What is a transurethral prostatectomy (TURP)?
A transurethral prostatectomy (TURP) is an operation designed to remove the prostate through the urethra; no external incision is made. A TURP is performed using a resectoscope, which scrapes out the center of the prostate by using an electrical current to cut out the tissue with a loop. This procedure is ideal for men with small to moderate size prostate glands. It is difficult to perform in men with extremely large prostates, i.e. those 100 grams or larger, due to the duration of time that it takes to resect the prostate tissue and the risks incurred with the lengthy resection. Lengthy resections pose the risk of absorbing too much of the irrigation fluid and lowering the salt level in the blood stream (hyponatremia) In severe cases, hyponatremia can cause neurologic symptoms, including seizures. Fortunately, these complications occur vary rarely. TURPs are usually limited to prostate glands of 100 grams or smaller.
After the TURP has been completed, a urethral catheter is left to enable irrigation of the bladder with fluid to prevent blood clots from forming in the bladder, typically for 1 to 2 days. After that period of time, the catheter is removed, and the patient is given a voiding trial. Sometimes, a patient will have troubles urinating right after a TURP and if this is the case, then the catheter will be replaced and left in place for about a week and another trial of voiding will be performed.
What is a transurethral incision of the prostate (TUIP)?
A transurethral incision of the prostate (TUIP) is exactly that: an incision rather than a resection of the prostate. Using a special knife-like instrument, a Colling's knife that is placed through the same resectoscope sheath used for TURPs two incisions are made at 5 o'clock and 7 o'clock through the bladder neck and prostate to the verumontanum where the ejaculatory ducts exit.
A TUIP is a quicker, easier procedure than a TURP. TUIPs tend to be used in younger men with smaller prostate glands. The incidence of retrograde ejaculation after TURP ranges from 50 to 95%, whereas the incidence is from 0 to 37% with TUIP. In properly selected patients, those with small glands, the rate of symptom relief with TUIP approaches that of TURP.
What is electrovaporization of the prostate?
Electrovaporization of the prostate (TUVP) is, similar to a TURP. Rather than a resecting loop, the urologist uses a roller ball to heat and desiccate the prostate instead of actually resecting tissue (Figure 24).
Electrovaporization of the prostate has been used in patients with a history of bleeding disorders or in cases in which it is desired to minimize blood loss. Electrovaporization of the prostate tends to be used in patients with small- and medium-sized glands. Like TUIP, in properly selected patients, it is an alternative to TURP.
What are the side effects of surgical treatment (TURP) of BPH?
The side effects associated with TURP can be divided into intraoperative and postoperative complications. A TURP is performed under either spinal or general anesthesia,
Figure 24. Electovaporization of the prostate using a TURP VaporTrode™.
Courtesy of Gyrus ACMI, Southborough , MA
and the usual complications that are associated with these forms of anesthesia can occur during a TURP. The introduction of either spinal or general anesthesia can result in hypotension or a drop in blood pressure.
Bleeding can occur with a TURP, and it is correlated with the size of the prostate and the duration of the operation; however, it should be emphasized that significant bleeding is uncommon when an experienced urologist performs the TURP.
Extravasation or perforation of the prostate can occur during a TURP. This causes some of the irrigation fluid used during a TURP to extravasate, or leak outside the prostate. If the patient is awake under spinal anesthesia, this can result in nausea, vomiting, or abdominal pain. Most often, this complication can be managed by cessation of the operation and urethral catheter drainage. As with bleeding, extravasation in the hands of an experienced resectionist is uncommon.
The most dramatic complication that occurs intraoperatively or in the immediate postoperative period is TUR syndrome. TUR syndrome occurs when there is too much absorption of the irrigation fluid and resultant lowering of the salt level in the blood, hyponatremia. The manifestations of the TUR syndrome include nausea, vomiting, brachycardia or slow heart rate, and visual disturbances.
The treatment of the TUR syndrome is principally diuretic medications, which help the patient urinate out the excess fluid that has been absorbed. Some urologists will also give high concentration saline or high-concentration sodium solutions to increase the serum sodium. In most circumstances, the TUR syndrome can be corrected in the immediate postoperative period.
Recent studies report that blood transfusions are required in about 4% of the patients who undergo the procedure. Because the apex of the prostate is near the external urinary sphincter, incontinence is a potential complication. Fortunately, the risk of urinary incontinence after a TURP has been estimated to be about 1%. Erectile dysfunction or impotence can occur after a TURP. It is theorized that some of the electrical current from the resectoscope loupe scatters beyond the prostate capsule and injures the nerves. Other complications include urethral stricture and urinary tract infection.