Surgery Ill SURGERY ILLUSTRATED MAY nd HARTUNG Surgicl Atls Trnsurethrl resection of the prostte Florin My nd Rudolf Hrtung Deprtment of Urology, Klinikum rechts der Isr, Technische Universität München, Munich, Germny INTRODUCTION Through improvements in endoscopic instruments nd new high-frequency technology, TURP hs ecome n incresingly sfe procedure. Modified opticl devices nd video cmers enle experts nd residents to tech nd lern this technique like ny open procedure. Innovtive technologicl pproches include the cogulting intermittent cutting (Storz Medicl AG, Tägerwilen, Switzerlnd), the Instnt Response (Vlleyl, Boulder, CO), s well s the Dry-Cut technology (ERBE Elektromedizin GmH, Tüingen, Germny) tht comine cutting nd cogulting effects, llowing lood-spring cut nd significntly lowering lood loss nd moridity. Bipolr resection (Olympus, Tokyo, Jpn) represents further step to reduce the periopertive moridity of TURP. Vrious techniques hve een suggested for the systemtic removl of the denomtous tissue, ll sed on the principle tht the resection should e done stepwise. As leeding is the surgeon s mjor prolem, leding to loss of visul field nd disorienttion, it is impertive tht resection nd hemostsis should oth e completed in one re of the foss efore the next re is tckled. In the following rticle, the resection technique used t our institution is descried, nd ws initilly developed y Muermyer [1] nd susequently improved y the uthors [2]. INDICATION AND PATIENT SELECTION The correct indiction sed on clinicl symptoms nd relile ojective findings in the evlution of enign prosttic ostruction is still crucilly importnt for the long-term outcome. The risk of needing surgery for BPH increses with ge nd with the degree of clinicl symptoms t seline. Evluting symptom severity with symptom score is n importnt prt of the initil ssessment of the ptient. It is helpful in llocting tretment, nd oth predicting nd monitoring the response to therpy. Among ll different vlidted symptom score systems, the use of the IPSS is recommended. Although symptoms constitute the primry reson for recommending intervention, there re some solute indictions for surgicl tretment. Contemporry guidelines on BPH recommend surgery, rther thn ny of the other ville tretment options, in ny of the following conditions secondry to BPH [3]: refrctory urinry retention; recurrent UTI; recurrent hemturi refrctory to medicl tretment (finsteride); renl insufficiency; nd ldder stones. ANAESTHETIC CONSIDERATIONS AND PREOPERATIVE MANAGEMENT TURP cn e done under ll forms of regionl nesthesi, usully under generl or spinl nesthetic. Occsionlly, high-risk ptients require n interdisciplinry preopertive evlution to determine whether surgery cn e sfe. In cse of cute urinry retention, JOURNAL COMPILATION 2006 BJU INTERNATIONAL 98, 921 934 doi:10.1111/j.1464-410x.2006.06474.x 921
MAY nd HARTUNG suprpuic cystostomy should e inserted insted of urethrl ctheter, to void postopertive urethrl strictures. There is no need for routine preopertive urethrogrm unless there is cler suspicion of urethrl stricture. EQUIPMENT Modern high-frequency genertor, e.g. Autocon II 400 (Storz). 24 F resectoscope (constnt-flow resectoscope optionl for low pressure irrigtion). 0 lens (preferred y the uthors), 15 nd 30 lenses optionl. Otis urethrotome. Sterile, luricnt nesthetic jelly, conductive for electricl current. 20 F three-wy ctheter with either 50, 80 or 100 ml lloon cpcity. PATIENT POSITIONING AND IRRIGATION Lithotomy position. Sterile, pyrogen-free, non-hemolytic irrigtion solution (e.g. 1.5% glycine), the reservoir 60 70 cm ove the level of the symphysis (irrigtion pressure 60 70 cmh 2 O). Suprpuic trocr optionl for lowpressure irrigtion. SURGICAL TECHNIQUE INSERTION OF THE INSTRUMENT The metl sheth of the resectoscope is generously luricted with conductive jelly. An oturtor is plced through the sheth to provide smooth, lunt tip for esy pssge through the foss nviculris nd nterior urethr. The instrument should gently enter the urethr under its own weight, to mke the introduction s trumtic s possile. If there is resistnce to the pssge, ny force should e strictly voided. If the metus is nrrow, or there is stricture of the metus or the nterior urethr, lind internl urethrotomy up to 30 F with the Otis urethrotome is recommended. Further pssge is either lind with the oturtor inside the sheth or under direct vision using the 0 endoscope nd the video cmer. Gentleness nd cre re essentil to void urethrl strictures. Vi the video monitor the ulr urethr, the externl sphincter nd the prosttic urethr with the prosttic loes nd the verumontnum re inspected. Then systemtic evlution of the entire ldder surfce using ngulr opticl lenses is mndtory. BLADDER CALCULI If there re ldder clculi, lithotripsy is conducted efore TURP egins. Lrger stones cn e frgmented using n ultrsonic lithotripter or Lithoclst (mechnicl impctor), nd smller stones or frgments re crushed y stone punch until smll enough to e evcuted. Only fter ensuring tht the ldder mucos is free should the jws of stone punch e screwed together to crush the stone inside the ldder cvity. Crushing should never e ttempted without cler view, to void ldder dmge. The frgments re irrigted from the ldder with n Ellick evcutor. 922 JOURNAL COMPILATION 2006 BJU INTERNATIONAL
SURGERY ILLUSTRATED Figure 1 The externl sphincter is esily identifile t the level of the memrnous urethr y the hydrulic sphincter test. With n empty ldder, the tue etween the irrigtion reservoir nd the resectoscope is repetedly squeezed together nd reopened. These rpid chnges in the hydrosttic pressure led to contrction of the externl sphincter. Contrcting circulr mucosl folds rditing from nrrow lumen re pprent. The externl sphincter should e repetedly identified during resection, especilly when resecting the picl denom, to void dmge to this re. JOURNAL COMPILATION 2006 BJU INTERNATIONAL 923
MAY nd HARTUNG Figure 2 Resection usully egins t the proximl portion of the middle loe t the 6 o clock position. The resectoscope is plced just proximl to the verumontnum nd the resection crried out lwys controlling the endpoint of ech cut. It is necessry to e wre of the position of the verumontnum to see tht the lower prt of the cut is not extending elow this level, otherwise dmge to the sphincter mechnism my occur. 924 JOURNAL COMPILATION 2006 BJU INTERNATIONAL
SURGERY ILLUSTRATED Figure 3 Resection should e crried out with long cuts towrds the verumontnum. A lrge overhnging middle loe should e resected with specil cre. It is importnt to mke short cuts in the region of the ldder neck, s the surgeon might not e wre tht he or she is cutting down the trigone towrds the ureteric orifices. Susequent cuts re mde down to the peripherl tissue, which is recognized s rther firous structure compred with the grnulr ppernce of the prosttic denom. JOURNAL COMPILATION 2006 BJU INTERNATIONAL 925
MAY nd HARTUNG Figure 4 After resecting the middle loe from the 7 to 5 o clock positions, the resection is crried to oth sides of the verumontnum with prticulr cre. When this stge is completed, the surgeon should pull the resectoscope into the urethr, just distl to the verumontnum, nd note tht there is no flling nd ostructing tissue. During this stge, the surgeon must lwys e wre of the position of the externl sphincter to void ny sphincter lesion. 926 JOURNAL COMPILATION 2006 BJU INTERNATIONAL
SURGERY ILLUSTRATED Figure 5 Resection in smller denoms is now crried directly to the side loe. It depends on the preference of the surgeon whether to egin on the left nd then resect the other side, or vice vers. JOURNAL COMPILATION 2006 BJU INTERNATIONAL 927
MAY nd HARTUNG Figure 6 Cre must e tken to mke susequent long cuts next to ech other to chieve smooth surfce. First the proximl prts of the prosttic denom must e completely removed (), then the remining picl portion is reseceted with prticulr cre (). 928 JOURNAL COMPILATION 2006 BJU INTERNATIONAL
SURGERY ILLUSTRATED Figure 7 Very lrge side loes should e resected using modified technique. After removing the middle loe nd the re next to the verumontnum, oth side loes re cleved t the 9 nd 3 o clock positions. The groove should e extended towrds the peripherl firous prosttic tissue. This speeds the susequent resection of the loes nd fcilittes control of leeding y cogulting rteril rnches entering the prostte in this re. After removing the distl prts etween the 9 nd 6 o clock nd 3 nd 6 o clock positions, resection is crried on to the ventrl prts of the side loe etween the 3 nd 12 o clock nd 9 nd 12 o clock positions, respectively, in the sme mnner. Intrvesicl view JOURNAL COMPILATION 2006 BJU INTERNATIONAL 929
MAY nd HARTUNG Figure 8 The pex is resected with controlled short cuts next to ech other. Beginning next to the verumontnum, the whole pex is resected clockwise. The sheth of the resectoscope should e fixed very crefully nd one short cut follows the other. Complete control of the full excursion of the loop is mndtory to restrict ech cut to the remining picl tissue. Intrvesicl view Intrvesicl view 930 JOURNAL COMPILATION 2006 BJU INTERNATIONAL
SURGERY ILLUSTRATED Figure 9 After thoroughly resecting the denom, the remining picl tissue ecomes quite moile, similr to folding doors. These remnnts cn e more esily identified using reduced irrigtion. Identifying the remining moile picl tissue is esy, moving the instrument slowly ck nd forth in the picl re, requiring n empty ldder nd full irrigting fluid pressure. JOURNAL COMPILATION 2006 BJU INTERNATIONAL 931
MAY nd HARTUNG Figure 10 The remining tissue is resected y controlled short cuts to crete round or ovl picl outlet ( ). Prticulr cre must e tken t the pex, nd the verumontnum is n importnt lndmrk. Resection should not e stopped in ll denoms next to the verumontnum; in lrge glnds resection cn e extended to more distl endpoint. The hydrulic sphincter test should e repeted occsionlly to clerly identify the externl sphincter during this stge of resection. INCISION OF THE INTERNAL SPHINCTER Intrvesicl view Especilly fter resecting smll denoms nd in ptients with deep vesicl recess, ilterl incisions of the internl sphincter re re done t the 5 nd 7 o clock positions, to reduce the incidence of postopertive ldder neck contrcture. After incising, the ldder neck usully springs prt. An dequte depth of the incision is indicted y visuliztion of fires from the prosttic cpsule or even protrusion of periprosttic ft. HAEMOSTASIS Hemostsis is chieved y spot-cogulting with the resection loop. Irrigtion cn e reduced to identify even smll vessels. After the resection, ll chips must e evcuted from the ldder with ul syringe, s they cn occlude the ctheter fter surgery. The resectoscope is then reinserted to control the whole resection re for ny residul leeding. Return irrigtion should e cler or light pink t the end of the opertion. Intrvesicl view 932 JOURNAL COMPILATION 2006 BJU INTERNATIONAL
SURGERY ILLUSTRATED Figure 11 We prefer to plce 20 F three-wy ctheter for dringe; it should lwys e inserted with the finger in the rectum, pressing the prosttic tissue up to void dmge to the ldder neck nd trigone. The lloon is inflted to 20 ml (ctheter with mximum lloon volume of 50 ml) or 30 ml (mximum lloon volume of 80 or 100 ml), the ctheter is withdrwn in the prosttic foss (Fig. 11). The finl lloon infltion filling the prosttic foss should correspond to the weight of the resected tissue plus 20 ml (Fig. 11). Ctheter fixtion in the prosttic foss is mintined y mull ndge t the top of the penis. If persistent leeding occurs tht does not cler esily with continuous irrigtion fter correctly plcing the ctheter, the resectoscope should e reinserted efore leving the opertive suite nd the prosttic foss reviewed for leeding vessels. JOURNAL COMPILATION 2006 BJU INTERNATIONAL 933
MAY nd HARTUNG POSTOPERATIVE CARE Ctheter fixtion in the prosttic foss is stopped fter 3 h y removing the mull ndge. Occsionlly, if persistent venous leeding occurs tht does not cler esily with continuous irrigtion, the ctheter cn e replced on gentle trction for few hours. After finl creful irrigtion with ul syringe, the urethrl ctheter is removed fter 24 48 h of continuous irrigtion. INTRAOPERATIVE COMPLICATIONS Intropertive prolems include mssive hemorrhge nd sorption of irrignt (TUR syndrome). Bleeding cn lwys e controlled endoscopiclly y electrocogultion, s descried. A continuous hemostsis during resection is especilly importnt to prevent sorption of irrignt. Other complictions tht do not necessrily terminte the opertion include perfortion of the prosttic cpsule nd leeding from lrger veins (sinus venosus). Intropertive lood loss must e estimted crefully y the surgeon nd the nesthesiologist notified of ny prolems. Diuretics cn e given during surgery to prevent TUR syndrome. POSTOPERATIVE COMPLICATIONS Using the TURP s descried there should e no stress incontinence. The incidence of urethrl stricture is highly vrile in peerreviewed reports, t 0.5 6.3% [4]. Retrogrde ejcultion resulting from destruction of the ldder neck is common finding, occurring in 65 70% of ptients fter TURP. There is no consensus on the effect of TURP on erectile function. The only rndomized controlled tril compring TURP to wtchful witing reported identicl rtes of erectile dysfunction in oth rms [5]. REFERENCES 1 Muermyer W. Allgemeine und spezielle Opertionslehre. Bd. VIII, Trnsurethrle Opertionen. Berlin, Heidelerg, New York: Springer Verlg, 1981 2 Hrtung R, Leyh H, Lipi C, Fstenmeier K, Br M. Cogulting intermittent cutting. Improved high-frequency surgery in trnsurethrl prosttectomy. Eur Urol 2001; 39: 676 81 3 de l Rosette JJ, Aliviztos G, Mderscher S et l. Europen Assocition of Urology. EAU Guidelines on enign prosttic hyperplsi (BPH). Eur Urol 2001; 40: 256 63 4 Turo A, Vicentini C, Renzetti R, Mino L. Invsive nd minimlly invsive tretment modlities for lower urinry trct symptoms: wht re the relevnt differences in rndomised controlled trils? Eur Urol 2000; 38 (Suppl. 1): 7 17 5 Wsson JH, Red DJ, Bruskewitz RC, Elinson J, Keller AM, Henderson WG. A comprison of trnsurethrl surgery with wtchful witing for moderte symptoms of enign prosttic hyperplsi. The Veterns Affirs Coopertive Study Group on Trnsurethrl Resection of the Prostte. New Engl J Med 1995; 332: 75 9 Correspondence: Rudolf Hrtung, Urologische Klinik und Poliklinik, Klinikum rechts der Isr, Technische Universität München, Ismningerstr. 22, 81675 Munich, Germny. e-mil: r.hrtung@lrz.tu-muenchen.de r.hrtung@lrz.tu-muenchen.de 934 JOURNAL COMPILATION 2006 BJU INTERNATIONAL