TUR - PROSTATE
Consultant Urologist, Jaslok
Hospital and PD Hinduja National Hospital, Mumbai.
The success of any surgical procedure depends not only on technique of
surgery but also on careful attention to the following factors :
i) Selection of patient with clear and appropriate indication for surgery.
ii) Pre-operative assessment and treatment of patho-physiological changes that
may be present as a result of the disease and may affect the outcome of surgery.
iii) Pre-operative assessment and treatment of co-morbidities affecting risk
iv) Careful attention to surgical technique including full awareness of possible
complications and steps necessary to avoid them.
Let us consider all these one by one.
INDICATIONS FOR SURGERY IN ENLARGED PROSTATE
In earlier days, symptoms of prostatism were indications for surgery. Now the
indications for surgery are :
i)Refractory urinary retention
iii)Large bladder diverticulum
iv)Recurrent gross haematuria to BPH
v)Bladder stone due to BPH
vi)Renal impairment due to BPH
vii)Failure of medical treatment
A patient with enlarged prostate may present with :
Obstructive symptoms (hesitancy, thin stream, interrupted flow, straining to
void and sense of incomplete voiding) respond well to TUR-P.
Symptoms of detrusor irritability (frequency, urgency and urge-incontinence)
may improve in course of time after TUR-P if the irritability is secondary to
Some patients have primary detrusor instability (uninhibited bladder contractions)
and require treatment with anti-cholinergic drugs even after TUR-P. The advantage
of TUR-P in these cases is that the required dosage of anti-cholinergic drugs
can be used without fear of retention.
Pre-operative Assessment and Treatment of Patho-physiological Changes that
may be Present as a Result of the Disease and may Affect the Outcome of Surgery
Hypotonic or atonic bladder due to longstanding obstruction and large residual
urine is not uncommon. With adequate drainage over a period of time, most of
these bladders regain adequate tone and function. Assessment with cystometry
is essential and TUR-P should be done after the detrusor function is regained.
Large diverticulum must be excised along with removal of prostate. A diverticulum
does not have muscle wall and if it is not removed, patient will continue to
have residual urine, infection etc. even after TUR-P.
Obstructive uropathy with impaired renal function : Increases the risk of surgery.
Severe urinary infection must be controlled be fore surgery.
Other pathologies that are not uncommonly associated and may affect the outcome
Small prostate with prostatitis and/or fibrous prostate : The incidence of bladder
neck stenosis after TUR-P is higher in these cases. TUI-P with, if necessary,
limited resection of posterior ridge, is preferable.
Prostate abscess : delay in healing and persistent bacteriuria after TUR-P can
Associated urethral stricture : obstructive symptoms recur because of re-stenosis
of stricture and are wrongly attributed to failure of TUR-P.
Diabetes and Parkinsonism : Neurological effects on bladder may affect the final
Pre-operative assessment and treatment of co-morbidities affecting risk of
The common diseases encountered in these old patients are : Diabetes, ischemic
heart disease, hypertension.
Other common problems are : Anti-coagulants / haematologic problems / G6-PD-deficient
/ electrolytes imbalance due to use of diuretics etc.
Careful attention to surgical technique including awareness of possible complications
and steps necessary to avoid them
Pre-op : Proper and adequate antibacterial coverage. This is particularly
important in patients with urinary infection to prevent septicaemia, because
bacteraemia can take place during resection of prostate.
Assessment of electrolytes and correction of imbalance : Hypertensive patients
who are on diuretics may have low serum sodium and this may contribute to TUR-P
Resectoscope: "Continuous Irrigating Resectoscope" is essential. It
reduces the time of resection and minimizes the absorption of irrigation fluid
by keeping the vesical pressure low. The 30 degree macrolense telescope must
be in good condition.
Electro-surgical Unit : I cannot emphasize enough the necessity of a good electro-surgical
unit, the one that provides precise cutting and coagulation without charring
Video : Use of video during resection has many advantages. It gives magnification
and without awkward movements of neck, operator can visualize all areas of prostate.
Changing from direct vision to use of video is not difficult.
Anaesthesia : Spinal or epidural is preferred. It has many advantages such as
: no bladder spasms during resection, patient being fully awake any signs of
hypervolaemia can be detected early, anaesthetic effect lasts even after completion
of surgery and gradually wears off avoiding bladder spasms and pain in the immediate
Irrigating solution : The two commonly used are water and glycine. Though glycine
is commonly used, I prefer sterile water, except in large adenomas with renal
Water gives clear view but has the disadvantage that its extreme hypotonicity
causes haemolysis. If absorbed in larger quantities, haemolysis will cause renal
Many urologists are not fully aware of the problems glycine can cause. 1.5%
glycine used for irrigation is not isotonic, its osmolality is 230 mosm/l compared
to serum osmolality of 290 mosm/l and hence some haemolysis can occur after
its absorption. 2.2% glycine is isotonic but at this concentration it is highly
Glycine is toxic to heart and retina, causing visual disturbances and increasing
the long-term risk of myocardial infarction. It is a major inhibitory neurotransmitter
in the spinal cord and brain stem, probably acting in the same manner as gamma
amino butyric acid on the chloride ion channel. High concentration causes depressant
effect on the CNS.
Ammonia is a major by-product of glycine metabolism. High ammonia concentration
suppresses dopamine and norepinephrine release in the brain, causing encephalopathy.
Fortunately, ammonia toxicity is rare.
Actual technique : Urethroscopy and careful cystoscopy examination is done.
If urethra cannot easily accommodate the resectoscope, I prefer urethral dilatation
Resection should start at the floor of the bladder neck, taking care not to
cut the trigone. In large median lobe, there is a danger of resecting the trigone.
The resection of lateral lobes is done in a concentric fashion. This means cutting
a little bit all around till a passage is obtained from the verumontanum to
the bladder cavity. This allows easy flow of irritating fluid in the bladder
when deeper resection of the lobes is undertaken, thus minimizing the absorption
of irrigation fluid. As the concentric resection proceeds, deeper parts of adenoma
are resected till the fibres of the surgical capsule are exposed.
Resection of the distal adenoma is done last. Before undertaking this, the haemostasis
should be good so that the vision is not impaired. Distal adenoma is resected
with "scooping" movements of the resecting loop. This avoids cuts
from extending beyond the verumontanum. Complete coagulation is obtained at
Post-operative : 22-Fr three-way Foley is left indwelling at the end of resection.
Gentle traction is applied to the catheter. Bladder irrigations are continued
for 24 hours. The catheter is usually removed after 48 hrs. Antibacterial coverage
is continued at least for a week after removal of the catheter and thereafter
only if the urine shows infection.
The two important complications of TUR-P surgery that need attention are :
With clear wide-angle macro-lenses and further magnification obtained by the
use of video, arterial bleeding can be easily identified and coagulated. Therefore,
with good equipment, the blood loss during TUR-P is minimal.
If you do not see any bleeder and yet the drainage is bloody, there are two
possibilities : i) Venous sinus bleeding which stops temporarily due to the
flow of irrigation fluid and hence not seen when looked at. Bleeding from venous
sinus cannot be stopped by coagulation. It will subside after the Foley catheter
has been inserted. ii) Arterial bleeder pumping into bladder cavity and not
seen while inspecting the resected prostate cavity. Careful look at the vesical
side of bladder-neck will reveal it.
This is a syndrome that results from absorption of irrigation fluid causing
i) circulatory overload and ii) dilutional hyponatraemia.
The main factor that contributes to this is increased absorption of irrigation
fluid during resection. This can be minimized by the following measures : i)
keeping the irrigation can less than two feet above the level of bladder, ii)
avoiding opening of venous sinus, iii) limiting the time of resection to less
than one hour.
Glycine or water will have the same effect on circulatory overload. However,
larger amount of glycine stimulates the release of atrial natriuretic peptide
in excess of that expected by the volume load. This promotes natriuresis and
further aggravates hyponatraemia.
Since patient is awake under spinal anaesthesia and is being monitored during
surgery with ECG monitor and pulse oxymeter, the following points should be
The symptoms of hyponatraemia are : restlessness, confusion, incoherence, coma
and seizures. The serum sodium fall effects are :
< 120 meq/l : hypotension and reduced myocardial contractility.
< 115 meq/l : bradycardia and widening of QRS complexes, ventricular ectopics
and T wave inversion
< 100 meq/l : generalized seizures, coma, respiratory arrest, ventricular
tachycardia, ventricular fibrillation and cardiac arrest.
With proper precautions and attention to technical details outlined above, TUR-P
syndrome can be avoided.
The overall results of TUR-P in properly
selected cases are excellent. Patient is unhappy only when the symptoms of bladder
instability viz. frequency, urgency continue even after TUR-P. As explained
above, in some elderly patients these are due to "primary bladder instability"
and require the use of anti-cholinergic drugs. The patients in whom the obstruction
and primary bladder instability co-exist, TUR-P allows us to use these drugs
without the fear of retention. The urodynamic study cannot distinguish between
primary bladder instability and that which is secondary to bladder outlet obstruction.