent catheterization, recurrent gross hematuria, incomplete emptying, and obstructive azoospermia are all indications for a TURP. A bladder diverticulum is not regarded an adequate indicator in and of itself.
Men with BPH typically seek medical attention when they suffer unpleasant lower urinary tract symptoms (LUTS). Patients who appear with LUTS are often started on pharmacological treatment, such as an alpha-adrenergic blocker and/or 5 alpha-reductase inhibitor. If medicinal therapy fails, they can continue with a TURP.
A bladder stone suggests that a patient is not entirely emptying his bladder and may benefit from medicinal BPH therapy or a TURP to alleviate the blockage. Initially, medical treatment is frequently recommended. TURP surgery is also indicated in cases of renal failure due to obstructive uropathy with bilateral hydronephrosis, evidence of irreversible bladder injury, and persistent or numerous bouts of acute retention.
Prostate size alone is not considered an indication for surgery. In general, there should be evidence of genuine or possible irreversible kidney or bladder damage. A surgical indication might also include subjective or objective proof of troublesome symptoms that are not satisfactorily treated by conventional procedures.
A large intravesical median lobe, especially if it appears to be causing a ball-valve effect that is unlikely to be relieved by medications or alternative surgical procedures, would be a relative indication, as transurethral resection is particularly effective in eliminating these types of obstructions that are resistant to medical therapy.
A TURP can quickly unroof a prostatic abscess that requires drainage and is shallow and easily accessible via the urethra. Difficulty inserting a catheter in a patient with continued retention or partial emptying might potentially be grounds for a TURP. If a patient has obstructive azoospermia of the ejaculatory ducts, they can be removed transurethrally.
To reduce postoperative problems, surgeons should not perform a TURP on prostates that are bigger than they can realistically resect in 90 minutes of operating time. Most resectionists consider this to be 75 to 80 grams, while exceptionally skillful and experienced surgeons can handle prostates weighing 100 to 150 grams. Very large prostates that require surgery but are too large for TURP can usually be treated with a simple open prostatectomy or laser enucleation (HoLEP)
Contraindications to TURP
An absolute contraindication would be a patient who could not withstand the anesthetic or potential complications of the procedure. Another absolute contraindication would be an active, untreated urinary tract infection.
Post-radiation therapy for prostate cancer, myasthenia gravis, multiple sclerosis, and Parkinson's disease would be relative contraindications, as these patient groups have a high risk of postoperative incontinence due to a malfunctioning external sphincter. Another relative contraindication to a standard TURP is active anticoagulation, however a laser TURP may be conducted on anticoagulated patients, or blood thinners can be temporarily postponed to allow for the treatment.
If a prostate is particularly enormous, larger than 100 grams, it is typically an indicator that a simple prostatectomy or HoLEP should be performed, since most urologists lack the required ability and experience to do a TURP of that size safely. An extremely overactive bladder that is difficult to regulate is another relative contraindication.
Who is a candidate for a TURP?
Before undergoing a TURP, patients must be aware of what to expect before, during, and after the procedure. Initially, a detailed history must be taken, with particular attention paid to their voiding history, urine symptoms, frequency, urgency, flow rate, dysuria, nocturia, and incontinence. A review of everything they have tried to control their LUTS, as well as their medication history, should be performed.
A physical exam concentrating on the genitalia, as well as a digital rectal exam, should be performed to evaluate for other pathology that describes symptoms and to estimate the size of the prostate. Prior to surgery, a post-void residual and urine analysis is suggested to check the patient's voiding capacity and rule out a UTI.
Some urologists will do urodynamics on some or all of their preoperative patients before TURP for urinary retention to verify bladder functioning. This testing gives additional information regarding bladder functionality and may help with the informed consent discussion prior to surgery. This is most likely in circumstances when detrusor muscle contractile ability is unknown, such as in individuals with underlying neuropathy, chronically high bladder capacity, or urine retention of more than 1,500 mL. However, there is limited evidence that urodynamics is beneficial in the perioperative environment.
Other urologists think that doing the TURP regardless of the outcome gives the patient the highest chance of spontaneous voiding post-operatively. In some of these dubious instances, a suprapubic tube can be placed at the time of the TURP with the understanding that it will be withdrawn if the patient has continuously low (200 mL) postvoid residuals following surgery.
This eliminates the need for a further suprapubic tube installation operation. Preoperative urodynamics is also advised in patients with detrusor instability and poor bladder compliance, as these individuals are more prone to have post-operative urine frequency and urgency concerns that should be addressed prior to surgery.
All LUTS management alternatives should be addressed and assessed to ensure that the patient completely knows the risks and advantages of all reasonably accessible options. Following this in-depth conversation, an educated choice to continue with a TURP operation can be taken.
Patients can now undergo a TURP resection with an electrical element or prostatic vaporization with a laser fiber thanks to developments in medical technology. The TURP has been around for a long time and allows for the rapid excision of big prostates in patients with obstructive BPH who are not on active anticoagulation. This method also enables for a pathologic examination of the prostatic chips to check for signs of prostate cancer.
Separate generators are required for cutting and coagulating currents, which are often bundled together inside one electrosurgical equipment. Cutting current quickly gets maximum voltage, however coagulating current takes much longer to reach peak levels—this slower sort of current causes charring and fulguration, which results in the coagulating action. To minimize any unexpected interaction with bodily tissue, the generators additionally considerably raise the electrical frequency from the typical 60 Hz current.
A history and physical examination, as well as baseline electrolytes, CBC, PSA, a post-void residual determination, and urinalysis, are all suitable preoperative testing prior to urologic surgery. Coagulation investigations are no longer recommended unless there has been a history of unexplained or unusual bleeding. In most situations, renal imaging investigations and urodynamics are also unneeded.
Before any operation, the American Urological Association Guidelines for Management of Benign Prostatic Hyperplasia 2021 propose that the prostate size and shape be evaluated. Cystoscopy, transrectal ultrasonography, computed tomography (CT), or magnetic resonance imaging(MRI) may be used to do this
Uroflowmetry and residual post-void measures are also recommended. Peak flow rates of 10 mL/sec strongly suggest a restricted bladder outflow. If there is any question about the diagnosis, pressure-flow testing are advised. The presence of an intravesical lobular extension, such as a ball-valving median lobe, strongly predicts that medical BPH treatment is unlikely to be successful.
Two weeks of finasteride medication, a 5 alpha-reductase inhibitor, has been demonstrated to lower microvascular density and intraoperative blood loss; hence, it is suggested prior to TURP, particularly in bigger prostates.
Preoperative antibiotics are advised to be taken one hour before surgery. Based on urine culture findings, patients with indwelling catheters should get prolonged antibiotic treatment. Except for early ambulation, venous thromboembolism prophylaxis is typically not indicated in TURP due to the substantial risk of increased bleeding.
What to Expect During a Transurethral Resection (TURP)
Transurethral resection is a minimally invasive procedure that takes between 60 and 90 minutes to complete. It is usually done under general anesthesia (you will be sleeping) or spinal anesthesia (you will be awake).
Your doctor will put a resectoscope into the penis, via the urethra, and into the prostate during the surgery. The resectoscope will cut tiny pieces of prostate tissue inside the prostate and deliver them to the bladder through irrigating fluid. These particles are flushed out through the urethra at the end of the procedure. To empty the urine, a catheter will be implanted.
After the Procedure
You will usually be in the hospital for 1 to 3 days. In rare situations, you may be permitted to return home the same day.
Following surgery, a tiny tube called a Foley catheter will be placed in your bladder to drain urine. To keep clots at bay, your bladder may be flushed with fluids (irrigated). At first, the urine will seem bloody. The blood usually disappears after a few days. Blood may also leak from the catheter. To protect the catheter from becoming clogged with blood, a specific solution may be used to clean it out. Most patients will have their catheter removed within 1 to 3 days.
You will be able to go back to eating a normal diet right away. Your health care team will:
- Help you change positions in bed.
- Teach you exercises to keep blood flowing.
- Teach you how to perform coughing and deep breathing techniques. You should do these every 3 to 4 hours.
- Tell you how to care for yourself after your procedure.
You may need to wear tight stockings and use a breathing device to keep your lungs clear. You may be given medicine to relieve bladder spasms.
Your Recovery
Transurethral resection of the prostate (TURP) is a procedure that removes prostate tissue through the urethra. It is performed when an enlarged prostate gland presses on the urethra, making urination difficult. You may require a urinary catheter for a short period of time. When you are unable to pee on your own, a flexible plastic tube is used to drain urine from your bladder. If your catheter is still in place when you go home, your doctor will give you instructions on how to care for it.
You may have burning when urinating for many days following surgery. For the first 1 to 3 weeks following surgery, your urine may be pink. You may also have bladder cramps or spasms. Your doctor may prescribe medication to help you control the spasms.
In the weeks following your operation, you may still feel the need to urinate often. It might take up to 6 weeks for this to improve. You may have less difficulty urinating when you have recovered. You may have more control over the start and stop of your urine stream. You may also feel more relieved when you urinate.
In 1 to 3 weeks, most people may return to work or many of their typical responsibilities. However, for around 6 weeks, avoid heavy lifting and other activities that may put extra strain on your bladder. After surgery, the majority of men can still have erections (if they were able to have them before surgery). When they have an orgasm, they may not ejaculate. Semen may enter the bladder rather than exit through the penis. This is referred to as backward ejaculation. It is not painful or hazardous to your health.
This care sheet will give you an estimate of how long it will take you to recuperate. However, everyone recovers at their own speed. Follow the actions outlined below to get better as soon as possible.
Potential Risks of TURP Surgery
In addition to the risks associated with any surgery, some of the potential risks of TURP surgery include:
- Difficulty Urinating:
A temporary problem associated with post-surgery swelling. A catheter may be placed until you’re able to urinate on your own.
- Urinary Tract Infection (UTI):
A UTI is possible after any prostate surgery. The longer a catheter is in place, the greater the risk of infection. Following TURP surgery, some men develop reoccurring UTIs.
- Retrograde Ejaculation:
This phenomenon, often known as dry orgasm, causes sperm to migrate into the bladder rather than out the penis after ejaculation. While this typically has no effect on sexual enjoyment and is not hazardous, it can have an effect on fertility.
ED is a rare side effect of TURP surgery, but is possible.
- Retreatment:
The prostate may continue to develop over time, necessitating further therapy. Retreatment may also be indicated to address urethral stricture produced by the TURP. This is not a full list of the potential dangers of TURP surgery. Prior to surgery, discuss all risks and implications with your doctor.
Conclusion
A transurethral resection (TURP) is a surgical procedure that includes removing sections of the prostate gland through the penis. TURP is a minimally invasive treatment that uses no incisions to treat individuals with an enlarged prostate. A surgical device called a resectoscope is put into the penis through the urethra and threaded to the prostate during the surgery. Once in place, the resectoscope cuts any extra prostate tissue that may be obstructing urine passage out of the urethra.