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The metal sheath of the resectoscope is generously lubricated with a conductive jelly. An obturator is placed through the sheath to provide a smooth, blunt tip for easy passage through the fossa navicularis and anterior urethra. The instrument should gently enter the urethra under its own weight, to make the introduction as atraumatic as possible. If there is resistance to the passage, any force should be strictly avoided.
If the meatus is narrow, or there is a stricture of the meatus or the anterior urethra, a ‘blind’ internal urethrotomy up to 30 F with the Otis urethrotome is recommended. Further passage is either blind with the obturator inside the sheath or under direct vision using the 0° endoscope and the video camera. Gentleness and care are essential to avoid urethral strictures. Via the video monitor the bulbar urethra, the external sphincter and the prostatic urethra with the prostatic lobes and the verumontanum are inspected. Then a systematic evaluation of the entire bladder surface using angular optical lenses is mandatory.

If there are bladder calculi, lithotripsy is conducted before TURP begins. Larger stones can be fragmented using an ultrasonic lithotripter or Lithoclast (mechanical impactor), and smaller stones or fragments are crushed by a stone punch until small enough to be evacuated. Only after ensuring that the bladder mucosa is free should the jaws of a stone punch be screwed together to crush the stone inside the bladder cavity. Crushing should never be attempted without a clear view, to avoid bladder damage. The fragments are irrigated from the bladder with an ‘Ellick’ evacuator.

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