A variety of instruments are available to perform TURP. The basic requirements are a standard cystoscopy lens (usually 30°), a bridge that accommodates a resection loop, and a cystoscopy sheath specifically designed for resection (Fig. 3A,B). This entire setup is typically called a resectoscope. Each one of the segments of a resectoscope can be altered to fit the needs and preferences of the surgeon. A major improvement in the sheath element has been the development of the ability for continuous irrigation. This required creating an inner sheath that provides inflow with an outer sheath that has fenestrations and is connected to suction for aspiration of the irrigation fluid. In addition, a continuous flow pump is necessary to help evacuate the fluid and dispose of it. There are two common types of bridges, the Stern-McCarthy and the Iglesias (Fig. 4). The latter is probably used more frequently because it allows the surgeon to move the resection loop through the tissue predominately with the thumb. Other options for the resectoscope include the type of loop used for resection and/or cauterization (Fig. 5). The thin-wired loop has been in use the longest and is still the most popular. Advantages include the ability to cut through the prostate tissue easily and the ability to accurately cauterize bleeding vessels. More recently, surgeons have used one of the many types of loops in which the cutting element is wider, often with serrated edges. A theoretical advantage is the ability to reduce the amount of bleeding during the resection because the wider loop allows for some cauterization even in the cut mode. The thickness of these types of loops and the goal of trying to cauterize as one cuts reduce the speed with which it can be pulled through the prostate tissue, a distinctive disadvantage. Loops with rollerballs are also available, and although not generally used to ablate tissue, can be helpful in obtaining hemostasis because of the wider surface area in contact with the tissue.
Various devices are available to assist with recovery of the prostate chips. One of the most common is the Ellik evacuator, consisting of dual connected glass chambers, oriented vertically, and attached to a suction bulb (Fig. 6). The upper chamber is connected to the suction bulb and allows the surgeon to irrigate the bladder in and out. The lower chamber collects the prostatic chips as they fall by gravity from the upper chamber. Other devices of similar design (albeit with different composition) and piston-like devices are also available for prostatic chip evacuation, and are used at the discretion of the surgeon. Finally, the use of fiberoptic technology to transmit the image from the cystoscope lens to a television monitor has greatly improved the surgeon's ability to perform the
procedure, reduced exposure to the blood-contaminated irrigant, and enhanced resident learning (Fig. 7 A,B).
Irrigation is required for visualization during TURP because bleeding begins once the prostate tissue is incised. Sterile water was initially used for the irrigant during TURP until it was recognized that absorption of large volumes could result in complications, particularly hemolysis and hyponatremia (17-19). Although sterile water can still be effective as an irrigant when used appropriately, the use of more isotonic solutions has become practically universal. These relatively isotonic and nonionizing irrigants typically are made by adding glucose, mannitol, and/or glycine to sterile water, increasing the osmolality. Common solutions include 1.5% glycine, Cytal (a combination of sorbitol and mannitol), 2.5% glucose, mannitol, and 3% sorbitol. It should be recognized, however, that even though the likelihood of hemolysis is dramatically reduced, use of these irrigants might still result in dilutional hyponatremia when they are absorbed in high volumes.
bladder neck bladder neck
There are many techniques for performing TURP, all of which have advantages and disadvantages. In each, the technique involves resection of transition zone prostate tissue from the bladder neck to the verumon-tanum. Differences in the various techniques revolve primarily around the initial stages of the resection. Most advocate resection of the anterior and lateral portions of the prostate first, allowing the tissue on each side to fall to the floor. This tissue is then subsequently resected, followed by the apex. Others believe that initial resection of the bladder neck and median lobe, when present, allows better flow of irrigation into the bladder, thereby facilitating easier resection of the remaining tissue. Nevertheless, most of the other aspects of the resection remain the same, and the choice of technique should be based on the individual surgeon's experiences, preferences, and judgment based on patient anatomy.
When performing the first technique, the resection should start at either the 12 o'clock position or slightly lateral to this position, at the level of the bladder neck. Typically, there is a paucity of hyperplastic tissue in this area, which primarily encompasses the anterior fibro-muscular zone of the prostate (Fig. 8). To facilitate resection down to the appropriate depth throughout the entirety of the procedure, early iden tification of the surgical capsule is desirable. Although distinct from the true fibrous capsule of the prostate, and furthermore not an anatomic capsule in the traditional sense, this important landmark identifies the ideal depth of resection. It is formed by the compression of normal, nontransition zone prostate tissue by the expanding transition zone that enlarges as a result of the hyperplastic process. Resection deep to this level often results in perforation of intraprostatic and periprostatic venous sinuses, causing excessive bleeding and impairing visualization during the procedure. In addition, prolonged irrigation with relatively hypo-osmolar fluid increases the risk for the development of absorptive hyponatremia, fluid overload, and other manifestations of the transurethral resection syndrome (TUR). Very deep resection may also reveal perivesical or periprostatic fat.
Resection should then proceed from the 12 o'clock position approximately down to the 4 and 8 o'clock positions, extending distally to a point just proximal to the verumontanum (Fig. 9A,B). Throughout this phase, care must be taken to maintain the appropriate depth of resection as described above. This maneuver effectively causes the lateral tissue of the prostate to fall to the floor. The remaining portions of the lateral lobe on each side are then resected (Fig. 10). The arterial supply to the prostate and vesical neck generally enters at the 5 and 7 o'clock positions. Brisk bleeding should be expected from this area and should be rapidly controlled with electrocautery. At this point, the floor of the prostate is resected, including the median lobe if it is present. The latter should be resected completely down to the circular fibers of the bladder neck; however, the resection should be distal enough to avoid injury to the ureteral orifices.
A fair amount of apical tissue often remains at this point, and resection of this area requires extra care. Sacrifice of the internal urethral sphincter (bladder neck) is an accepted consequence of TURP. Consequently, preservation of the external urethral sphincter complex, particularly the intrinsic rhabdosphincter, which projects into the distal prostatic urethra, is paramount in maintaining continence with increasing intraabdominal pressure. This remaining tissue should be resected carefully, with particular attention to the location of the verumontanum, as this represents the proximal extent of the external sphincter complex. This tissue can often be better visualized by elevating it with a gloved finger placed in the rectum (Fig. 11A,B). Once this has been done, an open prostatic urethra should be seen when the cystoscope is positioned at the level of the verumontanum (Fig. 12A,B).
Resection of the prostate using the second technique begins with removal of the median lobe/median bar and some of the bladder neck
from approximately the 4 o'clock to 8 o'clock positions. Resection is carried down to the circular fibers of the bladder neck. In theory, removal of this tissue early in the procedure allows better flow of irrigation fluid from the prostatic fossa into the bladder, thereby optimizing visualization. The rest of the resection proceeds similarly to the former technique by starting anteriorly and resecting the lateral lobes, followed by the apex.
After completion of the resection portion of the procedure, all prostatic chips should be evacuated. As mentioned above, the Ellik evacu-ator and similar devices allow this to be done efficiently. It is imperative that prostatic chips be removed because those that go undetected may occlude the urethral catheter postoperatively and interfere with bladder irrigation, possibly necessitating reexploration. Following complete evacuation, all prostate tissue should be collected and sent to the pathologist for histologic evaluation to rule out the presence of occult prostate cancer.
Finally, once the prostate tissue has been completely evacuated from the bladder, hemostasis should be achieved. The level of hemostasis obtained before completion of the procedure will vary among individual surgeons and individual patients. In general, smaller prostates tend to
bleed less and larger prostates more. Some surgeons are more comfortable than others with greater amounts of bleeding. In all situations, however, arterial bleeding must be stopped because catheter placement
and drainage will generally not provide satisfactory hemostasis. The prostatic fossa should be examined carefully, and bleeding sites should be cauterized with either the resection loop or rollerball electrode (Fig. 13). Ideally, cessation of the irrigation should allow reasonable visualization of the prostatic fossa. If any bleeding persists, further cauterization should occur, recognizing that bleeding from venous sinuses deep to the surgical capsule may be difficult or even impossible to stop. When hemostasis is thought to be sufficient, the resectoscope should be removed and a three-way urethral catheter should be inserted. Occasionally, because of an undermining of the bladder neck, this is difficult. In these situations, a catheter guide should be used to ensure that the balloon is not inadvertently inflated in the prostatic fossa. Following inflation of the balloon, irrigation of the catheter should reveal at most a pink-tinged effluent. If bright red blood is obtained on irrigation, the catheter should be removed and the prostatic fossa reexamined with the resectoscope for additional sites of bleeding, particularly arterial sites.
Once adequate hemostasis has been obtained, with confirmation by placement of the urethral catheter and drainage as indicated above, the three-way urethral catheter should be connected to continuous irrigation, if necessary. Gentle traction on the catheter, maintained by attaching it to the leg with tape or other specifically designed devices, can prevent entrance of prostatic fossa blood into the bladder and allow for slower irrigation rates. The patient is then transported to the post-anesthesia recovery unit.
If used, continuous bladder irrigation should be performed until the effluent is essentially clear. Time on catheter traction should be minimized because it may promote ischemia of the bladder neck and subsequent contracture formation. Furthermore, it could also mask significant bleeding in the prostatic fossa. Therefore, traction should be released before determining whether or not continuous irrigation can be discontinued. When the urine is clear without traction and continuous irrigation, the catheter is removed, the patient is given a trial of void, and if successful, is discharged home. Most patients require at least 1 to 2 d of hospitalization; however, some patients can be discharged following 23 h or less. Occasionally, patients are unable to void following catheter removal. This can be a result of persistent obstruction, edema of the prostatic urethra, retained prostatic tissue, or unrecognized detrusor dysfunction as a cause for urinary retention. If a retained prostatic chip is suspected, evacuation with cystoscopy if often required. On the other hand, the remaining causes of postoperative urinary retention are usually managed by re-inserting the urethral catheter or instituting clean intermittent catheterization. In the former case, the catheter can be removed at a later date and another trial of void performed. In the latter case, the patient can be discharged with instructions to carry out clean intermittent catheterization and is told to continue this procedure until postvoid residual urine measurements decrease to an acceptable level.
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