Transurethral Resection of Prostate

Reporter: H.ABDUL RAUF, Ayna Jalya M.

What is a transurethral resection of the prostate (TURP)?

The prostate gland is found only in males. It sits below the bladder and wraps around the urethra.
The urethra is the tube that carries urine out of the body. The prostate helps produce semen.
A transurethral resection of the prostate (TURP) is surgery to remove parts of the prostate gland
through the penis. No incisions are needed
This instrument, called a resectoscope, is about 12 inches long and .5 inch in diameter. It contains
a lighted camera and valves that control irrigating fluid. It also contains an electrical wire loop that
cuts tissue and seals blood vessels.

What is the purpose of TURP?

▪ Is to relieve obstruction due to the prostate, but it can also unroof prostatic abscesses and to open
ejaculatory duct obstructions
▪ Is most often done to relieve symptoms caused by an enlarged prostate
▪ The aim of surgery is to make the prostate gland smaller so that it no longer pushes against the
bladder and urethra.
SURGICAL PROCEDURE
➢ TURP - performed by inserting a Resectoscope through urethra.
➢ Prostatic tissue is resected into pieces with an electrically powered cutting- coagulating metal loop.
-Pieces washed out by irrigating solution.
➢ Prostatic capsule preserved- If violated, large amounts of irrigating fluid is absorbed into circulation,
periprostatic and retroperitoneal spaces.
➢ Surgery normally takes 30-60 mins- depending on size of gland and experience of surgeon.
➢ Position- Lithotomy position
➢ At the end of surgery- a 3-lumen catheter placed to allow continuous irrigation using normal saline
for up to 24 hours after surgery
NURSING RESPONSIBILITIES
A. PREOPERATIVE CARE
✓ Preoperative assessment
✓ Proper explanation of surgical procedure
✓ Proper explanation of the complications and risks
✓ Ensure that informed consent has been signed
✓ Notify physician for allergies
✓ Notify physician of all medications taken
✓ Notify for history of bleeding disorders

B. INTRAOPERATIVE CARE
✓ Maintain Safety and Prevent Injury
✓ Position in Client
✓ Provide Equipment Safety
✓ Maintain Surgical Asepsis
✓ Assist in Wound Closure
✓ Monitoring:
✓ –V/S (Body temperature)
✓ –Malignant Hyperthermia
✓ –Cardiac Respiratory Arrest
✓ Allergic Reactions
C. POST OPERATIONAL PHASE
✓ Maintaining patency of catheter system
✓ Monitoring urine appearance
✓ Monitoring signs of water intoxication
✓ Avoid enemas and rectal thermometer use
✓ Instruct patient not to void around catheter
✓ Give prescribed medications
✓ After catheter removal frequently change dressings
✓ Give opportunities to discuss any concerns
✓ Do health teachings to client
Transurethral Resection Of The Prostate
Continuing Education Activity
Transurethral resection of the prostate is a procedure used in the management of bladder outlet obstruction
caused by prostatic hypertrophy and prostatic abscess management. This procedure should be performed if
the patient desires to be off medical management for bladder outlet obstruction or who fail medical
management. This activity describes and explains the role of the physician and medical staff in evaluating
patients for possible TURP.

Objectives:
Identify the indications for performing transurethral resection of the prostate (TURP).
Describe the equipment, personnel, preparation, and technique needed for transurethral resection of the
prostate (TURP).
Review the appropriate evaluation of the potential complications and their clinical significance with
transurethral resection of the prostate (TURP).
Outline some interprofessional team strategies for improving care coordination and communication to
advance transurethral resection of the prostate (TURP) and improve outcomes.

Introduction
Transurethral resection of the prostate or TURP is a procedure where the prostate is resected from an
endoscopic approach. This procedure has been in use for many years and is still the surgical gold standard
for bladder outlet obstruction (BOO), with some minor changes. A TURP can also be used to unroof prostatic
abscesses, as well as open ejaculatory ducts in obstructive azoospermia.
Anatomy and Physiology
The prostate is an organ that functions in male fertility. It provides prostatic secretions to the ejaculate,
composed of an alkaline solution and prostate-specific antigen, which functions to liquify the ejaculate. These
prostatic secretions make up approximately 30% of ejaculate fluid. The prostate is derived from the urogenital
sinus and becomes stimulated by androgens.
The average prostate is approximately 33 grams.It is composed of a capsule that surrounds the parenchyma,
with three zones: central, peripheral, and transition. The transition zone is typically where hypertrophy exists
in benign prostate hypertrophy or BPH. Fortunately, the transition zone is easily resected with a TURP. The
peripheral zone is often the location of prostate cancer. The prostate parenchyma is composed of stroma,
ducts, and acini.
The prostate enlarges due to testosterone and age. When the prostate enlarges, it classifies as BPH. When
BPH causes urinary obstruction, it may indicate the need for a TURP procedure.
Indications
Indications for a TURP include failure of medical management for LUTS or BOO, obstructive nephropathy,
bladder stone formation, 2+ episodes of urinary retention, prostate abscess, difficulty with clean intermittent
catheterization and obstructive azoospermia.
Generally, men with BPH experience lower urinary tract symptoms (LUTS). Patients presenting with LUTS
are initially started on medical management, an alpha-adrenergic blocker, and/or 5 alpha-reductase
inhibitors. Should they fail medical management, they can then proceed with a TURP. If a patient is found to
have a bladder stone this is an indication that the patient is not completely emptying his bladder and may
benefit from a TURP to relieve BOO. Multiple episodes of acute retention is also an indication for a TURP.
A prostate abscess that requires drainage and are superficial and easily accessible via the urethra can be
unroofed with a TURP. Difficulty with catheterization in a patient that requires catheterization can also be an
indication for a TURP, as this may decrease the difficulty in placing a catheter. If a patient is found to have
obstructive azoospermia at the level of the ejaculatory ducts, these can be resected in a technique very
similar to a TURP.

Contraindications
Absolute
A TURP should be forgone if the patient will not tolerate the risks or the possible sequelae.
Relative
Anticoagulation is a relative contraindication in a traditional TURP, but one can perform a laser TURP on
anticoagulation or with the appropriate holding of anticoagulation. If a prostate is extremely large, greater
than 100 g, this is an indication to perform a simple prostatectomy. But as with anything in medicine,
discussing the options with the patient is the most appropriate decision prior to performing an irreversible
surgery.

Equipment
Antimicrobial prep
Resectoscope with a bipolar loop or laser fiber
Normal saline irrigation
Large bore 3-way foley catheter
Continuous bladder irrigation (CBI)
Foley bag
Catheter tipped syringe or Ellik bladder evacuator
Personnel
Urologic surgeon – performs the TURP
Anesthesia – maintains anesthesia
Operating room nurse – supports the surgeon and anesthesia
Surgical technician – supports the surgeon

Preparation
Before performing a TURP, patients must understand the expectations before, during, and after the case.
Initially, a thorough history needs to be performed, focusing on their voiding history, ensuring documentation
of symptoms, frequency, urgency, dysuria, nocturia, incontinence—a discussion of what they have tried for
management of their LUTS and medication history. A physical exam should also be completed focusing on
the genitalia and digital rectal exam, which is utilized to evaluate for other pathology that describes symptoms
and to estimate the size of the prostate. A post-void residual and urine analysis is preferred to understand
patients voiding ability as well as ruling out UTI.
Some urologists, prior to TURP for urinary retention, will perform urodynamics to determine the functionality
of the bladder. This testing provides more information and may aid in informed consent before the TURP.
Other urologists believe that the best option is to perform the TURP, providing the patient with the best voiding
parameters post-operatively. However, there is little data on the benefit of urodynamics in the perioperative
setting.[7]
One needs to discuss all options for the management of LUTS and ensure the patient understands the risks
and benefits of all the choices. After this in-depth discussion, an informed decision can be made to proceed
to TURP.
With advances in medical equipment, patients can have resection of a TURP with a bipolar element or a
laser fiber. The bipolar TURP has been around for many years and allows quick resection of large prostates
on select patients that are not on anticoagulation. This technique also allows for pathologic review of the
prostatic chips to look for incidentally found prostate cancer.
The laser technique, or photo vaporization of the prostate, can be utilized safely for men on anticoagulation.
This technique is generally slower than the bipolar TURP and does not allow for pathologic evaluation as the
prostatic tissue is vaporized and not resected. Monopolar TURP is also an option, and instead of using saline
irrigation, this procedure uses non-conducting irrigation such as water, glycine, sorbitol, mannitol. The uses
of these types of irrigation cause a greater chance of TUR syndrome.

Technique
The patient arrives in the preoperative area. The surgeon and staff should answer all questions, review the
risks and benefits, and consent is signed. The patient is taken back to the operating room and anesthetized.
The patient is placed in the lithotomy position and prepped and draped in a sterile fashion.
The resectoscope is inserted through the urethra into the bladder using a visual obturator. The entire bladder
will be visualized with particular attention to the ureteral orifices, as these need to be spared in the resection.
The location of the verumontanum or veru is also noted, as this makes up our distal resection edge. The
visual obturator is then removed, and the working element with the resection loop or laser fiber inserted.
A channel is made at the 5 and 7 o’clock position down to the veru using the cut feature; this allows better
continuous irrigation during resection, improving visualization. Resection then continues between the two
channels down to the prostatic capsule. Then the resection is continued laterally up to the 3 and 9 o’clock
positions, working to keep the same depth and not violate the prostate capsule. During the resection and at
the completion of resection, hemostasis is maintained using the coagulation setting. This process should
occur with little to no irrigation running to evaluate for venous bleeding. All of the prostate chips are removed
from the bladder using either the Ellik, catheter tipped syringe, or breaking the resectoscope. Finally, a large-
bore 3-way catheter is placed with 30 ml of water put into the balloon. CBI is started in the OR to allow for
observation of the urine color. The CBI should be titrated to light pink.
Patients are typically admitted one night. If the urine has remained clear, a voiding trial is performed the next
morning. If a patient is unable to void, a foley will be placed, and follow up with the patient will be conducted
in about one week for a voiding trial in the clinic.

Complications
It is easiest to split complications into intraoperative and postoperative complications, to manage patient
expectations as well as ensure the discussion of all complications.
Intraoperative complications include general anesthesia risks, bladder perforation, ureteral orifice injury,
bladder neck undermining, prostatic capsule perforation, inability to complete case due to bleeding, or poor
visualization.
Postoperative complications include transurethral resection syndrome (TUR syndrome), LUTS but these
typically improve as the patient is further from surgery, but they may never completely resolve, retrograde
ejaculation, infection including UTI and prostatitis, urethral stricture, bladder neck contracture, incontinence,
urinary retention due to either obstruction or poorly functional bladder requiring CIC or catheter, and
recurrence.
TUR syndrome is very concerning. This condition arises due to the irrigation fluid used during the resection
being pushed intra-vascularly, causing hyponatremia and neurologic symptoms, such as confusion. The risk
of this is low, as modern-day TURPs utilizing bipolar technology and saline as irrigation, as compared to a
monopolar TURP.

Clinical Significance
The clinical significance of a TURP is typically to relieve obstruction due to the prostate, but it can also unroof
prostatic abscesses and to open ejaculatory duct obstructions. The importance of a TURP for bladder outlet
obstruction is to prevent obstructive nephropathy, LUTS due to incomplete emptying, and UTI due to
incomplete emptying. If a patient utilizes CIC to empty the bladder, a TURP can allow for easier catheter
placement. Abscess management requires drainage, as it is difficult for antibiotics to penetrate the abscess
cavity. When patients have obstructive azoospermia due to ejaculatory duct obstruction, an incision of this
structure can relieve the obstruction and allow patients to father children.
Enhancing Healthcare Team Outcomes
TURP is typically an elective procedure used in the treatment of BOO. Because of this, appropriate
indications and discussion of the complications associated with the procedure require an integrated
interprofessional team to communicate effectively and initiate treatment plans, so the patient has proper
expectations. This approach will ensure that patients are prepared for their procedure and what to expect.
When patients are better informed, they are more invested in their decision and are happier with their
outcome.
Collaboration shared decision making and communication are key elements for a good outcome. The
interprofessional care provided to the patient must use an integrated care pathway combined with an
evidence-based approach to planning and evaluation of all joint activities. The earlier signs and symptoms of
a complication are identified, the better is the prognosis and outcome of the procedure.

Article Details
Article Author
Gavin Stormont
Article Editor:
Soumaya Chargui
Updated:
7/18/2020 12:24:59 PM
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