Intraoperative Bleeding

The prostate is a highly vascular organ and some degree of bleeding is expected during any surgical approach to BPH. Hemorrhage is the main cause of surgical vision loss, which can lead to prolonged operative time, capsular perforation, fluid absorption, and excessive use of irrigation fluids, all of which are risk factors for transurethral resection syndrome (TURS) and sepsis. The risk of bleeding increases with larger prostate size, longer operative time, increasing tissue resected, general anesthesia, positive urine culture, indwelling catheter, and the use of antiplatelet therapy or anticoagulation. While several older series have demonstrated less blood loss with regional anesthesia, the mechanism for this is not well understood. The rate of blood transfusion following endoscopic BPH surgery is low and depends on the type of procedure performed (see Table 26.1 ). A meta-analysis comparing HoLEP and TURP found a lower transfusion rate in those undergoing prostatic enucleation.

Several steps can be taken preoperatively to decrease the risk of excess bleeding and potential blood transfusion. First, platelet count and coagulation panel are obtained and any abnormalities addressed preoperatively. Assessing for preoperative anemia will aid in counseling the patient on the risk of perioperative blood transfusion. A type and screen should be sent preoperatively to facilitate timely transfusion if necessary. Second, if the patient is taking antiplatelet therapy or anticoagulants, a discussion must take place with his primary care provider (PCP) as to whether it is safe to hold and/or bridge these medications. If the procedure must be done on antiplatelet or anticoagulants, then laser and bipolar techniques have been shown to provide the best hemostasis. Men undergoing PVP and bTURP have less bleeding, need for blood transfusions, and postoperative clot retention compared to those undergoing monopolar TURP in some series. Preoperatively, the patient is carefully counseled on the risk of bleeding. If the risk of bleeding is high due to medical comorbidities and/or the need to remain on blood thinners, medical therapy or management with catheterization may be more prudent. The use of 5α-reductase inhibitors prior to TURP has not consistently been shown to reduce blood loss or the need for transfusion, and thus this approach in an attempt to reduce perioperative bleeding is not recommended by the AUA guidelines.

Intraoperative techniques to prevent bleeding complications include avoiding capsular perforation and entry into venous sinuses where bleeding is difficult to control. Additionally, controlling bleeding vessels as they are encountered and aiming for a shorter operative time will result in less blood loss. If electrocautery is being used some advocate first fulgurating all of the friable mucosa with the button electrode to prevent bleeding from this friable tissue prior to loop resection of adenoma.

When significant intraoperative bleeding is encountered, the best way to obtain hemostasis, decrease blood loss, and avoid the need for a staged procedure is to advance the scope into the bladder and slowly pull it back into the prostatic fossa to identify the bleeding vessels and fulgurate or laser. If arterial bleeding is directed straight at the lens, an optimal angle to visualize the bleeding stump must be found to achieve hemostasis. Simultaneous digital rectal manipulation may help to expose vessels over the prostate floor. Venous bleeding is usually dark red and may be found in areas of capsular perforation. Small venous bleeders can be controlled with direct pressure from a three-way Foley catheter. Excessive coagulation is avoided in areas of capsular perforation to decrease the risk of aggravating this defect. Hemostasis is assessed at the end of the case with the bladder minimally full, irrigation flow off, and patient normotensive. Hypotension at the end of the procedure can mask arterial bleeding. Blood work can be performed intraoperatively as well to monitor for anemia if there is concern for significant blood loss.

Transurethral Resection Syndrome

TURS is a serious and potentially life-threatening complication of mTURP as one of the requirements of monopolar resection is the use of hypotonic fluid, typically glycine or sorbitol. TURS occurs with early perforation of the capsule and venous sinuses resulting in the absorption of hypotonic solution and a dilutional hyponatremia. These patients can be confused and disoriented and may experience nausea, vomiting, seizures, blurred vision, bradycardia, and hypotension. The incidence of mild-to-moderate TURS has decreased during the last few decades from 0.5–8% to 0–1.4% secondary to the use of saline irrigant with laser and bipolar techniques. Several meta-analyses of monopolar and bipolar resection have reported a significant decrease in TURS, with no patient developing TURS following bTURP.

TURS may be seen from as early as 15 minutes after the start of resection and up to 24 hours postoperatively. Hyponatremia can be very severe and result in significant morbidity and even mortality at a rate up to 50% when the sodium concentration drops below 120 mEq/L. Hyponatremia and hypoosmolality result in acute cerebral or bronchial edema secondary to large absorption of fluid and expansion of extracellular fluid. TURS most commonly occurs when 1.5% glycine is used as the irrigant fluid during mTURPs. This irrigant is nonconductive, nonhemolytic, and hypotonic with an osmolality of about 220 mmol/L irrigant. Excessive absorption of glycine solution results in TURS in 5–20% of mTURPs.

The best way to prevent TURS is to avoid endoscopic procedures using hypotonic solutions. If mTURP must be performed, then it is important to avoid deep resections and extravasation, which will increase the amount of fluid absorbed. If a venous sinus is opened or capsular perforation has occurred, hemostasis is achieved and the procedure aborted. When performing mTURP, even if capsular perforation or major venous sinuses are not encountered, the procedure is generally limited to 60–90 minutes in order to minimize the amount of fluid absorbed and decrease the risk of TURS. Therefore, if a larger prostate is approached with TURP, the patient is counseled that he may need to be treated in a staged manner and if the prostate is very large, a simple prostatectomy can be considered if mTURP is the only endoscopic surgical option. During the procedure, anesthesia may periodically send blood gases to check electrolytes and the procedure may be aborted if the serum sodium is low.

Besides limiting operative time and selecting patients with smaller prostate volumes, another method to prevent TURS includes minimizing irrigant fluid pressure. Techniques that have been described to decrease fluid pressure at the time of TURP include the standard use of a continuous flow resectoscope that allows drainage out of the scope (Iglesias), suprapubic fluid evacuation using a Reuter’s trocar or via suprapubic catheterization, and intermittent drainage of irrigant fluid. Irrigation fluid is always kept on gravity and not placed under pressure. The urologist can also attempt to monitor fluid absorption. This is done by calculating the difference between irrigation fluid used and the volume of fluid that drains from the resectoscope and into the collection bag. Accurate measurement of fluid absorption may be challenging given the mixture of blood and urine and the inevitable spillage of irrigant fluid onto the floor.

It is prudent to monitor the serum sodium postoperatively for TURS for all men undergoing endoscopic BPH treatments when hypotonic fluids such as glycine are used. If serum sodium is only mildly decreased (about 5 mEq/L) on postoperative lab work and the patient is asymptomatic, then no specific therapy is indicated. If renal function is normal, then the hyponatremia will correct with the natural excretion of excess water. If there is concern for pulmonary congestion, a loop diuretic can be given. The management of patients with symptomatic hyponatremia is variable depending on the severity. For patients with severe hyponatremia, low serum osmolality, and/or cerebral edema, hypertonic saline can be considered. Hypertonic solution reduces cerebral edema and replaces urinary sodium losses that result from the osmotic diuresis that occurs with glycine, mannitol, or sorbitol. This osmotic diuresis perpetuates hyponatremia and results in hypotension secondary to hypovolemia.

Hypertonic saline can initially be administered as a 100-mL bolus of 3% saline, giving 51 mEq of sodium, which will increase serum sodium by 2–3 mEq/L. If symptoms do not improve, 100-mL boluses can be given one to two more times in 10-minute intervals. Given the acute onset and short duration of hyponatremia in patients following endoscopic BPH surgery, rapid correction of hyponatremia and hypoosmolality is generally safe, unlike in those with chronic hyponatremia who are at risk for central pontine demyelination with rapid correction of serum sodium. For patients with hyponatremia and normal serum osmolality, hypertonic saline has not been shown to be beneficial and actually there have been reports of delayed osmotic demyelination. Hemodialysis (HD) can rapidly correct hyponatremia, osmotic abnormalities, and volume status. HD may be preferred in those with chronic kidney disease, marked hyponatremia without significant osmolality abnormalities, or those with severe neurologic symptoms. Ultimately, nephrology should be consulted as well to assist with the management of symptomatic electrolyte abnormalities, fluid overload, or refractory hyponatremia.

False Urethral Passage

A false urethral passage is an iatrogenic defect somewhere along the course of the urethra. This complication probably occurs more frequently than is reported in the literature. One series reported this complication in 0.5% of men undergoing endoscopic surgery for BPH. This can happen with blind urethral catheter insertion and cystoscope placement. At the time of endoscopic BPH treatment, a false urethral passage may occur if the resectoscope is inserted haphazardly and if inadequate lubrication is used. To avoid this complication, place the scope under direct vision using a visual obturator instead of a blind obturator, especially if any resistance is noted with an attempt at blind insertion. On insertion of the scope, if narrowing or stricturing of the urethral lumen is noted, then the scope can be passed over a catheter or a wire to ensure that it follows the natural lumen and does not go off-course creating a false urethral passage. Additionally, urethral dilation can be performed prior to scope placement to facilitate successful passage. The Foley catheter may be left in place for a few more days postoperatively in the setting of a significant false passage.

Injury to the Bladder or Ureteral Orifices

Injury to the bladder or ureteral orifices is rare but can occur if one is not careful. Using a surgical table with radiologic capabilities is ideal to allow for cystogram and ureteral stent placement if these complications do occur. Bladder perforation has been described for all types of endoscopic BPH procedures and can occur from perforation with the scope, with Ellik evacuation of prostate chips, laser application or transurethral resection beyond the prostate, and at the time of morcellation with enucleation procedures. Several case reports describe bladder rupture at the time of TURP related to the ignition of flammable gases created by electrical activity during resection.

On initial cystourethroscopy, landmarks are identified including the ureteral orifices. Generally, the ureteral orifices are located between 4–5 o’clock (patient’s left side) and 7–8 o’clock (patient’s right side) over the trigonal ridge on endoscopic evaluation. Sometimes, when there is significant intravesical tissue – especially from a large median lobe – identification of the ureteral orifices may be very difficult and even impossible. Additionally, on initial inspection the bladder is characterized not only with regard to the presence of trabeculation, stones, diverticula, and mucosal lesions, but also bladder capacity as morcellating in a smaller capacity bladder can be more challenging and potentially dangerous.

Injury to the ureteral orifice has been reported to occur in 0–2% of patients undergoing various endoscopic procedures for BPH. Some have suggested suprapubic cystoscopy to help identify the ureteral orifices in some cases, though this technique is rarely employed today. Knowledge of ureteral orifice location relative to the bladder neck will decrease the risk of injury. The ureteral orifices will be closer to the bladder neck when the bladder is underfilled. Familiarity with equipment is essential to avoid complications including where a side-firing laser will penetrate tissue to avoid accidently firing past the bladder neck and causing bladder or ureteral orifice injury. Depending on the degree of ureteral orifice injury, placement of a ureteral stent may be considered to prevent stenosis. If there is concern the ureteral orifice was injured, but the opening cannot be identified, the patient can be monitored for symptoms of obstruction postoperatively. Imaging with renal ultrasound or computerized tomography may be necessary. If hydronephrosis is present, placement of a ureteral stent, nephrostomy tube, or nephroureteral stent can relieve the obstruction. Agents such as indigo carmine, methylene blue, and fluorescein can be used to dye the urine and aid with localization of the ureteral orifice if it is not completely obstructed at the time of cystoscopy.

Bladder injury can also occur if resection, ablation, or vaporization is performed within the bladder. This may happen if visualization is obscured secondary to bleeding, inadequate irrigation, and/or broken equipment. If hemostasis is adequate and visualization is poor, check the irrigation flow and equipment. The irrigant bags can be raised to increase the flow of gravitational irrigation. Sometimes, the outflow port of the continuous flow resectoscope can be obstructed with clot, which will limit the inflow of irrigant. This can usually be fixed by flushing the outflow port.

With enucleation procedures, removal of prostatic tissue is achieved through morcellation. Morcellator injury of the bladder occurs when engagement of the bladder with the morcellator blades is not recognized. Sometimes the bladder mucosa is just engaged by the suction mechanism of the morcellator and not the blades themselves. Superficial bladder mucosal injuries without perforation have been reported in 0.7–5% of cases and bladder perforation in 0–1.5% of cases. Anecdotally, the risk of morcellation injury increases with poor visualization, large adenoma in a small capacity bladder, inadequate anesthesia resulting in patient motion during morcellation, and surgeon inexperience. In order to decrease the risk of morcellator injury, it is recommended that both ports of the resectoscope be used as “inflow” ports with irrigation fluid running continuously through both. This allows for adequate distension of the bladder for safe morcellation. If visualization is poor secondary to bleeding, some describe leaving the adenoma in the bladder and coming back 1–2 days later to morcellate when there is better visibility and the tissue is less firm. Some advocate for morcellating the enucleated adenoma in the prostatic fossa to avoid bladder injury. Others recommend a “mushroom” technique where the prostatic lobes are enucleated but left attached at the bladder neck and then electroresected. This technique is not employed by most urologic surgeons performing HoLEP who have access to a tissue morcellator.

If the bladder becomes engaged in the blades of the morcellator, morcellation ceases. The morcellator is left in place, while the suction is relieved by opening the hinged gate of the roller ball. This will release the bladder from the morcellator blades. Next, examine the bladder carefully. If it was only engaged and not actually cut, proceed with morcellation, and take care to correct whatever caused the bladder to become engaged in the blades. If there is concern for bladder perforation, perform a cystogram on the table to assess for extravasation. If extraperitoneal injury occurred, obtain hemostasis, place a catheter, and abort the procedure. Come back in 1–2 weeks after the bladder has healed to complete the morcellation and or treatment of BPH. If an intraperitoneal bladder injury occurs, then immediate cystotomy repair is recommended. This is typically performed with exploratory laparotomy, though laparoscopic repairs have been reported. In the case of enucleation procedures, the remainder of the adenoma can be extracted from the bladder via the cystotomy prior to repair. A drain should be placed outside the bladder at the time of cystotomy repair.

Injury Beyond the Prostate

Endoscopic BPH procedures can all be complicated by capsular perforation, undermining of the bladder neck, and rarely though potentially morbid, rectal injury. As previously described, capsular perforation ( Fig. 26.1 ) can result in increased fluid absorption and TUR syndrome and potentially erectile dysfunction (ED) secondary to neurovascular bundle injury.

Capsular perforation. Small perforation in the prostatic capsule encircled.

In men with significant BPH, it is not uncommon to have prostatic adenoma protruding under the bladder neck and approaching the trigone. This adenoma must be carefully resected, enucleated, or vaporized to avoid undermining and/or perforation. Depending on the extent of undermining and/or perforation, there is the potential to injure the ureters as they insert into the bladder. If significant undermining of the trigone occurs, place the urethral catheter over a wire, otherwise it will likely preferentially pass into this defect, possibly worsening this injury. If the patient fails a voiding trial postoperatively, consider replacing the catheter cystoscopically over a wire, or at least using a coude catheter.

Rectal injury at the time of endoscopic BPH surgery is an incredibly rare but very serious and morbid complication. This can happen when the surgeon carries the treatment plane too far posteriorly. One French study reported their experience with four rectal perforations that occurred at the time of transrectal ultrasound-guided PVP of the prostate in two cases, TURP in one case, and TUIP in another in a series of 450 patients. Rectal injury was managed with either colostomy or primary closure. Ultimately two patients died from this complication and two others were doing well at 1-year follow-up. History of prior BPH surgery, prostatitis, and/or prostatic/rectal abscesses may also increase the risk of this injury. If a rectal injury is noted, abort the procedure and consult a colorectal or general surgeon immediately. Bowel diversion and urinary diversion with suprapubic catheter drainage may be required.

Challenges to Initiating Treatment

At times there are barriers to treatment, which represent situations where the procedure cannot proceed due to some physical obstacle. These difficult situations include patients with phimosis, meatal stenosis, urethral stricture, intraoperative priaprism/penile erection, and excessive urethral length that prohibit passage of the resectoscope into the bladder. We will briefly discuss these situations and how to manage them to facilitate endoscopic BPH treatment.

Phimosis occurs in adult uncircumcised men most commonly when the distal prepuce skin develops scar tissue from chronic inflammation. The scarred tissue loses its elasticity and, if severe, may not allow for retraction of the foreskin beyond the glans of the penis, obscuring visualization of the urethral meatus and prohibiting scope placement. A thorough examination of the phallus and meatus prior to BPH surgery will identify this pathology preoperatively and allow for appropriate counseling and surgical preparation. A dorsal slit may be required to facilitate scope placement and BPH treatment. Circumcision at the time of the operation or on a date prior to BPH surgery may also be considered.

Meatal stenosis identified preoperatively allows for patient counseling for meatal dilation and meatotomy at the time of BPH surgery. Meatal dilation can be facilitated with Van Buren sounds. An Otis urethrotome is an excellent tool to perform meatotomy and will be discussed later in the section describing ways to prevent postoperative meatal stenosis. It is not uncommon to identify concurrent urethral stricture disease in those men with BPH who may have undergone urethral instrumentation for management and diagnosis of BPH. In some cases, the scope can be gently passed through the narrowed urethral segment over a wire or catheter so as to maintain the lumen. For a more robust stenosis, dilation over a wire with a balloon or sequential urethral dilators with filiforms and followers is usually effective.

Priapism is defined as a persistent erection of the penis not associated with sexual stimulation or desire. Penile erections at the time of transurethral surgery occur in 0.1% to 1% of cases. Transiently ceasing stimulation in some cases will return the phallus back to a flaccid state. These series all found that a single dose of phenylephrine given intracorporeally resulted in successful detumescence and allowed for completion of the endoscopic procedure. We recommend starting with a dose of 100 to 200 µg of phenylephrine.

Due to significant urethral and penile length, especially in the setting of very large and long prostates or malleable penile prostheses, a resectoscope may not reach the bladder. In these cases, an extra-long resectoscope can be used if available. Another option is to perform a perineal urethrostomy and insert the scope through this opening. A perineal urethrostomy can be created by passing a van Buren sound down to the bulbar urethra and incising down onto it. Once the van Buren sound is visible, place stay sutures in the urethra and pass the resectoscope into the bladder for BPH treatment. At the conclusion of the procedure, a Foley catheter is placed into the bladder and the perineal urethrostomy is closed in several layers over the catheter. The catheter is left indwelling for at least 1–2 weeks and a pericatheter retrograde urethrogram (RUG) or RUG following catheter removal is performed to ensure the urethra has healed.

Postoperative Bleeding

The rate of postoperative bleeding and hematuria following endoscopic BPH procedures is variable. Some degree of postoperative hematuria is expected following these procedures. However, significant bleeding and hematuria resulting in clot urinary retention and the need for hand irrigation, continuous bladder irrigation (CBI), blood transfusions, and surgical intervention with cystoscopy, clot evacuation, and fulguration is rare. The need for postoperative clot evacuation and fulguration for the management of clot retention ranges from 0% to 2.2%.

The best way to prevent postoperative bleeding is to obtain excellent hemostasis at the time of surgery. The prostatic fossa is evaluated at the end of the procedure with the bladder minimally full, irrigation fluid off, and any bleeders noted controlled. The patient should be normotensive at the time of evaluation, as hypotension can mask bleeding. Blood thinners and antiplatelet agents are held postoperatively when deemed safe by the patient’s PCP.

When significant postoperative bleeding is encountered, many patients can be managed conservatively with hand irrigation, CBI, and serial hemoglobin/hematocrit levels. CBI through a large bore three-way catheter (20–24Fr) helps to stop the bleeding secondary to pressure of the urethral catheter across the resection bed, contraction of the prostatic capsule and prostatic peripheral zone, and vasoconstriction.

Some have reported reduction in postoperative bleeding following TURP by placing the catheter on traction and effectively compressing the prostatic fossa, achieving hemostasis with pressure. Depending on the size of the prostate and amount of tissue resected, one must be sure an adequate amount of fluid is placed in the balloon to avoid migration into the fossa. Others describe digital compression via the rectum on the prostate to tamponade bleeding vessels. If hematuria does not improve with these conservative measures and/or there is significant acute blood loss anemia, evaluation of platelet count and coagulation panel are necessary. Some series have reported severe bleeding associated with disseminated intravascular coagulation following endoscopic BPH treatment. Some patients may require blood transfusions and observation in an intensive care unit with appropriate monitoring and supportive measures. If bleeding persists, ultimately cystoscopy with clot evacuation and fulguration may be required. Some case reports describe the rare need for angiography and embolization when bleeding is refractory to cystoscopy and fulguration.

Infection

Urinary tract infections (UTIs) can occur following any endoscopic urologic treatment and can manifest as a lower UTI, pyelonephritis, prostatitis, prostatic abscess, epididymitis, and/or urosepsis. Patients with indwelling urethral catheters, on intermittent catheterization, with incomplete bladder emptying, prior history of UTI, and diabetes mellitus are at higher risk for bacterial colonization and postoperative infections. One prospective study looking at patients without indwelling urethral catheters or on intermittent catheterization and sterile urine preoperatively reported a 26% rate of postoperative bacteriuria, which was associated with an operating time of greater than 52 minutes and disconnection of the closed urinary drainage system.

In order to prevent postoperative UTIs, a preoperative urine culture is sent and if positive the patient treated with a course of culture-specific antibiotics. The urine culture can be repeated to assure clearance of the bacteria. For patients with negative preoperative urine cultures, AUA guidelines recommend perioperative coverage with fluoroquinolones, trimethoprim-sulfamethoxazole, aminoglycoside ± ampicillin, first- or second-generation cephalosporins, or amoxicillin/clavulanate. However, given the black box warning placed on fluoroquinolones by the Food and Drug Administration in 2016 secondary to the risk of serious side effects, including debilitating tendon injuries, this antibiotic class should be used only when there are no other reasonable alternatives. A course of preoperative antibiotics can be considered in patients with an indwelling catheter or on intermittent catheterization and negative preoperative urine culture, as these patients are at high risk of being colonized with bacteria. It is our practice to change the catheter in the office and send urine for culture from the new catheter. A meta-analysis found that a short course of antibiotics may be superior compared to a single-dose regimen to prevent postoperative UTI. We often extend the course of postoperative antibiotics in patients with positive preoperative urine culture and/or urinary retention requiring an indwelling catheter or intermittent catheterization.

If the patient develops a UTI postoperatively, he can be managed with empiric broad-spectrum antibiotics followed by a course of culture-specific antibiotics once the urine culture finalizes. Given the black box warning of and rising antimicrobial resistance to fluoroquinolones, including in men with UTIs and prostatitis, alternate empiric antibiotic is preferred. If they are stable, reliable, and have minimal medical co-morbidities they can likely be managed on an outpatient basis. However, patients who are elderly often have significant medical comorbidities, and any signs of sepsis should prompt admission and close monitoring. A Foley catheter may be placed for maximal drainage if systemic infection is suspected.

Rarely an inflammation of the pubic bone can occur following endoscopic BPH surgery. Pubic symphysitis has been described in 0.297% of patients following TURP. This is thought to be secondary to infection, trauma, or impaired blood flow and possibly related to preoperative instrumentation and capsular perforation with sinus or fistula formation. Clinically, these patients complain of severe pain in the pubic region and groin with difficulty walking about 1 month following surgery. A minority present with fevers as well. On physical exam these patients are tender over the pubic bone and groin. MRI and CT imaging may be useful diagnostic adjuncts. Temporary catheterization, supportive measures, and a long course of antibiotics (at least 4 weeks) resulted in complete resolution of symptoms in one series of 12 patients.

Urinary Incontinence

Men may experience both stress urinary incontinence (SUI) and/or urge urinary incontinence (UUI) following endoscopic BPH procedures. Transient SUI is not uncommon following most bladder outlet obstruction (BOO) procedures. However, long-term SUI is related to sphincter injury at the time of BPH treatment or preexisting intrinsic sphincter deficiency, which is impossible to determine in the setting of prostatic obstruction. The rate of long-term SUI following endoscopic BPH surgery ranges from 0% to 2.2% (see Table 26.2 ). In order to prevent long-term SUI the urologist must be cognizant of the location of the external urethral sphincter at all times. The verumontanum ( Fig. 26.2 ) is used as a landmark of the external urinary sphincter, which is an omega-shaped rhabdosphincter. Resection or laser ablation/vaporization distal to the verumontanum should be avoided to prevent injury to the sphincter. For enucleation procedures the laser energy can be reduced when incising the mucosa near the apex of the prostate and blunt enucleation implemented preferentially in this region.

Verumontanum.

While they are not well studied in men undergoing prostate surgery for benign disease, Kegel exercises are known to improve postoperative urinary incontinence following radical prostatectomy. One series reported a continence rate of 95% versus 65% at 6 months follow-up after radical prostatectomy (p < 0.001) favoring those performing postoperative pelvic muscle floor training with Kegel exercises. Many urologists encourage their patients to perform Kegel exercises following endoscopic BPH surgery. For long-term SUI not responsive to pelvic muscle floor training, treatment options include penile compression devices, urethral sling, or artificial urethral sphincter. If the patient is not that bothered, he may elect to use incontinence pads. Cystoscopy is performed prior to surgical intervention to rule out strictures or bladder neck contracture (BNC) that would require treatment before incontinence surgery. If the patient’s incontinence is not clearly stress based on history and exam, urodynamic evaluation may be considered prior to surgical intervention.

Irritative lower urinary tract symptoms (LUTS) develop with BPH secondary to long-standing BOO causing detrusor hypertrophy, bladder-wall thickening, and bladder dysfunction. When the obstruction is relieved, some men can develop de novo UUI or exacerbation of preexisting UUI. Some series have found improvement in detrusor overactivity in 30–62% of men following TURP. If symptoms persist, medical therapy with anticholinergics, a β ₃ -adrenergic agonist, or botulinum toxin injections can be trialed.

Urethral Stricture

Urethral stricture can occur anywhere along the urethra following endoscopic management of BPH. The rate of postoperative urethral stricture ranges between 0% and 10% (see Table 26.2 ). Possible mechanisms leading to urethral stricture following BPH surgery include trauma from resectoscope insertion and monopolar current leakage secondary to insufficient insulation. While one series comparing bTURP versus mTURP noted a significantly higher rate of urethral strictures in the group of men with prostates greater than 70 g undergoing bTURP and contributed this to the differences between bipolar and monopolar energy, a meta-analysis comparing bTURP versus mTURP found no difference in the rate of postoperative urethral stricture. This meta-analysis actually found an association of larger prostate size and incidence of postoperative urethral stricture. The authors recommend that larger prostates be treated with HoLEP or simple prostatectomy to avoid this complication. Prostate size and surgical time for HoLEP have not been associated with risk of urethral stricture.

Several studies comparing the size of the resectoscope and postoperative urethral stricture have found an association with larger scope diameter and increased risk of urethral stricture. One series evaluating different scope diameters (24Fr vs 26Fr) reported a significantly higher rate of bulbar urethral strictures (11.4% vs 2.9%, p = 0.018) with the larger scope. A higher rate of urethral stricture has also been reported in men undergoing retreatment versus primary therapy for BPH (3.3% vs 1.5%, p = 0.043). Series localizing urethral stricture report that most occur in the bulbar urethra.

Some older series found that patients whose bladders were drained with a suprapubic tube (SPT) following TURP had a lower rate of urethral stricture compared to those drained transurethrally (17% vs 4%). However, in contemporary practice, SPTs are rarely placed at the time of endoscopic BPH treatment unless there is a high risk of permanent urinary retention postoperatively. Other older series also found lower postoperative rates of urethral stricture when prostate resection was performed through a perineal urethrostomy instead of transurethrally. Again – this is rarely performed today unless the resectoscope cannot reach the prostate. To prevent postoperative urethral stricture, great care must be taken to atraumatically insert the resectoscope at the time of surgery. Also, consideration should be given to selecting HoLEP for larger glands and using the smallest diameter resectoscope necessary to perform the procedure safely.

Urethral stricture may be suspected when a patient who initially reported significant improvement in voiding symptoms following a bladder outlet procedure begins to complain of obstructive urinary symptoms. He will likely have a reduction in his urinary flow rate and possibly an elevation in his post-void residual (PVR). Cystoscopy will identify the location and severity of the stricture, and if further characterization is necessary a RUG to help determine stricture length can be performed ( Fig. 26.3 ). Treatment options for postoperative urethral stricture include dilation with sequential or balloon dilators, direct vision internal urethrotomy, urethroplasty, or, in severe cases, perineal urethrostomy. Chronic catheterization is also an option.

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