Q. A fit 64-year-old man is reviewed in your clinic with severe LUTS which have not responded to medical therapy. Investigations confirm benign prostatic obstruction. He is bothered by his LUTS and wants further treatment. What would you offer him?
A. I would offer him a transurethral resection of prostate (TURP) or a Holmium laser enucleation of the prostate (HoLEP).
Q. What will you tell him about the likely symptomatic outcome of this operation?
A. I would advise him that he has a 90% chance of symptom improvement given that he has bladder outlet obstruction. I would also counsel him that voiding symptoms tend to improve much more quickly after surgery than storage symptoms of frequency, urgency and nocturia.
Q. What other groups of patients may benefit from TURP or HoLEP?
A. In addition to men with bothersome LUTS who have failed a trial of medical management, the EAU gives the following indications for TURP:
Refractory urinary retention
Recurrent urinary retention
Recurrent haematuria refractory to medical treatment with 5-a-reductase inhibitors
Renal insufficiency
Bladder stones
Recurrent urinary tract infections as a result of BPH resulting in BOO
Increased post-void residual volume (exact value not defined)
Also TURP is indicated in those with chronic high-pressure urinary retention
Q. What complications will you warn him about?
A. I would use the BAUS procedure specific consent form for TURP or HoLEP. Potential complications of TURP include
Early
Anaesthesia related, ischaemic event, deep vein thrombosis
Blood transfusion in 1%-2% (on average 10 mL blood loss per gram of tissue resected) Urinary sepsis in up to 3%
Systemic sepsis in up to 1.5%
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Risk 0.8% if <45 g tissue resected and 1.5% if >45 g tissue resected |
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TUR syndrome |
Risk 0.8% if resection time <90 minutes and 2% if resection time >90 minutes (No risk of TUR syndrome in HoLEP) |
There is a risk of mortality of approximately 0.3% (within 30 days of operation)
Late
Urinary incontinence in <1%
Retrograde ejaculation in 80%-100%
Erectile dysfunction is reported in approximately 10%
Bladder neck stenosis/urethral stricture in 3%-5%
Need for re-do surgery - There is cumulative risk of 2% per year needing re-do surgery (thus 10% at 5 years and 16% at 8 years require re-do TURP)
Q. How do you perform a TURP?
A. I would take an adequately prepared and consented patient to theatre and after the patient has been anaesthetised, I would perform the following steps:
Place patient in Lloyd-Davies position
Clean and drape with TUR drape allowing rectal examination to be performed to assess size of prostate
Perform initial cysto-urethroscopy to exclude other abnormalities of lower urinary tract Perform a urethral dilatation or Otis urethrotomy if either urethra is tight or using a 28 Fr resectoscope
Insert resectoscope and begin by resecting median lobe down to circular fibres of bladder neck
Resect each lateral lobe in turn by resecting a channel down to capsule at 10 or 2 o’clock and then dislocating lateral lobe to allow efficient resection
If <10 g resected then perform additional TUIP
Remove prostate chips using Ellik bladder evacuator
Achieve haemostasis with rollerball
Check that all chips have been removed, ureteric orifices are visible and undamaged and that no flaps have been created which might cause obstruction
Insert three-way urethral catheter using introducer
Assess catheter drainage and degree of haematuria before endoscopic equipment is removed
Abdominal palpation to exclude extravasation
Q. What is TUR syndrome?
A. TUR syndrome is the absorption of irrigating fluid during the procedure. The risk of this is 2% in some large series. In the United Kingdom 1.5% glycine solution is the most commonly used irrigating fluid. This fluid is hypotonic with respect to plasma and There fore absorption of irrigating fluid can lead to dilutional hyponatraemia and fluid overload. The clinical manifestations of this may include tachycardia, bradycardia, other cardiac dysrhythmias, hypotension, headache and convulsions. Glycine itself can be metabolised in the GABA pathway to produce a neurotransmitter causing opisthotonus and cerebral irritation (see Chapter 7 for a discussion of TUR syndrome in more detail).
Q. What steps can you take to reduce the likelihood of TUR syndrome?
A. I would keep the height of the irrigating fluid above the patient to the minimum consistent with good vision. I would avoid prolonged resection particularly if there is evidence of capsular perforation or venous haemorrhage. I routinely use a continuous flow resectoscope and examine the patient’s abdomen at the end of the operation for any sign of extravasation.
Q. How would you treat a full-blown TUR syndrome?
A. If evidence of TUR syndrome occurred during the procedure then I would act swiftly to obtain haemostasis and bring the operation to a close. I would place a 24 Fr three-way catheter in the bladder and consider traction if there has been venous perforation or in the presence of persistent bleeding. I would ensure that irrigation is kept to an absolute minimum using normal saline solution. I would examine the abdomen for signs of extravasation and if present I would place a retropubic drain. I would ask the anaesthetist to send bloods including full blood count (FBC), urea and electrolytes (U&E) and clotting studies and to give a 40 mg dose of intravenous furosemide. Any dysrhythmias should be treated in accordance with cardiac guidelines and the patient should be carefully monitored post-operatively in an intensive therapy unit (ITU) facility. The serum sodium concentration should be restored slowly through the judicious use of fluid restriction, diuretics and, rarely, hypertonic saline.
Q. You are called to recovery to see your patient on whom you have just performed a TURP. The nurses are concerned by the extent of the haematuria and inform you that the catheter keeps clotting off. What actions would you take?
A. I would assess the patient urgently to ensure that he is stable and resuscitate as necessary.
If stable, I would examine the patient’s abdomen to see if the bladder is distended. I would then perform a bladder washout with normal saline, also ensuring that the irrigation channel is patent. I would washout any clots and recommence bladder irrigation.
If this failed to control the haematuria, I would then deflate the catheter balloon, push the catheter further into the bladder and then insert 50 mL of water into the catheter balloon and apply traction by strapping the catheter to the patient’s thigh. I would reassess the patient’s cardiovascular status and the degree of haematuria.
If faced with ongoing haematuria, I would urgently consider returning to theatre, to endoscopically assess the prostate cavity and stop the bleeding. I would ensure that blood was cross-matched and explain to the patient the need to return to theatre to control bleeding. Assuming the patient’s condition allows I would take writhen consent. In theatre, I would re-insert the resectoscope and perform Ellik bladder washouts until no further clots are retrieved, and vision has improved. I would then conduct a thorough inspection of the prostatic bed to look for obvious sources of bleeding. The most common sites of bleeding are from arteries at the bladder neck or from venous perforation. I would attempt to control bleeding with the rollerball accepting that this is usually more successful in arterial bleeding.
In the presence of significant venous perforation I would re-insert a catheter, overinflate the balloon and apply traction for 10 minutes by the clock. If none of these measures controlled the bleeding then I would make a lower midline incision, open the bladder between stay sutures, inspect the cavity for bleeding points, diathermise or under-run bleeding vessels as appropriate and ultimately pack the prostatic cavity if none of the aforementioned steps have worked.
Q. What other conventional operations have been used for the treatment of BPH?
A. Transvesical prostatectomy was commonly used at the beginning of the twentieth century and is still practised in many developing countries. It can still be indicated if there are large bladder calculi or other bladder abnormalities, e.g. large diverticulae which require simultaneous treatment. Millin’s retropubic prostatectomy is the preferred operation if open surgery is indicated as it allows better haemostasis and visualisation of the prostatic cavity.
Open prostatectomy is not commonly performed in the United Kingdom anymore but is indicated with large prostate size (>100 g) or difficulty positioning the patient due to hip contractures. Cancerous prostates or small, fibrous glands in which there is no surgical plane in which to conduct the enucleation should not be treated by a Millin’s prostatectomy. In general, the risks of open prostatectomy are greater than those of TURP particularly with respect to bleeding, blood transfusion, incontinence, bladder neck contracture and thromboembolic complications (although need for re-do procedures is decreased).
Small prostate glands (<30 mL) may be treated by transurethral incision of the prostate (TUIP) with good symptomatic results and reduced complications.
Q. What would you do if you found a stone in the bladder on initial cystoscopy?
A. Clearly, in an elective setting, one would have anticipated this finding and appropriately counselled the patient pre-operatively, with the preferred treatment strategy. In unforeseen circumstances, the decision making would be based on the size of the stone as well as the size of the prostate gland.
For example, if the stone was small (<3 cm) and the prostate of a reasonable size then I would consider performing a cystolitholapaxy first and then to TURP at the same sitting, if vision was good and patient was clinically stable (not developing sepsis).
If the stone was larger but could still be safely managed endoscopically, then I would deal with the stone and perform a TURP at a later date.
In the situation where the stone was too large to be dealt with endoscopically then open surgery would be necessary, if the patient had consented to it pre-operatively, as an additional procedure. Traditionally this would be an indication for a transvesical prostatectomy and open stone removal. If patient had not consented, then I would stop after cystoscopy and re-evaluate electively. Clearly, if a very large stone had been found on pre-operative assessment, the possible need for open surgery with its attendant complications would have been discussed with the patient.
Q. What other procedures are you aware of as alternatives to conventional monopolar TURP for managing voiding LUTS presumed secondary to BPE?
A. Alternatives to conventional monopolar TURP include that I may offer include Holmium laser enucleation of the prostate (HoLEP). I am aware that I would only perform HoLEP at a centre specialising in the technique, or with mentorship arrangements in place. HoLEP is the endoscopic equivalent of an open prostatectomy in which the plane between the adenoma and the prostatic capsule is developed to dissect the lobes of the prostate out before they are then morcellated to allow extraction. A 10-year follow-up study for HoLEP with 949 patients has shown a significant improvement in IPSS, quality of life, maximum urinary flow rate, and post-void residual urine volume, which was maintained over the 10-year period. Persistent urge and stress incontinence were found in 1% and 0.5% of patients, respectively. Bladder neck contracture, urethral stricture and reoperation due to residual adenoma developed in 0.8%, 1.6% and 0.7% of patients [18]. This may well become the gold standard treatment for BOO in the future as symptomatic outcomes are at least equivalent to, if not better than, conventional TURP but there is a lower risk of bleeding and earlier return to normal activities. The main drawbacks of HoLEP are the expense of the laser, the perceived difficulty of learning the procedure and the inherent risks of bladder damage during the morcellation process.
KTP lasers (greenlight lasers) have been in use for over a decade, but have gradually increased in power with a corresponding increase in vaporisation efficiency (vaporisation creates a cavity by repeated passage of the laser over the surface of the prostate). Currently National Institute for Health and Care Excellence (NICE) suggests that there is insufficient high-quality, comparative evidence to support the routine adoption of the GreenLight XPS in high-risk patients, i.e. those who have an increased risk of bleeding, have prostates greater than 100 mL or have urinary retention.
Recently, NICE guidance has recommended use of Urolift [19] and TURIS (Transurethral Resection in Saline) for BPH surgery [20].
Urolift relieves LUTS while preserving sexual function, with the added advantage of being performed as a day case operation. NICE guidance recommends its use in men who are 50 years or older, with prostate volume less than 100 mL and without an obstructing middle lobe.
NICE recommendations state that TURis, instead of a monopolar system, avoids the risk of TUR syndrome and reduces the need for blood transfusion. It may also reduce the length of hospital stay and hospital readmissions. Using TURis also has some cost savings and there is some evidence of a reduction in readmissions with the TURis system compared with monopolar TURP.
I would offer transurethral incision of the prostate (TUIP) as an alternative to other types of surgery to men with a prostate estimated to be smaller than 30 g. Finally, I am aware that I would only consider offering laser vaporisation techniques, bipolar TUVP or monopolar or bipolar transurethral vaporisation resection of the prostate (TUVRP) as part of a randomised controlled trial that compares these techniques with TURP.