Editing Transurethral resection of the prostate

{{redirect|TURP|other uses|Turp (disambiguation){{!}}Turp}}
{{short description|Surgical procedure to perform a prostatectomy}}
{{Infobox medical intervention |
  Name        = Transurethral resection of the prostate |
  Image       = Nodular hyperplasia of the prostate.jpg |
  Caption     = [[Micrograph]] of a transurethral resection of the prostate (TURP) specimen, showing BPH (nodular hyperplasia of the prostate) – left-of-center in image. [[H&E stain]]. |
  ICD10       = |
  ICD9        = {{ICD9proc|60.29}} |
  MeshID      = D020728 |
  MedlinePlus = 002996 |
  synonyms  = TURP|
}}

'''Transurethral resection of the prostate''' (commonly known as a '''TURP''', plural '''TURPs''', and rarely as a '''transurethral prostatic resection''', '''TUPR''') is a [[urology|urological]] operation. It is used to treat [[benign prostatic hyperplasia]] (BPH). As the name indicates, it is performed by visualising the [[prostate]] through the [[urethra]] and removing tissue by [[electrocautery]] or sharp dissection. It has been the standard treatment for BPH for many years, but recently alternative, minimally invasive techniques have become available.<ref>{{cite journal | vauthors = Rassweiler J, Teber D, Kuntz R, Hofmann R | title = Complications of transurethral resection of the prostate (TURP)--incidence, management, and prevention | journal = European Urology | volume = 50 | issue = 5 | pages = 969–79; discussion 980 | date = November 2006 | pmid = 16469429 | doi = 10.1016/j.eururo.2005.12.042 }}</ref> This procedure is done with spinal or general anaesthetic. A triple lumen [[catheter]] is inserted through the urethra to irrigate and drain the bladder after the surgical procedure is complete. The outcome is considered excellent for 80–90% of BPH patients. The procedure carries minimal risk for [[erectile dysfunction]], moderate risk for bleeding, and a large risk for [[retrograde ejaculation]].<ref>{{Cite web|url=https://www.nhs.uk/conditions/transurethral-resection-of-the-prostate-turp/risks/|title=Transurethral resection of the prostate (TURP) – Risks|date=2017-10-24|website=nhs.uk|language=en|access-date=2020-03-05}}</ref>

== Indications ==
BPH is normally initially treated medically through [[alpha blocker|alpha]] [[Receptor antagonists|antagonists]] such as [[tamsulosin]], or [[5-alpha-reductase inhibitor]]s such as [[finasteride]] and [[dutasteride]]. If medical treatment does not reduce a patient's urinary symptoms, a TURP may be considered following a careful examination of the prostate or bladder through a [[cystoscope]]. If TURP is contraindicated, a urologist may consider a simple [[prostatectomy]], in and out catheters, or a supra-pubic catheter to help a patient void urine effectively.<ref>{{Cite journal | vauthors = Collins MA, Terris MK | veditors = Talavera F, Noble MJ |url= https://emedicine.medscape.com/article/449781-overview|title=Transurethral Resection of the Prostate: Overview, Treatment & Management, Post-Procedure|date=October 25, 2021| journal = EMedicine }}</ref>  As the medical management of BPH improves, the number of TURPs has been decreasing.{{cn|date=February 2022}}





==Types of TURP==
{{Medical citations needed|section|date=September 2020}}
[[File:Rtu.jpg|thumb|Urologist with a rigid cystoscope inserted into the urethra]]
Traditionally, a [[Cystoscopy|cystoscope]] (a "resectoscope") has been used to perform TURP. The scope is passed through the [[urethra]] to the prostate where surrounding prostate tissue can then be excised. There are two types of modalities:
* '''Monopolar TURP:''' A monopolar device utilizing a wire loop with electric current flowing in one direction (thus monopolar) can be used to excise tissue via the resectoscope. A grounding ESU pad and irrigation by a non conducting fluid is required to prevent this current from disturbing surrounding tissues. This fluid (usually [[glycine]]) can cause damage to surrounding tissue after prolonged exposure, resulting in TUR syndrome, so surgery time is limited.
* '''Bipolar TURP:''' This is a newer technique that uses bipolar current to remove the tissue. Bipolar TURP allows saline irrigation and eliminates the need for an ESU grounding pad thus preventing post-TURP [[hyponatremia]] (TUR syndrome) and reducing other complications. As a result, bipolar TURP is also not subject to the same surgical time constraints of conventional TURP.

A 2019 Cochrane review of 59 studies including 8924 men with BPH urinary symptoms found that bipolar and monopolar TURP probably result in comparable improvements in urinary symptoms, as well as in similar [[erectile function]], incidence of urinary incontinence and need for retreatment. Bipolar surgery likely reduces the risk of [[Transurethral resection of the prostate syndrome|TUR syndrome]] and the need for [[blood transfusion]].<ref>{{cite journal | vauthors = Alexander CE, Scullion MM, Omar MI, Yuan Y, Mamoulakis C, N'Dow JM, Chen C, Lam TB | display-authors = 6 | title = Bipolar versus monopolar transurethral resection of the prostate for lower urinary tract symptoms secondary to benign prostatic obstruction | journal = The Cochrane Database of Systematic Reviews | volume = 12 | pages = CD009629 | date = December 2019 | issue = 12 | pmid = 31792928 | pmc = 6953316 | doi = 10.1002/14651858.CD009629.pub4 }}</ref>

Another transurethral method utilizes laser energy to remove tissue. With laser prostate surgery a fiber optic cable pushed through the urethra is used to transmit lasers such as holmium-Nd:YAG high-powered "red" or potassium titanyl phosphate (KTP) "green" to vaporize the adenoma. More recently the KTP laser has been supplanted by a higher power laser source based on a lithium triborate crystal, though it is still commonly referred to as a "Greenlight" or KTP procedure. The specific advantages of utilizing laser energy rather than a traditional electrosurgical TURP is a decrease in the relative blood loss, elimination of the risk of post-TURP hyponatremia (TUR syndrome), the ability to treat larger glands, as well as treating patients who are actively being treated with anticoagulation therapy for unrelated diagnosis.

A further transurethal method utilizes a robotically-controlled waterjet to remove prostate tissue. Visualization is provided by a combination of cystoscope and transrectal ultrasound methods.  This procedure claims risk reduction advantages as a result of being heat free.

==Risks==
{{tone|section|date=August 2020}}
{{cleanup rewrite|section|date=August 2020}}
{{Technical|section|date=October 2020}}

Because of bleeding risks associated with the procedure, TURP is not considered safe for many patients with cardiac problems.{{According to whom|date=October 2020}}

Postoperative complications include:<ref>{{cite journal | vauthors = Rassweiler J, Teber D, Kuntz R, Hofmann R | title = Complications of transurethral resection of the prostate (TURP)--incidence, management, and prevention | journal = European Urology | volume = 50 | issue = 5 | pages = 969–79; discussion 980 | date = November 2006 | pmid = 16469429 | doi = 10.1016/j.eururo.2005.12.042 }}</ref>

=== Acute complications ===
* [[Bleeding]] (most common). Bleeding may be reduced by pre-treatment with an anti-androgen such as [[finasteride]]<ref name="Özdal_2005">{{cite journal | vauthors = Özdal OL, Özden C, Benli K, Gökkaya S, Bulut S, Memiş A | title = Effect of short-term finasteride therapy on peroperative bleeding in patients who were candidates for transurethral resection of the prostate (TUR-P): a randomized controlled study | journal = Prostate Cancer and Prostatic Diseases | volume = 8 | issue = 3 | pages = 215–218 | date = 2005 | pmid = 15999118 | doi = 10.1038/sj.pcan.4500818 | s2cid = 20871409 | doi-access = free }}</ref><ref>{{cite web | vauthors = Li MX, Tang ZY, Su J, etal | title = Effect of Finasteride on Perioperative and Postoperative Bleeding Following Transurethral Resection of Prostate | work = CNKI | url = http://en.cnki.com.cn/Article_en/CJFDTOTAL-SYYY200903092.htm }}</ref><ref>{{cite journal | vauthors = Rassweiler J, Teber D, Kuntz R, Hofmann R | title = Complications of transurethral resection of the prostate (TURP)--incidence, management, and prevention | journal = European Urology | volume = 50 | issue = 5 | pages = 969–79; discussion 980 | date = November 2006 | pmid = 16469429 | doi = 10.1016/j.eururo.2005.12.042 }}</ref> or [[flutamide]].{{Citation needed|date=May 2012}}
* [[Clot]] retention and clot colic. The blood released from the resected prostate may become stuck in the [[urethra]] and can cause pain and [[Urinary retention|urine retention]].
* Bladder wall injury, such as perforation (rare). Intraperitoneal bladder rupture will present with upper abdominal pain and referred pain to the shoulder. Extraperitoneal bladder rupture may present with inguinal, peri-umbilical pain.
* [[Transurethral resection of the prostate syndrome|TURP syndrome]]: [[Hyponatremia]] and [[water intoxication]] caused by an overload of fluid absorption from the open prostatic sinusoids during the procedure.<ref>{{cite journal | vauthors = Jensen V | title = The TURP syndrome | journal = Canadian Journal of Anaesthesia | volume = 38 | issue = 1 | pages = 90–96 | date = January 1991 | pmid = 1989745 | doi = 10.1007/BF03009169 | doi-access = free }}</ref> This complication can lead to confusion, changes in mental status, vomiting, nausea, and even coma. To prevent TURP syndrome, the length of the procedure is limited to less than one hour in many centers, and the height of the container of irrigating solution above the surgical table – determining the hydrostatic pressure driving fluid into the prostatic veins and sinuses – is kept to a minimum.{{cn|date=October 2022}} The classic triad of TURP syndrome includes elevated systolic and diastolic blood pressures with increased pulse pressure, [[bradycardia]], and mental status changes (assuming an awake patient under regional anesthesia).<ref name = "Barash_2009">{{cite book | vauthors = Barash PG, Cullen BF, Stoelting RK, Cahalahan MK, Stock MC |title=Clinical Anesthesia |date=2009 |publisher=Wolters Kluwer/Lippincott Williams & Wilkins |location=Philadelphia |isbn=978-0-7817-8763-5 |edition=6th | pages = 1365–1368 }}</ref><
* The different types of irrigation fluids used for TURP each have specific disadvantages.<ref name="Barash_2009" /> [[Glycine]] irrigating solution may cause transient blindness. [[Distilled water]] has the highest risk for [[intravascular hemolysis]], [[hypervolemia]], and [[Water intoxication|dilutional hyponatremia.]] Balanced salt solutions (such as [[Saline (medicine)|normal saline]]) cause electrical current dispersion during TURP, but significantly reduce the risk of TURP syndrome.  [[Sorbitol]] and [[mannitol]] solutions may lead to [[hyperglycemia]] (sorbitol), intravascular fluid expansion with absorption (mannitol), and [[Diuresis|osmotic diuresis]] (sorbitol and mannitol).<ref name="Barash_2009" />

=== Chronic complications ===
In most cases, urinary incontinence and erectile dysfunction resolve on their own within 6 to 12 months post-TURP. Therefore, many doctors will postpone invasive treatment until a year after the surgery.
* [[Urinary incontinence]] – most commonly [[stress incontinence]] – due to injury of the external sphincter system, may be prevented by taking the [[verumontanum]] of the prostate as a [[distal]] limiting boundary during TURP. Initial management includes lifestyle changes, [[bladder training]], [[Kegel exercise|pelvic floor muscle training]], and using [[incontinence pad]]s. The current gold standard of management for persistent urinary incontinence after prostatectomy is the placement of an [[artificial urinary sphincter]].<ref>{{cite journal | vauthors = Suarez OA, McCammon KA | title = The Artificial Urinary Sphincter in the Management of Incontinence | journal = Urology | volume = 92 | pages = 14–19 | date = June 2016 | pmid = 26845050 | doi = 10.1016/j.urology.2016.01.016 | author-link2 = Kurt A. McCammon }}</ref> [[Stress incontinence#Slings|Male slings]] are an alternative for mild to moderate post-prostatectomy incontinence.<ref>{{cite journal | vauthors = Bauer RM, Gozzi C, Hübner W, Nitti VW, Novara G, Peterson A, Sandhu JS, Stief CG | display-authors = 6 | title = Contemporary management of postprostatectomy incontinence | journal = European Urology | volume = 59 | issue = 6 | pages = 985–996 | date = June 2011 | pmid = 21458914 | doi = 10.1016/j.eururo.2011.03.020 }}</ref><ref>{{cite journal | vauthors = Cordon BH, Singla N, Singla AK | title = Artificial urinary sphincters for male stress urinary incontinence: current perspectives | journal = Medical Devices: Evidence and Research| volume = 9 | issue = 9 | pages = 175–183 | date = 4 July 2016 | pmid = 27445509 | pmc = 4938139 | doi = 10.2147/MDER.S93637 | doi-access = free }}</ref>
* [[Retrograde ejaculation]] due to injury of the [[prostatic urethra]]. This is one of the most frequent complications of the procedure, occurring in about 65% of patients.<ref name="pmid24972732">{{cite journal | vauthors = Cornu JN, Ahyai S, Bachmann A, de la Rosette J, Gilling P, Gratzke C, McVary K, Novara G, Woo H, Madersbacher S | display-authors = 6 | title = A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update | journal = European Urology | volume = 67 | issue = 6 | pages = 1066–1096 | date = June 2015 | pmid = 24972732 | doi = 10.1016/j.eururo.2014.06.017 }}</ref>
* Bladder neck [[stenosis]].
* [[Erectile dysfunction]] may be seen in some patients, however, many have reported that erectile function improved after TURP.

Additionally, transurethral resection of the prostate is associated with a low risk of mortality.{{According to whom|date=October 2020}}

== Research ==
The UNBLOCS trial compared using TURP to the thulium laser transurethral vaporesection of the prostate (ThuVARP). Both methods led to similar improvements, number of complications and lengths of hospital stay. Both were effective as treatment but TURP resulted in a better [[Urine flow rate|urinary flow rate]].<ref>{{Cite journal |date=2021-02-17 |title=Laser surgery for an enlarged prostate is no more effective than standard surgery |url=https://evidence.nihr.ac.uk/alert/laser-surgery-for-an-enlarged-prostate-is-no-more-effective-than-standard-surgery/ |journal=NIHR Evidence |type=Plain English summary |language=en |publisher=National Institute for Health and Care Research |doi=10.3310/alert_44637|s2cid=241164315 |url-access=subscription }}</ref><ref>{{cite journal | vauthors = Worthington J, Lane JA, Taylor H, Young G, Noble SM, Abrams P, Ahern A, Brookes ST, Cotterill N, Johnson L, Khan R, Fernandez AM, Page T, Swami S, Hashim H | display-authors = 6 | title = Thulium laser transurethral vaporesection versus transurethral resection of the prostate for benign prostatic obstruction: the UNBLOCS RCT | journal = Health Technology Assessment | volume = 24 | issue = 41 | pages = 1–96 | date = September 2020 | pmid = 32901611 | pmc = 7520718 | doi = 10.3310/hta24410 }}</ref>

== See also ==
* [[Transurethral incision of the prostate]]
* [[GreenLight Laser Therapy|Transurethral greenlight laser therapy]]
* [[Prostate steam treatment|Transurethral steam treatment (Rezum)]]

== References ==
{{Reflist}}

== External links ==
* [http://emedicine.medscape.com/article/449781-overview#showall Medscape: Transurethral Resection of the Prostate]
{{Male genital procedures}}

[[Category:Male genital surgery]]
[[Category:Urologic surgery]]
[[Category:Prostatic procedures]]