TURP (Transurethral prostate resection).


15-20% of patients develop significant complications and a second intervention is necessary in 10-15% within 10 years.

About 10% are found to coincidentally have carcinoma of the prostate.

Risk of morbidity (18%) and mortality (0.23%).

Mortality reported to be 0.2-2.5%.

Gold standard for benign prostatic hypertrophy but is now being challenged by 5-alpha reductase inhibitors and alpha-1-receptor inhibitors and less invasive alternatives.

The number of procedures is decreasing, mortality <0.25%, major complication is hemorrhage.

Mean transfusion rate is 7.2% after TURP.

Surgical complications from TURP include a bladder infection, bleeding from the prostate, scar formation, inability to hold urine, and inability to have an erection.

Majority of these complications are short lived, and most individuals recover fully within 6–12 months.

Incidence of postoperative urinary retention for TURP is 4.7%.

Transurethral Resection of the Prostate

The standard therapy for obstructive prostatic hypertrophy and is both the surgical treatment of choice and the standard of care when other methods fail.

With the advent of medical therapy for symptomatic prostatic hypertrophy with 5-alpha reductase inhibitors and alpha-adrenergic blockers, the need for immediate surgical intervention in symptomatic prostatic obstruction has been reduced substantially.

However, alpha-blockers do not modify prostate growth.

The use of prostatic growth inhibitors such as finasteride or dutasteride often fail to prevent recurrent urinary symptoms of BPH and retention.

Incidence of postoperative urinary retention for TURP IS 4.7%.

The criteria for performing TURP surgery are more stringent than before.

TURP surgery is reserved for patients with symptomatic BPH who have acute, recurrent, or chronic urinary retention, in whom medical management failed or who have prostates of an unusual size or shape, or who renal insufficiency due to prostatic obstruction, who have the most severe symptoms of prostatism, recurrent hematuria, bladder calculi, permanently damaged or weakened bladders, or large bladder diverticula that do not empty well secondary to an enlarged prostate.

It can be performed for intractable prostatitis or for tissue sampling when standard biopsy techniques cannot be used.

The relative frequency of TURP compared to open prostatectomy in surgical patients in the United States is 97%.

The average age of patients currently undergoing TURP is approximately 69 years.

The average amount of prostate tissue resected at TURP is 22 g.

Risk factors associated with increased morbidity with TURP include: prostate glands larger than 45 g, operative time longer than 90 minutes, and acute urinary retention as the presenting symptom.

The 5-year risk rate for a reoperation following TURP is approximately 5%.

Overall mortality rates following TURP by a skilled surgeon are virtually 0%.

African Americans who present for TURP surgery have a greater likelihood of urinary retention or urinary infections and have a higher incidence of preexisting medical problems compared to the general population.

Asian and Asian American men have the lowest overall risk of clinical BPH and eventual TURP.

Most TURP patients have urinary outlet obstruction for which medical therapy or alternative procedures have failed.

Persistent symptoms of urinary obstruction due to prostatic hypertrophy refractory to medical therapy constitute the most common indication for TURP,

Patients in whom alpha-blocker therapy is ineffective or failed tend to have poorer outcomes after TURP than men who proceed directly to a transurethral resection: presumably due to preoperative bladder damage and other risk factors that affect voiding rather than the size of the prostate.

70% of men undergoing a TURP have multiple indications for the procedure.

As many as 10% of men with BPH present with some degree of renal insufficiency.

The only absolute indication for an open prostatectomy over a TURP is the need for an additional open procedure on the bladder that must be performed at the same time as the prostatectomy.

A relative indication for the selection of an open prostate surgery over a TURP is generally based on prostatic volume and the ability of the surgeon to complete the TURP in less than 60 minutes.

Open prostatectomy, in general, can be justified in a patient with a prostate of 45 g or larger.

Most experienced urologists use a prostatic volume of 60-100 g as the upper limit amenable to endoscopic removal.

Highly skilled urologic resectionists are capable of safely treating a 200-g prostate with TURP in less than 90 minutes.

The number of TURP procedures has dropped dramatically over the years, and the median age of the typical patient is rising.

The size of the average resected prostate gland is increasing, and the typical patient has more comorbidities and is generally less healthy than surgical patients of the past.

Alternative surgical procedures, such as microwave therapy and prostatic laser surgery, are reimbursed at much higher levels, even though they may not be as durable or effective, they creates a strong financial disincentive for urologists to perform TURP procedures.

The prostate is divided into 3 zones: peripheral, central, and transition.

The peripheral zone is the largest of the zones, and is where most prostate cancers start, and encompasses approximately 75% of the total prostate glandular tissue in men without BPH.

The central zone is smaller and extends primarily around the ejaculatory ducts, and differs from the peripheral zone primarily in cytologic details and architecture.

The transition zone is usually the smallest of the 3, occupying only 5% of the prostate volume in men younger than 30 years.

The transition zone is thought to be the origin of BPH.

The transition zone consists of two separate lobes on either side of the urethra and usually involves a small ductal tissue near the central portion of the prostatic urethra near the internal sphincter.

With transition zone expansion,it can comprise up to 95% of the prostate volume, compressing the other zones.

As the hyperplastic process increases the volume of the prostate, the urethral lumen is compressed, causing outlet obstruction.

An enlarged median lobe may cause relatively more severe symptoms than lateral lobe hyperplasia of similar magnitude because it can act as a valve at which increased bladder pressure may actually cause further obstruction.

Intraoperatively, the 2 enlarged lobes of the transition zone can be seen obstructing the prostatic urethra on either side.

The periurethral glands are less commonly involved with BPH.

Prostatic calculi formed from calcification and precipitation of prostatic secretions, occurring between the transition zone and the compressed peripheral zone.

Prostatic calculi are usually composed of calcium phosphate and are not considered clinically significant.

Chemical analysis of prostate calculi is unnecessary.

Prostatic calculi may arise spontaneously, or be formed in response to an inflammatory reaction or as a consequence of another pathological process that produces acinar obstruction.

Some believe calcifications that form in response to bacterial prostatitis may harbor bacteria that periodically flourish, causing recurrent prostatitis, suggesting calcifications as a treatment for recurrent prostatitis.

The prostate is thinnest and most narrow anteriorly, at the 12-o’clock on cystoscopy.

The prostatic capsule in this portion contains abundant venous blood vessels which can cause significant bleeding.

The external urethral sphincter’s most proximal portion located anteriorly, opposite the verumontanum.

The external urethral sphincter is identified cystoscopically by its wrinkling and constricting action as the resectoscope is withdrawn.

The external sphincter muscle is imbedded within the urogenital diaphragm.

The single most important anatomical landmark in TURP is a midline structure, the verumontanum, located on the floor of the distal prostatic urethra just proximal to the external sphincter muscle.

The orifices to the ejaculatory ducts emerge in the verumontanum.

Its position immediately proximal to the external sphincter muscle which allows it to be used as the distal landmark for prostate resection.

The blood supply of the prostate comes primarily from branches of the inferior vesical artery, which is a branch of the internal iliac artery.

Vessels that parallel the prostatic urethra supply most of the blood to the hypertrophied lateral lobes.

The second large group of arteries follows the exterior of the prostatic capsule posterolaterally, periodically giving rise to perforating vessels, and supplies the area around the verumontanum.

Prostate size alone is not a reliable or accurate predictor of the presence or degree of urinary outlet obstruction.

BPH has both a dynamic and a mechanical component.

The same time as the occurrence of mechanical obstruction, a dynamic component involving the stromal prostatic tissue and bladder is present.

The dynamic component is often more significant in causing urinary symptoms than simple mechanical obstruction from an enlarged prostate.

When a bladder empties through a blocked outlet from an obstructing prostate gland, the intravesical pressure required to open the bladder neck is increased.

The bladder is initially able to produce a higher transitory voiding pressure, but loses muscle tone over time.

The need for a higher intravesical pressure to overcome the increased resistance to voiding, causes isolated muscle bundle hypertrophy, and bladder trabeculation often follows.

As the spaces between these hypertrophied bundles tend to become thinner, there is less functional muscle, that can progress to the point at which the bladder becomes almost nonfunctional.

Bladder trabeculation is usually graded on a scale of I-IV.

Bladder trabeculation seen on cystoscopy images, it is a relative indicator of the degree and duration of any bladder outlet obstruction, such as BPH.

Symptomatic changes of bladder outlook obstruction include increased bladder instability and irritability, which can eventually progress to muscular decompensation with permanent loss of detrusor contractile ability.

Bladder obstruction causes partial denervation of bladder smooth muscle, which results in further bladder irritability and involuntary detrusor contractions.

Most hyperactive symptoms resolve over time with removal of the prostatic obstruction or with a response to appropriate medications.

Over time the detrusor becomes less able to maintain a constant voiding pressure, which leads to early termination of voiding, intermittency of the urinary stream, and higher residual urine volume, accompanied by loss of bladder compliance.

Bladder mass increases because of detrusor muscle hypertrophy, but collagen deposition is also increased.

Increased bladder muscle collagen contributes to decompensation, urinary retention, and permanent loss of detrusor contractile ability.

BPH is thought to be caused by aging and by long-term testosterone and dihydrotestosterone (DHT) production.

BPH is present in approximately 8% of men in their fourth decade and in 90% of men by their ninth decade.

Loss of testosterone early in life prevents the development of BPH.

The similarities in BPH among identical twins suggest a hereditary influence.

BPH tends to progress, as cross-sectional studies suggest that the growth rate of the prostate decreases with age.

In patients aged 31-50 years, the prostate doubling time averages 4.5 years. In men aged 51-70 years, the prostatic doubling time is approximately 10 years, while in men older than 70 years, the doubling time increases to more than 100 years.

A 5-year longitudinal study of 631 community men aged 40-79 years from Olmsted County, Minnesota demonstrated an average annual prostate growth rate of 1.6%, and in this study it remained essentially constant regardless of age, although men with larger prostates tended to have higher growth rates.

The average prostate weighs approximately 20 g by the third decade and remains relatively constant in size and weight unless BPH develops.

The typical patient with BPH has a prostate that averages 33 g.

Only 4% of the male population ever develops prostates of 100 g or larger.

The largest recorded prostatectomy specimen weighed 820 g.

Symptoms of BPH tend to progress slowly over time in most individuals, with an average annual increase of 0.14-0.44 points per year in the AUA symptom index for men aged 60 years and older.

Once BPH has begun, the prostate grows an average of 0.6 mL in volume annually, with has a mean decrease in average urinary peak flow rate of 0.2 mL per second each year.

Men older than 70 years and those with a baseline peak flow rate less than 10 mL/s tend to have a more rapid and dramatic decline in their peak flow rates over time.

5-alpha reductase blockers, such as finasteride and dutasteride reduce prostatic size and relieving symptoms.

BPH symptoms include a slow, intermittent, or weak urinary stream; the sensation of incomplete bladder emptying; double voiding, postvoid dribbling; urinary frequency; and nocturia.

Patients may also present with acute or chronic urinary retention, urinary tract infections, gross hematuria, renal insufficiency, bladder pain, a palpable abdominal mass, or overflow incontinence.

Prostate may be enlarged during the digital rectal examination.

Symptoms are not necessarily proportional to the size of the prostate.

Because there are alpha-adrenergic receptors are present and functional in the smooth muscle of the prostate and especially at the bladder neck various alpha-adrenergic blockers can relieve symptoms of BPH.

Therapy with both an alpha-blocker and a 5-alpha reductase inhibitor can delay the progression of symptoms and is more effective over time than either medication alone for reducing symptom scores and improving peak urinary flow rates.

Spinal anesthesia is generally pref2241ed for transurethral resections, as patients recovering from a general anesthetic often cough heavily, which tends to increase hematuria.

Because laryngeal mask anesthesia tends to minimize many of the negative aspects of general anesthetic and is now used for many cases.

A large national survey confirmed that up to 79% of transurethral prostate resections are performed with the patient under spinal or epidural anesthesia.

Several studies failed to show any significant differences in complication rates, operative mortality and morbidity, or blood loss between regional and general anesthesia.

The obturator nerve runs near the prostate and can be electrically stimulated during transurethral prostate surgery, causing a violent thrusting of the leg.


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