: DESCRIPTION OF PROCEDURE
:INTRODUCTION
Various techniques have been suggested for
the systematic removal of the adenomatous
tissue, all based on the principle that the
resection should be done stepwise. As
bleeding is the surgeon’s major problem,
leading to loss of visual field and
disorientation, it is imperative that resection
and haemostasis should both be completed in
one area of the fossa before the next area is
tackled. In the following article, the resection
technique used at our institution is described,
and was initially developed by Mauermayer
[1] and subsequently improved by the
authors [2]. Through improvements in endoscopic
instruments and new high-frequency
technology, TURP has become an
increasingly safe procedure. Modified
optical devices and video cameras
enable experts and residents to teach
and learn this technique like any open
procedure. Innovative technological
approaches include the ‘coagulating
intermittent cutting’ (Storz Medical AG,
Tägerwilen, Switzerland), the ‘Instant
Response’ (Valleylab, Boulder, CO), as
well as the ‘Dry-Cut technology’ (ERBE
Elektromedizin GmbH, Tübingen,
Germany) that combine cutting
and coagulating effects, allowing a
blood-sparing cut and significantly
lowering blood loss and morbidity. Bipolar
resection (Olympus, Tokyo, Japan) represents
a further step to reduce the perioperative
morbidity of TURP.
INDICATION AND PATIENT SELECTION
The correct indication based on clinical
symptoms and reliable objective findings in
the evaluation of benign prostatic obstruction
is still crucially important for the long-term
outcome. The risk of needing surgery for BPH
increases with age and with the degree of
clinical symptoms at baseline. Evaluating
symptom severity with a symptom score is an
important part of the initial assessment of the
patient. It is helpful in allocating treatment,
and both predicting and monitoring the
response to therapy. Among all different
validated symptom score systems, the use of
the IPSS is recommended.
Although symptoms constitute the primary
reason for recommending intervention, there
are some absolute indications for surgical
treatment. Contemporary guidelines on BPH
recommend surgery, rather than any of the
other available treatment options, in any of
the following conditions secondary to BPH
[3]: refractory urinary retention; recurrent
UTI; recurrent haematuria refractory to
medical treatment (finasteride); renal
insufficiency; and bladder stones.
ANAESTHETIC CONSIDERATIONS AND
PREOPERATIVE MANAGEMENT
TURP can be done under all forms of regional
anaesthesia, usually under a general or spinal
anaesthetic. Occasionally, high-risk patients
require an interdisciplinary preoperative
evaluation to determine whether surgery can
be safe. In case of acute urinary retention, a
suprapubic cystostomy should be inserted
instead of a urethral catheter, to avoid
postoperative urethral strictures. There is no
need for a routine preoperative urethrogram
unless there is a clear suspicion of urethral
stricture.
EQUIPMENT
• Modern high-frequency generator, e.g.
Autocon II 400 (Storz).
• 24 F resectoscope (constant-flow
resectoscope optional for low pressureirrigation°
lens.0 (preferred by the authors), 15
Otis urethrotome.
Sterile, lubricant anaesthetic jelly,
conductive for electrical current.
20 F three-way catheter with either 50, 80
or 100 mL balloon capacity.
PATIENT POSITIONING AND IRRIGATION
• Lithotomy position.
• Sterile, pyrogen-free, non-hemolytic
irrigation solution (e.g. 1.5% glycine), the.
eservoir 60–70 cm above the level of the
symphysis (irrigation pressure 60–70 cm(H2O)
Suprapubic trocar optional for lowpressure
irrigation.
SURGICAL TECHNIQUE
INSERTION OF THE INSTRUMENT
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 usin the
0endoscope 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.
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