TURP step by step operative urology series for more resources: www.uronotes2012.blogspot.com enter your mail & press follow us by mail to receive our daily feeds

1. TURP
M.A.Wadood Aref

2. TURP set
• Lens
• Resectoscope sheath 24-
Fr or 27-Fr. (single flow
or continous flow).
• HF resection electrodes:
band electrode & roller
electrode (coagulation).
• Ellic evacuator
• Electrolyte-free and
sterile irrigation fluid.
• Lubricant.
• Optional suprapubic
catheter (12-Fr) for
continuous irrigation.
©

3. Right position (lithotomy Wrong position (extended
position) (45 degrees) lithotomy position) (90 degrees)
M.A.Wadood Aref

4. Sphincteric mechanism
The three components of the sphincter mechanism are:
 bladder neck
 intramural external sphincter (just distal to the verumontanum)
 levator ani.
M.A.Wadood Aref

5. The operation
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6. Basic skills for TURP
M.A.Wadood Aref

7. Cutting a chip
1. lift the resectoscope
to allow the loop to
sink in
2. keep it level as you
cut the chip
3. depress the sheath to
cut off the chip.
M.A.Wadood Aref

8. Cutting a chip
• The shape of the chip • Cutting the chip off
is like a canoe. It is as before the loop
enters the sheath
wide and deep as the prevents any
loop, and its length is possible damage to
determined by the the telescope.
travel of the loop.
M.A.Wadood Aref

9. Bleeding control
• Smaller vessel may be • larger vessel is
controlled by controlled by
coagulating its applying the loop just
mouth. to one side of wall to
seal the walls
together.
M.A.Wadood Aref

10. Bleeding control
• When artery points straight at • If localization of bleeding
you all you can see is a red blur.
site is difficult consider
• advance sheath, tilt it to squeeze
‘Bouncing bleeding’.
vessel, coagulate just upstream.
M.A.Wadood Aref

11. Prophylactic coagulation sites
5 o’clock 7 o’clock 10 o’clock
Badenoch’s arteries
M.A.Wadood Aref

12. Main Steps of TURP
1. Identification of landmarks.
2. Removal of most of adenoma (stepwise) by
Mauermayer technique or Nesbit technique.
3. Tidying up & removal of apical tissue.
4. Catheter application
M.A.Wadood Aref

13. Initial steps – Identification of bookmarks
• Lithotomy position.
• Blind trocar or visual
insertion of the
resectoscope sheath.
• Urethrocystoscopy
with identification of
verumontanum,
prostatic urethra,
bladder neck and
ureteral orifices.
M.A.Wadood Aref

14. Orientation
• The external sphincter is easily • It is necessary to be aware of the position
identifiable at the level of the of the verumontanum to see that the
membranous urethra. lower part of the cut is not extending
below this level, otherwise damage to the
sphincter mechanism may occur.
M.A.Wadood Aref

15. Mauermayer Standard technique
(1981)
• Resection in lobes (middle lobe & tissues lat.
to veru. → Lt lobe→ Rt → lobe apical tissues).
• apical tissues last
M.A.Wadood Aref

16. Endoscopic view Diagramatic view
• Resection begins at the proximal portion of the middle lobe at the 6 o’clock
position.
• The resectoscope is placed just proximal to the verumontanum and the
resection carried out always controlling the endpoint of each cut.
M.A.Wadood Aref

17. Endoscopic view Diagramatic view
• Continue resecting the middle lobe from the 7 to 5
o’clock positions.
M.A.Wadood Aref

18. Endoscopic view Diagramatic view
• Resection at both sides of the verumontanum with particular care of the position
of the external sphincter (do not exceed distal end of verumontanum).
• pull the resectoscope into the urethra, just distal to the verumontanum, and note
that there is no falling and obstructing tissue.
M.A.Wadood Aref

19. Endoscopic view Diagramatic view
Resection of Left lateral lobe (proximal part) in long cuts
next to each other to achieve smooth surface (fossa).
• Which lobe first? depends on the preference of the surgeon.
M.A.Wadood Aref

20. Endoscopic view Diagramatic view
Resection of Right lateral lobe (proximal part) in long cuts
next to each other to achieve smooth surface (fossa).
M.A.Wadood Aref

21. • Shape of surface (fossa) after resection proximal
part of both lateral lobes in long cuts.
M.A.Wadood Aref

22. • Resection of apical tissues carefully (do not exceed
distal end of verumontanum)- finger in rectum can approximate
the apical tissues.
M.A.Wadood Aref

23. Nesbit Standard technique
(1943)
• Resection from proximal to distal (BN →
midportion → apical tissue).
• apical tissues last.
M.A.Wadood Aref

24. 1st stage: resect BN
• Resect BN in quadrants starting at 12 o’clock (until see circular
fibers of BN)

25. 2nd stage: resect midportion
in quadrants, (superiorly to inferiorly) (until see fibers of prostatic capsule)
• (a): Rt lobe upper quadrant (12 to 9 o’clock)

26. 2nd stage: resect midportion
in quadrants, (superiorly to inferiorly) (until see fibers of prostatic capsule)
 (b): Lt lobe upper quadrant (12 to 3 o’clock)


27. 2nd stage: resect midportion
in quadrants, (superiorly to inferiorly) (until see fibers of prostatic capsule)
 (c): Rt lower quadrant (9 to 6 o’clock) & Lt lower quadrant (3 to 6
o’clock)


28. 3rd stage: resect apical tissues
Residual tissue is carefully cleared on both sides immediately lateral
to veru (do not exceed distal end of verumontanum to preserve sphincter).
 begin next to the veru → toward the 12 o'clock position

29. Catheter application
M.A.Wadood Aref

30. Catheter at bladder neck catheter in prostatic fossa
• place a 20 F three-way catheter for drainage; can be inserted with the finger in the rectum,
pressing the prostatic tissue up to avoid damage to the bladder neck and trigone.
• The balloon is inflated to 20 mL or 30 mL
• the catheter can be left at bladder neck or withdrawn in the prostatic fossa.
M.A.Wadood Aref

31. Catheter at bladder neck
Balloon catheter within the
bladder (with traction on BN
to contract the fossa)
• this is the preferred method by
most of the surgeons because it
allows the capsule to contract
without much trauma to the
urethra.
M.A.Wadood Aref

32. catheter in prostatic fossa
Balloon catheter within
the prostatic fossa
• some surgeons
advocate that method
to control bleeding
(only for short time).
• However, Prolonged
traction with the balloon
in prostatic fossa has the
risk of traumatic injury &
prevent fossa contraction
leading to bleeding.
M.A.Wadood Aref

33. Skin traction
• some surgeons
advocate traction to be
maintained by a gauze
swab tied round the
catheter and pulled
back onto the glans
penis (for short time to
avoid ischemia).
M.A.Wadood Aref

34. EARLY LATE
intra-op POST-OP POST-OP
 Haemorrhage  Urinary retention  Retrograde
 Urethral injury  Clot retention Ejaculation
 Bladder injury  2ry Haemorrhage
 UTI
 TUR syndrome  Erectile Dysfunction
 Epididymo-orchitis
 Mortality  Bladder neck
 Septicaemia stenosis
 DVT  Urethral Stricture
 PE  Incontinence
 Re-operation
 Mortality

35. Thank You
M.A.Wadood Aref