How I do a TURP

How I do a TURPDavid GalvinMr. D. QuinlanIntroductionClinical AspectsWho gets a TURP and when ?What pre-op work up is needed ?What surgical approach is used ?Post-op considerations

Technical AspectsHow does a resectoscope resect ?Glycine/Saline, Mono/Bipolar, Continuous Flow etcBPH / BOOAims:Relieve symptoms and Improve QoLRelieve the obstruction to bladderTreat the complications of BOO

PathophysiologyStatic componentDynamic componentDetrusor / Psychosocial componentProstatic AnatomyBPH develops in the transition zone (2%) and periurethral glands - highly localised disease

Indications for TURPAbsolute

Recurrent Episodes of Urinary RetentionRecurrent UTIGross Prostatic HaematuriaBladder StonesObstructive UropathyRelative

Moderate to Severe Symptoms (IPSS)Bother / QoLIncreasing PVRLow Flow rateFailure of medical therapy / clinical progression

Pre-operative Assessment3 parameters that consistently predict need for intervention;IPSS ScoreFlow RatePost Void Residual

In addition, PSA (as an indicator of prostate volume) indicates increased risk of acute retention, disease progression and requirement for surgeryIPSS Score0 to 5, symptoms relate to within the last month:Incomplete emptying>2 hourly daytime frequencyIntermittent flowUrinary urgencyWeak streamStraining during urinationNocturiaQoL scoreIPSS score. Max 35IPSS ScoreAUA-7 / IPSS ScoreScore 0 - 7Mild Symptom scoreScore 8 - 19Moderate Symptom scoreScore 20 - 35Severe Symptom score

IPSS score is not diagnostic for BOO/BPH

An IPSS score >17 pre-TURP, predicts a >7 point improvement in 87% of patients post TURPHakenberg OW. J Urol. 1997 Jul;158(1):94-9Flow Rate and PVRPrognostic value of Qmax1Qmax ml/s15Obstructed88%57%25-41%Non-obstructed12%43%59-75%

There are no variables than can predict outcome following TURP, other than symptom severity (IPSS).

If obstructed, the more severe the symptoms, the greater the perceived benefit. 1 Urodynamics in prostatism. I. Prognostic value of uroflowmetry. Scand J Urol Nephrol. 1988;22(2):109-17.Jensen KM, Jorgensen JB, Mogensen P.Use of PSAElevated PSA is related to BOOPSA > 4 ng/ml 89% obstructed on CMGPSA < 2 ngml33% not obstructed

PLESS and MTOPS studiesPSA / prostate volume are powerful predictors of acute urinary retention and the need for surgeryLaniado ME et al. BJUI 20041 McConnell et al. N Engl J Med. 1998 Feb 26;338(9):557-632 McConnell et al. NEJM 349(25): 2387-98 Pressure Flow Studies Indications for Urodynamics pre-op:Age < 55 yearsEquivocal or Normal flow rates with significant symptoms (IPSS)Neurological disorders e.g. parkinsonsSymptoms suggestive of OAB (incontinence)Previous TURPPrevious pelvic surgery

Aim is to differentiate between obstruction and detrusor decompenastaion as the cause of a low QmaxOther ConsiderationsPatients preferenceInformed consentLikely benefit to be derived from surgeryPatients medical condition and co-morbiditiesPatients mobility - able to get to toiletSocial situation - can they live with an indwelling catheterHip and knee flexion for TURPSend Urine for analysis and treat infectionObtaining ConsentDiscuss the alternativesWatchful waiting, Medical treatment, Phytotherapy, TUNA, TUMT, Holmium (HoLEP) or Green Light Laser (KTP)

Probability of benefit:91% if symptoms were severe62% if symptoms were mild to moderate

Overall up to 88% achieve symptom improvementUp to 25% fail to improveObtaining ConsentComplications: Early (7-43%)

HaemorrhageTransfusion2-10%Failure to void6.5%Clot retention3%Infection/Septicaemia2%TUR Syndrome 2%Epididymo-orchitis1%Emberton M et al. UK National Prostatectomy Audit. Br J Urol. 1995 Mar;75(3):301-16.Obtaining ConsentComplications: LateRetrograde Ejaculation25 - 99%Secondary HaemorrhageErectile Impotence4 - 14 %Bladder neck stenosisUrethral StrictureIncontinence0.6 - 1.4%Mortality30 day post-op0.3%90 day post-op1.7%

9% Re-operation rate within 5 years0.6 - 10%Emberton M et al. UK National Prostatectomy Audit. Br J Urol. 1995 Mar;75(3):301-16.ResectionCurrent can be passed through the human body so long as it is turned on and off very rapidly, preventing cell membranes from re-polarising - thus having little effect (MHz).Large currents of alternating frequency are used - generating great heatThe diathermy pad (passive) raises skin temp by 1-2oCThe heat generated under the diathermy loop causes coagulation (active)Higher currents (cut) cause water between the electrode and the tissue to ionise, generating a sparkResectionThis spark then causes explosive vapourisation of the tissueThe cut is a clean one as the sparks do not affect deeper layersBlood vessels are not coagulated because cutting current is a continuous pure sine-waveCoagulation is achieved by short bursts / interruptions of sine waves. The longer the interruption the better,Current changes plasma polarity causing thrombosisHeating effect is proportional to square of diameter of contact - Roller ball coagulates deeperTechnical AdvancesIrrigation Fluid: Glycine v Saline1.5% Glycine is a non-haemolytic (not isotonic solution 200 mOsm/l) solution. Conducts current to diathermy pad in monopolar modelSaline may only be use with a bipolar resectoscope. Improved cut at reduced power. Eliminates TUR syndrome and obturator kick.Continuous Flow irrigationResectoscope

Light towerLens (30o)Continuous flow irrigationBipolar Resctoscope loopRotatable Sheath

How I do a TURPPatients INR < 1.2 / Off Clopidrogel 21 daysSpinal AnaestheticCreates a low BP surgical environmentExcellent pain control in an elderly population with significant co-morbidtiesSingle shot IV Gentamicin (8-24% have a UTI)Include IV Co-amoxiclav if there is catheter in-situLithotomy positionPre-operative rectal exam

Surgical TechniqueUrethroscopy (21Fr) and Cystoscopy with 30 degree lensNote position of veru, bladder neck and both UOs70 degree lens used to evaluate bladder mucosaDilate urethra to 28Fr with sounds (Urethrotomy)Resectoscope sheath passed with obturator26Fr resectoscope introducedConnect camera / irrigation / diathermy / white balanceMultiple techniques. Resection should be performed in a routine, step by step manner.Surgical TechniqueNesbit Technique (1943)First stage: resection of bladder neck from 12 oclock down to 6.Second stage: Adenoma is resected in quadrants beginning at 12 oclock so that the lateral lobes fall in. The right followed by left lateral lobes.Third Stage: resection of tissue at the apexSurgical TechniqueBlandy Technique 1Resection of middle lobe initiallyResect each lateral lobe from 12 oclock down to 6 oclock

Blandy Technique 2Resection of middle lobe initiallyWork on lateral lobe from 6 to 12 oclock and continue clock-like from 12 to 6 on other lobe

How I do a TURPCreate a channel at 5 and 7 oclock from bladder neck back to veru Deepen the channel to capsule so that you know how deep and how far to goTake each lateral lobe seperately from 12 to 6 oclockResect the median lobe last to avoid undermining of the bladder neck/trigoneHow I do a TURPOn last look, check:Veru and UOs intact, No Chips in bladder and satisfactory haemostasis is achievedInsert 22 3way reinforced PTFE catheter - spigott irrigation channel. Irrigate bladder.Place catheter on traction secured to right thigh with adhesive dressing.If clotting - 3 lt bladder washout +/- overnight saline irrigation.Check bloods mane. Remove UC in 48 hours.TroubleshootingHaemorrhageFlocks / Badenochs arteries / Capsular veinsFailure to CutEnsure Glycine and not saline connected.Do NOT turn up diathermy. Check pad and cable.Poor VisionEnsure correct brand is selected in light source.Change light cable.Obturator kick / Coughing / ErectionsFocus on SalineNon-conductive, non-haemolytic isotonic irrigation solutionMay be used now with the advent of bipolar resectoscopes (reduced power required)Allows for longer resection times / larger prostates / reduced bleeding / No hyponatraemia / No TUR Syndrome / Reduced costsRCT of Mono v Bipolar supports the advantages of bipolar diathermy and saline 11 Singh H et al. J Endourol. 2005 Apr;19(3):333-337

OutcomeEmberton M et al. Br J Urol. 1996 Feb;77(2):233-496% of all Urologists involved in 4 regions - 5276 patientsMean IPSS score fell from 20.1 to 7.4 post-TURPBother score fell from 14 to 465% showed significant improvements3.1% were worse, 9.6% were the same and 23% slightly improvedImproved IPSS correlated with improved Bother score and disease-specific QoL score but not overall QoL scoreOne-third reported some degree of new-onset incontinenceOnly 6% felt it was a problem though66% and 31% suffered retrograde ejaculation and EDOverall one-third experienced unfavourable resultsOutcomeOSullivan M. J Am Coll Surg. 2004 Mar;198(3):3 94- 40330 patients undergoing TURP in CUHIPSS fell from 19 to 5.4Significant decreases in:IPSS QoL IndexMontgomery and Asberg Depression rating scaleMcGill pain questionaireAll four components of the Short Form 36 QoLThe End