Current use of transurethral resection of the prostate

In the decade of the 1980s, TURP was the most common operation in the Medicare population after cataract surgery. TURP rates decreased in the 1990s from between 229.2 to 268.3 procedures per 100,000 population (1980–1991) to 131.3 per 100,000 in 1994. This 50% decrease in TURP procedures did not likely represent a decreased prevalence of BPH but rather an increased use of medical treatments and MIST procedures (eg, laser, microwave). Following a 10-year decrease in the number of BPH procedures, the total number of BPH procedures in Medicare patients increased 44% from 88,868 in 1999 to 127,786 in 2005. The number of MIST procedures for BPH increased 529% during this time. In fact, by 2005, TURP represented only 39% of all BPH procedures compared with 81% in 1999. A 2005 survey of a cohort of urologists demonstrated that 59% said they offer both MIST and TURP. Ten percent of urologists polled would offer only MIST while 29% would only offer TURP. Multiple forces, including economic, may have driven this trend toward increased MIST usage over TURP, but there has been no clear evidence that MIST is more efficacious or cost-effective than traditional TURP.

Indications for transurethral resection of the prostate

The traditional absolute indications for TURP were acute urinary retention, bladder stones, postrenal azotemia secondary to bladder outlet obstruction, and intractable gross hematuria from an enlarged adenoma. The clinical literature and the Medical Therapy of Prostate Symptoms Study demonstrated the success of alpha blockers and 5-alpha-reductase inhibitors for improving urinary symptoms and preventing clinical progression of BPH. The above medications, microwave therapy, and interstitial laser therapy have all been used successfully in patients with acute urinary retention. Hematuria secondary to BPH has been successfully managed with the 5-alpha-reductase inhibitor finasteride. Even acute urinary retention has been managed successfully with alpha blockers. The modern-day indications for TURP have not changed. However, it would seem that the operation is reserved for those indications for which medical therapy has failed. One could even argue that TURP is reserved for cases in which not only has medical therapy failed for the above indications, but at least one attempt at office-based MIST has also failed. A 2004 retrospective case-note analysis of TURP in 1990 compared with TURP in 2000 in the United Kingdom noted an increase in patients undergoing TURP for urinary retention in the 2000 group (33% to 58%). The same study also noted lower urinary tract symptoms as an indication for TURP fell from 65% to 42% in the year 2000. A comprehensive review of 15 international guidelines for the treatment of BPH listed the indications for TURP that ranged from “complicated BPH,” “moderate to severe symptoms,” International Prostate Symptom Scores of 20 to 35, or any of the “absolute indications” listed above.

Indications for transurethral resection of the prostate

The traditional absolute indications for TURP were acute urinary retention, bladder stones, postrenal azotemia secondary to bladder outlet obstruction, and intractable gross hematuria from an enlarged adenoma. The clinical literature and the Medical Therapy of Prostate Symptoms Study demonstrated the success of alpha blockers and 5-alpha-reductase inhibitors for improving urinary symptoms and preventing clinical progression of BPH. The above medications, microwave therapy, and interstitial laser therapy have all been used successfully in patients with acute urinary retention. Hematuria secondary to BPH has been successfully managed with the 5-alpha-reductase inhibitor finasteride. Even acute urinary retention has been managed successfully with alpha blockers. The modern-day indications for TURP have not changed. However, it would seem that the operation is reserved for those indications for which medical therapy has failed. One could even argue that TURP is reserved for cases in which not only has medical therapy failed for the above indications, but at least one attempt at office-based MIST has also failed. A 2004 retrospective case-note analysis of TURP in 1990 compared with TURP in 2000 in the United Kingdom noted an increase in patients undergoing TURP for urinary retention in the 2000 group (33% to 58%). The same study also noted lower urinary tract symptoms as an indication for TURP fell from 65% to 42% in the year 2000. A comprehensive review of 15 international guidelines for the treatment of BPH listed the indications for TURP that ranged from “complicated BPH,” “moderate to severe symptoms,” International Prostate Symptom Scores of 20 to 35, or any of the “absolute indications” listed above.

Preoperative evaluation of transurethral resection of the prostate

All patients should be suitable candidates for general anesthesia. Particular vigilance should be paid to the patient’s cardiac status. A recent analysis of Australian postoperative deaths over a 3-year period demonstrated that the largest number of deaths after surgery was among patients having TURP. Although the death rate was only 0.05% (9 of 17,044 patients), most of the deaths were secondary to acute myocardial infarction. We do not require formal upper tract imaging before standard TURP. A bowel preparation is not used. A single perioperative dose of cephalosporin antibiotic decreases the perioperative TURP infection rate. We typically use antibiotics until the Foley catheter is removed. It is necessary to select an anesthesiologist who is aware of the unique situations TURP can present both intraoperatively and in the perioperative period. Spinal anesthesia is the most frequently employed anesthetic for TURP in the United States. Blood loss is reduced in TURP with regional anesthesia compared with general anesthesia. More importantly, the signs of water intoxication should be more readily recognized and abdominal/shoulder pain may signify inadvertent bladder perforation.

Modern transurethral resection of the prostate technique

The standard TURP technique has not changed. The patient is placed in dorsal lithotomy position with his buttocks near the end of the table. After a sterile preparation, the urethra is dilated with sounds to one size larger than the resectoscope sheath. To prevent false passages from overzealous dilation, we usually only dilate the anterior urethra and then pass the scope through the prostatic urethra under direct vision. Lack of attention at this initial step may lead to an inadvertent anterior or posterior false passage ( Fig. 1 ). The basic resection technique may vary according to the size or configuration of the prostate but should be based on an orderly plan. Some advocate resecting ventral tissue first so that the adenomatous tissue drops down, allowing the surgeon to resect from the top downward rather than from the floor upward. However, some surgeons have suggested resecting the floor tissue initially to improve water flow during the resection ( Fig. 2 ). When dissecting around the floor of the prostate, care should be taken not to undermine the bladder neck. If possible, avoid angling the resectoscope downwards to prevent inadvertent undermining of the bladder neck. Resection should continue to the capsule. A trough should be resected that identifies capsule and all other resection planes on that level. No resection should take place distal to the veromontanum and the ureteral orifices should be identified and not violated.

Passage of resectoscope sheath into the bladder. ( A ) The resectoscope sheath is passed into the urethra. ( B ) At the level of the veromontanum, the scope must take a sharp angle upward to enter the bladder. ( C ) Failure to make the appropriate upward turn can lead to significant false-passage formation. ( From Mayo Clinic Florida, Jacksonville, Florida; with permission.)

( Left ) Before resection. ( Right ) After resection. Transurethral resection of prostate floor. In cases with elevated median lobes, the floor of the prostate is often resected first. This improves water flow during the procedure. Care must be taken not to undermine the bladder neck during this step. ( From Mayo Clinic Florida, Jacksonville, Florida; with permission.)

Numerous irrigating fluids are available to the urologist performing TURP. Because of the dangers of using water (absorption leads to hemolysis, shock, and renal failure), most urologists today use nonhemolytic irrigating solutions, such as 1.5% glycine, 3% sorbitol, or 3% mannitol. These solutions are inexpensive and maintain a degree of the transparency of water. It should be noted that these solutions are not isotonic but merely nonhemolytic and can have some deleterious effects if excessive amounts are absorbed.

Transurethral resection syndrome is characterized by hypertension, bradycardia, visual disturbances, mental confusion, and nausea. Untreated transurethral resection syndrome can have serious consequences, such as cerebral or bronchial edema. If capsular perforation is suspected, the procedure should be terminated. Serum sodium measurements should be monitored frequently and corrected as needed. Generous use of furosemide intravenously corrects sodium levels. We routinely give 20 mg intravenous furosemide following large resections or suspected capsular perforation. Infusion of hypertonic sodium chloride may be needed in certain instances but should be used carefully.

Various attempts have been made to improve the modern TURP technique by altering instrumentation. Most changes have focused on improving hemostasis to provide superior intraoperative visualization and thereby safety. Numerous changes in resection loop thickness and shape as well as roller balls with various surface areas have all been used to improve hemostasis and visualization. As stated by Issa, irrespective of the shape, thickness, and configuration of TURP loops, hemostasis is determined by the balance of wattage, power, voltage, surface contact, and exposure time to tissue. Excellent results may be achieved with cutting energy of 100 W set to medium “blend” with 30 W of coagulation power. Slowing down the resection through tissue provides longer exposure time and surface contact to improve hemostasis.

It was initially thought that transurethral vaporization of prostate tissue was as effective as TURP while providing the benefit of decreased blood loss that is inherent to techniques that do not actually resect tissue. However, despite its introduction in the mid-1990s, there is a dearth of long-term studies with transurethral vaporization of prostate tissue, so its long-term efficacy is not well documented. Most investigators agree that the technique has limited use for intravesical extension of tissue near the apex.

Efficacy of modern transurethral resection of the prostate

TURP is the only transurethral procedure for BPH that has durable follow-up in the literature ranging from 8 to 22 years. Wasson and colleagues noted the 5-year reoperation rate after TURP to be approximately 5% in a review of 188,161 Medicare beneficiaries. Nationwide analysis of 20,671 men undergoing TURP in Austria noted the incidence of secondary TURP to be 5.8% at 5 years and 7.4% at 8 years. A study of 577 patients with 10-year follow-up revealed a 6% incidence of re-resection. The studies demonstrate the long-term efficacy of TURP. What is not defined is whether these repeat resections are required because of tissue regrowth or because of inadequate initial resection. What is also not defined is how many patients with recurrent symptoms after TURP forgo repeat operation in favor of adjuvant medical therapy.

Madersbacher and colleagues analyzed 29 randomized controlled trials comparing TURP to less-invasive procedures. The mean decrease in urinary symptom scores after TURP in the 29 studies was 70.6%. Symptom scores decreased by half in 58% of the patients. The same investigators also noted that the mean increase in maximum flow in the TURP groups was 125%. The analysis of the randomized trials also noted that 93% of patients following TURP have a maximum flow greater than 15 mL/s, suggesting an absence of bladder-outlet obstruction in a majority of patients. A United Kingdom urodynamic study from 2005 evaluated 217 patients a mean 13.0 years following TURP. They noted a sustained improvement in a majority of urodynamic parameters over the follow-up period. Long-term symptomatic failure and decreased flow rate were associated with detrusor underactivity as opposed to repeat obstruction. A meta-analysis compared urodynamic efficacy on various forms of bladder-outlet obstruction therapies and found TURP to be better than all modalities except open prostatectomy. It should be noted that most urodynamic measurements improve after surgery but they often do not correlate with lower urinary tract symptoms as measured by symptom scores.

O’Sullivan and colleagues demonstrated that, in addition to improvement in American Urology Association score, patients undergoing TURP had improvement in quality-of-life indices, depression rating scales, and pain indices at 1 month and 3 months postoperatively compared with preoperatively. Although the importance of quality of life and patient satisfaction are acknowledged, long-term data of these measures following bladder-outlet surgery are rare. A 2008 prospective cohort study of 280 consecutive patients following TURP in the years 1993 and 1994 were noted to have consistent and statistically significant improvement in urinary bother and quality of life at 6 months, 6 years, and 12 years of follow-up. At 6 months, 6 years, and 12 years following treatment, 8.4%, 20.8%, and 13.3%, respectively, were truly dissatisfied with their outcome following TURP.

Morbidity/mortality of modern transurethral resection of the prostate

Improved antibiotics, perioperative care, and instrumentation have greatly improved the mortality/morbidity of the modern TURP. A 2008 prospective evaluation of 10,654 TURPs performed in the years 2002 and 2003 revealed a 0.10% mortality rate, a 2.9% blood transfusion rate, and a 1.4% risk of transurethral resection syndrome. The overall morbidity in the study was 11.1% with urinary retention (5.8%) and urinary tract infection (3.6%) being the most common complications. Mebust and colleagues noted a mortality rate of 0.2% in 3885 patients undergoing TURP. The investigators correlated postoperative morbidity with resection time over 90 minutes, gland size over 45 g, acute urinary retention, and age over 80 years. Both of these studies provide insight into the improved morbidity and mortality rates seen with TURP in the 1960s and 1970s. The published mortality rates were 1.3% to 2.5% in those earlier experiences. Myocardial infarction and septic complications were more prevalent in the earlier studies compared with the modern experience listed above. What is also becoming clear is that mortality and morbidity of the modern TURP have improved even though patients currently getting TURP are older and have more medical comorbidities than those in earlier TURP studies.

A comparison of TURP over 17 years at a single center revealed a significant decrease in mortality (0.5% to 0%), transfusion rates (20.3% to 3.8%), and postoperative urinary tract infections (37.1% to 6.2%) in TURPs performed from 1997 to 2004 versus those performed from 1987 to 1997. Examination of 577 patients 10 years following TURP demonstrated reoperation for bladder neck contracture to be 2.4% and for urethral stricture to be 1.9%. The data from most cohort studies do suggest that patient morbidity decreases with increased urologist caseload volume although the most recent studies examining caseload volumes and TURP are not consistent with the definition of high-volume surgeons. One study notes improved outcomes with high-volume surgeons (more than 55 cases annually), while the earlier study defines improved outcomes with surgeon volume over 29 cases per year. Incontinence following TURP for benign conditions has a noted incidence in the literature of 1% to 5%. Improved visualization of the modern TURP may limit accidental resection distal to the urethral sphincter and thereby decrease incontinence. Consequently, most surgeons today find urinary incontinence following TURP in the obstructed patient to be a rare event. Obstructed patients undergoing TURP following brachytherapy or radiation are at a much higher risk of urinary incontinence than the general population. Kollmeier and colleagues noted an 18% post-TURP incontinence rate in 38 patients following brachytherapy. The investigators noted that the incontinence rate increased if the procedure was performed more than 2 years following seed implantation.

Systematic reviews note that approximately 75% of patients experience retrograde ejaculation following TURP. Given the current medical-legal environment, it is highly prudent to clearly alert any patient undergoing an outlet procedure, especially TURP, of the high risk of retrograde ejaculation and the consequences for fertility and sexual functioning. Most studies dealing with sexual dysfunction following TURP lack a standard definition of sexual dysfunction. The most recent study examining erectile dysfunction following TURP concluded that the incidence of newly reported erectile dysfunction following TURP was 12% in 629 TURP procedures at 6-month follow-up. The investigators found that diabetes mellitus and observed intraoperative capsular perforation were statistical predictors of postoperative erectile dysfunction. The study is notable for using the validated International Index of Erectile Function Instrument (IEFF-5) to measure erectile dysfunction following TURP. A 2007 study of 1014 patients following TURP in Switzerland between January 2000 and January 2005 noted that 3 of 4 patients undergoing TURP remain sexually active and the surgery itself had no influence on this ratio.