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Trans-Urethral Resection of the Prostate (TURP)

What is a Trans-Urethral Resection of the Prostate Surgery?
Trans-urethral resection of the prostate (TURP) is an effective minimally-invasive surgical procedure used in the treatment of a non-cancerous enlargement of the prostate, referred to as benign prostatic hyperplasia (BPH). In this procedure, a part of the prostate that obstructs the urethra is removed with the help of an instrument that is passed through the urethra.

TURP is an endoscopic procedure and does not involve a surgical incision and is performed by urologist. Once the obstructed tissue of the prostate gland is removed it allows urine to flow more freely. The urologist passes a special thin tube through your urethra and uses a heated wire loop to shave off the overgrown areas of the prostate gland.

Trans-Urethral Resection of the Prostate (TURP)

Not everybody with an enlarged prostate gland will require a TURP; however the urologist may recommend this procedure on the basis of symptoms and the results of special investigations they carry out. By allowing urine to flow more freely, a TURP can often relieve or reduce symptoms.

Anatomy of the Prostate


The prostate is a small walnut-sized gland that forms a part of the male reproductive system. It is located just below the urinary bladder, behind the pubic symphysis and in front of the rectum. It surrounds the upper part of the urethra, referred to as prostatic urethra.

The urethra is the duct which passes through the penis and carries the urine to the exterior. The posterior wall of the prostatic urethra has the urethral crest, with a prominent elevation called the verumontanum. The secretion from the prostate, the prostatic fluid empties into the prostatic sinuses, which open on either side of the urethral crest. The ejaculatory ducts, which carry sperms and fluid from the seminal vesicles, open into the verumontanum.

Just below the verumontanum is the external urethral sphincter, which helps to control urine flow. Damage to the sphincter can result in urinary incontinence. Therefore, the surgery on the prostate should not go beyond the verumontanum to prevent damage to the external urethral sphincter.

Prostate Anatomy

Which Patients Require TURP?


TURP is used for the treatment of benign hyperplasia of the prostate (BPH). BPH is a condition that often affects older men. The prostate is enlarged in size and can affect the flow of urine through the prostatic urethra. TURP is used in those patients with symptoms of urinary retention in whom medical treatment does not work or those who suffer from complications like bladder stones, repeated urinary tract infections or even kidney failure. It may also be used to treat urinary obstruction caused by prostate cancer.

What are the Tests Done Before the TURP Surgery?


Before a TURP, the doctor examines the patient. A digital rectal examination is carried out to assess the size and surface of the prostate. During the examination, the patient lies on his side with legs folded and knees close to the chest. The doctor inserts a gloved and lubricated finger into the rectum, and through the anterior wall of the rectum, feels the size and shape of the prostate.

Tests done before a TURP procedure include the following:

Routine Tests:

Routine tests which are done before any surgery include:

  • Blood tests like hemoglobin levels, blood group, and liver and kidney function tests
  • Urine tests
  • ECG to study the electrical activity of the heart
  • Chest x-ray
In older group of patients, a detailed assessment of the heart may be required to make sure that they are fit for surgery.

A urine culture and sensitivity test are done to detect any urinary infection, which has to be treated prior to the procedure.

Prostate Specific Antigen (PSA) Estimation: The level of PSA may be increased in a patient with BPH or prostate cancer.

Prostate Specific Antigen (PSA) Test Done Before TURP

Urodynamic Tests are carried out to check for the degree of obstruction caused by the enlarged prostate. During a uroflowmetry test, the patient is asked to pass urine in a special container which measures the amount of urine passed and the flow rate. The amount of urine that remains in the bladder after voiding, called postvoid residual urine, indicates incomplete emptying of the bladder. It is measured using ultrasound or by inserting a catheter into the bladder.

Ultrasound is a painless imaging test where a gel is applied to the abdomen or pelvis, and a probe is passed over it. The images are obtained on a screen. It is used to measure postvoid residual urine in the bladder, and also rule out other pathologies in the urinary tract like bladder stones or swelling of the kidneys (hydronephrosis). A transrectal ultrasound, where the probe is introduced into the rectum, is sometimes used to examine the prostate.

What is the Procedure for TURP?


Type of Anesthesia TURP is usually done under spinal anesthesia or epidural anesthesia. You will be awake during the surgery but will not be able to feel anything in the lower part of your body. If general anesthesia is used, you will be asleep during the procedure and will not be aware of what is going on.

Pre-operative Check-up - Routine tests as indicated above are ordered a few days before the surgery. If the patient is on blood thinning medications, these will be stopped a few days prior to the surgery. Admission is required a day before the surgery.

Day Before Surgery - An enema is administered the previous afternoon or evening before the surgery along with gut-sensitive antibiotics.

Fasting Before Surgery - Overnight fasting is required and occasionally intravenous fluid maybe required to keep you well hydrated. Sedation is sometimes required for good overnight sleep before the surgery.

Shift from the Ward or Room to the Waiting Area in the Operating Room - An hour or two before the surgery, you will be shifted to the operating room waiting area on a trolley. Once the surgical room is ready, you will be shifted to the operating room.

Shift to the Operating Room - The ambience in the operating room can sometimes be very daunting and a small amount of sedation can help overcome your anxiety. From the trolley, you will be shifted on to the operating table. As you look up, you will see the operating light console and at the head end will be the anesthesia machine. There may also be monitors to check oxygen levels, ECG and other vital parameters. A constant beeping sound may be present from the monitors, which may sometimes be irritating.

Anesthesia before Surgery - If you are undergoing spinal or epidural anesthesia, you will usually be asked sit down to lie on one side and curl up your back. The anesthetist will find the right place in your backbone for the anesthesia. The area is sterilized and an injection in inserted in your spine. The anesthetist will then inject an anesthetic through the needle.

If you are undergoing general anesthesia, the anesthetist will inject drugs through an intravenous line and make you inhale some gases through a mask that will put you in deep sleep. Once you are asleep, a tube will be inserted into your mouth and windpipe to administer the anesthetic gases to overcome pain and keep you comfortable while the surgery is going on.

The TURP Procedure - For the TURP procedure, you will be placed on your back in the lithotomy position where your legs are separated and raised. An instrument called a resectoscope is advanced through the urethra, and the excess prostatic tissue is resected with the help of an electrical current. Large blood vessels are coagulated to prevent bleeding.

The bladder is irrigated with solutions like glycine or sorbitol / mannitol so that the debris can be washed out. Sterile water should be avoided since it can electrolyte abnormalities or breakdown of red blood cells. The pieces of prostate are sent for pathological testing to rule out prostate cancer. Vaporization of the chips is sometimes used to get rid of the debris and reduce the risk of bleeding. A three-way Foley catheter is kept in place following the surgery.

See Trans-Urethral Resection of the Prostate (TURP) - Urology Video




Waking Up from General Anesthesia If you have received general anesthesia, once the surgery is over, you will wake up and the tube down the wind pipe will be removed. You will be asked to open your eyes before the tube is removed. You will be sedated and the voice of the anesthetist may be faint. Once the tube is out, you may have cough and sometimes nausea.

There may be a tube going into the stomach called a Ryles tube to keep it empty. There will also be an intravenous line. You will remain on oxygen. Once fully awake, you will be shifted on the trolley and taken to the recovery room.

If you have received spinal or epidural anesthesia, it may take around an hour to four hours for the sensation to return and for you to move your legs. You may experience a tingling sensation as the sensation re-appears.

Recovery Room In the recovery room, a nurse will monitor your vitals and observe you for an hour or two before shifting you to the room or a ward.

Post-operative Recovery You will remain in the hospital for one or two days following the procedure. Light foods may be allowed following the surgery.

Chest physiotherapy maybe started after 24 hours to prevent chest infection.

DVT Prophylaxis Early movement of your legs and some mobilization prevents DVT or deep vein thrombosis, where a clot is formed in the deep veins of the legs. The clot can travel up to the lungs and even be fatal. Other measures like small dose of heparin and special stockings may also be used.

Pain relievers may be prescribed depending on the extent of the pain.

Instructions onDischarge Your doctor will advise drinking plenty of water and other fluids and check the color of the urine in the catheter on a regular basis. Some amount of blood will be present in the urine following the surgery. The catheter is usually removed prior to discharge depending on your recovery. Antibiotics will be prescribed for a few days to weeks following the procedure. Medications may also be prescribed to prevent bladder spasms.

What are the Risks or Complications of TURP?


Complications of TURP include the following:

  • Infections, if adequate aseptic precautions are not taken during surgery
  • Retrograde ejaculation, where the semen moves backward into the bladder - this means after surgery a patient becomes sterile and will not be able to parent a baby
  • TURP syndrome, where fluid may enter the blood stream resulting in low blood sodium levels. It can cause complications like heart disease, neurological symptoms including seizures and fluid accumulation in the lungs
  • Impotence or erectile dysfunction
  • Complication of TURP - Impotence

Damage to the bladder or the urethra resulting in perforation or stricture formation (narrowing of the urethra)

  • Heavy bleeding resulting in excessive blood loss.
  • Injury to surrounding structures like rectum especially if previous irradiation to prostate has taken place.
  • Urinary incontinence or inability to control urination if the urinary sphincter is damaged.
Frequently Asked Questions
1. Which doctor should I consult for TURP?

You should consult an urologist for TURP.

2. What are the non-surgical treatments available for BPH?

Medications are available for the treatment of BPH, which have reduced the need for TURP. Medications that are commonly used include the alpha blockers like terazosin, alfuzosin, tamsulosin, doxazosin and silodosin, and the 5-alpha reductase inhibitors like finasteride and dutasteride.

3. What is the difference between monopolar and bipolar TURP?

Saline cannot be used with monopolar cautery due to its electrical conducting properties. It can however be used with bipolar cautery. Bipolar cautery also causes lesser tissue damage, lesser chances of TURP syndrome, reduced duration when the patient will require a catheter, and sometimes faster discharge from the hospital.

4. Which are the other procedures that can be done for the treatment of BPH?

Prostate enlargement can be tackled through various surgical procedures besides TURP and these include -
  • Transurethral needle ablation: In this procedure, needles that transmit radio frequency energy and destroy prostatic tissue are introduced through a cystoscope.
  • Transurethral microwave thermotherapy: In this procedure, an antenna is introduced through a catheter which sends microwaves and heats and destroys the prostate tissue.
  • High-intensity focused ultrasound: A special ultrasound probe is introduced into the rectum, which destroys some of the prostate tissue
  • Water-induced thermotherapy: In this procedure, heated water is introduced into a treatment balloon through a catheter, which destroys the prostate tissue through heat
  • Prostate-stent insertion: In this procedure, a stent is inserted into the prostatic urethra so that it widens the opening and makes it easy for the urine to flow
  • Holmium Laser Enucleation of the Prostate (HoLEP): In this procedure, laser is used to cut off pieces of the prostate. The pieces are then sucked out from the bladder and sent for pathological examination.
  • Vaporization of the prostate tissue can be brought about with the help of an electric current (Transurethral Electroevaporation of The Prostate (TUVP)) or through laser Photoselective Vaporization (PVP)
  • Transurethral incision of the prostate (TUIP): In this procedure, small cuts are made in the prostate and bladder neck using laser or an instrument producing electric current introduced through a cystoscope
  • Open prostatectomy: Open prostatectomy is an open surgery on the prostate. Depending on the site of the incision, open prostatectomy may be retropubic prostatectomy, suprapubic prostatectomy, and perineal prostatectomy
Glossary
Urinary bladder: A pouch of the lower urinary tract that stores urine

Pubic symphysis: The midline joint of the pubic bones of the pelvis

Rectum: The lower part of the digestive tract that connects the large intestine to the anus

Urethra: Tube-like structure that carries urine from the bladder to the exterior

References
  1. Prostate Enlargement: Benign Prostatic Hyperplasia - (https://www.niddk.nih.gov/health-information/health-topics/urologic-disease/benign-prostatic-hyperplasia-bph/Pages/facts.aspx)
  2. Singhania P, Nandini D, Sarita F, Hemant P, Hemalata I. Transurethral Resection of Prostate: A Comparison of Standard Monopolar versus Bipolar Saline Resection. International Braz J Urol 2010; 36 (2): 183-189 doi: 10.1590/S1677-55382010000200008
  3. Ketabchi A, Ketabchi M, Barkam M. The Effect of Modified TURP (M-TURP) in Intra and Postoperative Complications. Nephrourol Mon. 2013; 5(2): 758761. doi: 10.5812/numonthly.6607

Author: Dr. Simi Paknikar

Editor: Dr. Shroff

Technically Checked by: Lingaraj

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