Transurethral Prostatic Resection

Transurethral prostate resection (TUR-P; TURP; synonyms: transurethral prostatectomy; transurethral resection (TUR) of the prostate; prostate resection) is a urologic surgical technique in which abnormally altered prostate tissue can be removed through the urethra (urinary tube) without an external incision. The surgical method is a minimally invasive method in which a wire snare is used to selectively remove the affected tissue using a resectoscope. Transurethral prostate resection is a frequently used therapy method for the treatment of benign tumors of the prostate such as prostate adenoma or benign prostatic hyperplasia (BPH; benign prostate enlargement). The cutoff for performing TUR-P appears to be a prostate volume of 80 ml. The surgery reduces both patients’ lower urinary tract symptoms (LUTS) and bladder outlet obstruction (partial or complete closure of the bladder; English : Bladder outlet obstruction, BOO) sustained.

Indications (areas of application)

Absolute indications

  • Recurrent urinary retention (ischuria).
  • Recurrent urinary tract infections (UTIs)
  • Recurrent macrohematuria that cannot be adequately treated with medication (> 1 ml of blood per 1 l of urine; presence of blood in the urine visible to the naked eye)
  • Urolithe (urinary stones)
  • Significant dilatation (widening) of the upper urinary tract due to narrowing of the urinary tract.

Relative indications

  • Symptomatic urinary leakage from the urinary bladder due to benign prostatic hyperplasia (BPH).
  • Congenital or acquired bladder diverticula (sac-like protrusions of the bladder wall).
  • Lack of therapeutic success or occurring allergies with conservative (without surgery) treatment.
  • Residual urine volume over 100 ml (remaining urine volume after urinary bladder emptying).

Contraindications

  • Indication for adenomectomy (removal of an adenoma) – if large adenomas with a volume greater than 75 ml are present, adenomectomy is preferable. Other indications for adenomectomy represent urinary bladder diverticula requiring surgery, urinary bladder stones, complex urethral disease and contraindication to lithotomy storage.
  • Blood clotting disorders
  • Acute or chronically active urinary tract infections

Before surgery

  • Discontinuation of anticoagulants (anticoagulants) – discontinuation of blood-thinning medications such as acetylsalicylic acid (ASA) or Marcumar should be done in consultation with the treating physician. Discontinuing medication for a short period of time significantly minimizes the risk of postoperative bleeding or intraoperative hemorrhage without a significant increase in risk to the patient. If there are diseases that can affect the blood clotting system and these are known to the patient, this must be communicated to the attending physician.
  • Discontinuation of antidiabetic medications (medications used to treat diabetes mellitus) – Medications such as metformin should usually be discontinued at least 24 to 48 hours prior to surgery, as there is an increased risk of lactic acidosis (form of metabolic acidosis (metabolic acidosis) in which a drop in blood pH is caused by the accumulation of acidic lactate (lactic acid)) due to the use of the medication during anesthesia.
  • Medical history and diagnostics – before surgery, a urinary tract infection must be excluded. Due to the increased risk of infection of the urinary tract, perioperative (during surgery) antibiotic administration is to be aimed for. Absolutely necessary is a prophylaxis with antibiotics at an increased risk of infection, which is present, among other things, in metabolic disorders such as diabetes mellitus, immunosuppression and repeat operations.

The surgical procedure

To perform transurethral resection of the prostate, a continuous irrigation resectoscope is used, which is advanced through the urethra (urethra) to the prostate. The prostate tissue is now removed under continuous irrigation. The tissue is removed with the help of a high-frequency current snare. At the same time, the snare can be used for precise coagulation (obliteration) of injured vessels.Transurethral resection (TUR) of the prostate (TUR-prostate, TUR-P, TURP) can be performed monopolar (irrigation solution is a saline-free solution) as well as bipolar (bipolar; irrigation solution is physiological saline). Bipolar TUR-prostatic has a more favorable safety profile (the risk of bleeding-related complications appears reduced) and is considered a modern alternative to monopolar TUR-prostatic. However, it is comparable in outcomes to those of monopolar TUR-P. Transurethral prostatic resection is considered the gold standard of prostatic resection because its use leads to improvement of symptoms in the majority of patients and has few complications. Furthermore, in addition to a significantly increased urinary flow rate, a reduced amount of residual urine can be observed after resection. In the majority of procedures, transurethral prostate resection is performed under spinal or peridural anesthesia. If indicated, intubation anesthesia may be preferred.During surgery, the patient is in the lithotomy position. Placement of a bladder fistula catheter is usually indicated during surgery. After removal of the prostate tissue, an irrigation catheter is usually inserted transurethrally (through the urethra) so that continuous irrigation of the bladder with physiological saline can be performed for up to 24 hours postoperatively. After removal of the irrigation catheter, the bladder is drained using a bladder fistula catheter for the following 24 hours. To reduce the risk of infection, prostate resection should definitely be performed under both perioperative and postoperative antibiotic prophylaxis.

After surgery

To reduce potential complications, continuous irrigation of the bladder is performed for approximately 24 hours. After about two days, micturition (emptying of the bladder) can be checked.

Possible complications

Early complications

  • Postoperative bleeding – Postoperative bleeding can be observed as a relatively common complication, although it is usually self-limiting. If bleeding does not resolve on its own, surgical recoagulation may be necessary as part of a second procedure.

Late complications

  • Urinary incontinence (involuntary, involuntary leakage of urine) – Due to scarring of the urethra (urethral) or muscular lesions (muscle damage), urinary incontinence may be caused.
  • Retrograde ejaculations (ejaculatory disorder in which seminal fluid is expelled backward into the urinary bladder) – Although the production of seminal fluid is physiological, the man is still infertile (infertile) because the ejaculate is not expelled forward but remains in the bladder until the next urination.
  • TUR syndrome – Hypotonic hyperhydration (disturbance of the water-electrolyte balance of the body with an increase in water content above normal levels) with cardiovascular stress to acute right heart failure (right heart weakness) due to wash-in of hypotonic irrigation fluid (in monopolar TUR prostate). TUR syndrome is present when there is at least one circulatory disorder (bradycardia (heartbeat too slow: < 60 beats per minute); hypertension (high blood pressure); hypotension (low blood pressure); or oliguria (decrease in urine output (below 500 ml/day. ); chest pain (chest pain)) and at least one neurologic complication (visual disturbances, nausea (nausea)/vomiting, fatigue, headache, agitation, confusion, impaired consciousness) occur.However, TUR syndrome is now very rare.

Further notes

  • Patients with benign prostatic hypertrophy (BPH) treated with a 5-alpha-reductase inhibitor (5-ARH: finasteride, dutasteride) four weeks before TURP have a lower risk of bleeding during and after TURP and also required fewer transfusions. The probable cause is the inhibition of angiogenesis (growth of blood vessels) and microvascularization by 5-ARH.