transurethral prostatic resection (TURP)

Introduction

transurethral prostatic resection (TURP) is used as one of the surgical managements for benign prostatic hyperplasia (BPH)
depending upon the size of the prostate, newer laser modalities such as Holmium laser enucleation of the prostate (HOLEP) or transurethral laser resection/vaporisation of the prostate allow for lower post-operative morbidity
the benefits of TURP usually last at least 10 years before the prostatic tissue grows back - 10% will need a further procedure within 10 yrs
higher anaesthetic risk patients may require a spinal anaesthetic rather than a GA
the procedure generally takes 1-2hrs

stat broad spectrum antibiotics are usually given during surgery (eg. gentamicin and amoxicillin or cefasolin)
VTE prophylaxis
- TED stockings
- pneumatic calf and thigh intermittent compressors are used intra-operatively and often until IDC removed
- low dose enoxaparin during surgery and the following day
IV fluids until eating and drinking
post-op analgesia
- usually only requires regular qid paracetamol with non-steroidal anti-inflammatory drugs (NSAIDs)
- opiates are NOT required
post-op stool softeners to minimise straining at stool which will cause frank bleeding around catheter
- eg. coloxyl and senna tablets plus lactulose
chest infection prevention - deep breathing, early mobilisation, etc
3-way IDC with continuous bladder wash out for 1st 12 hours or so post-op until consistently clear
- once bladder washout ceased, IDC is retained and leg bag used
- transient bright bleeding around catheter following straining should settle and usually does not need Rx
- IDC is usually removed on 2nd day and a trial of void before discharge home with the aid of urinary alkalinisers and analgesics as above
- initial haematuria post IDC removal should settle rapidly but one should expect mod-severe dysuria and mild urine leakage necessitating wearing a continence pad for some time

regular qid paracetamol with non-steroidal anti-inflammatory drugs (NSAIDs)
regular urinary alkalinisers is sodium load not contra-indicated
regular stool softeners
drink plenty of water to help flush the bladder, reduce risks of UTI and also keep stool soft
avoid URTIs/influenza to avoid sneezing/coughing which may cause bleeding
expect to feel tired and drained for 1st 2 weeks
for 4 weeks:
- no heavy lifting (maximum 1-2kg ie. no grocery shopping), no sex, no straining which may cause bleeding
- ie. no gym/pilates/stairs but gentle level walking is encouraged
- most people require 3-4 weeks off work
- can drive when you can comfortably carry out an emergency stop - this may be at 1-2weeks but may take 4 weeks
haematuria and dysuria should improve over first few days
urge incontinence is possible as urgency is likely and thus proximity to toilets is an advantage
control of urine stream direction and speed may cause issues with toilet aim initially
dribbling post void is common and warrants wearing continence pad until it settles
expect episode of haematuria/scabs at around 1-3 weeks as scab sloughs off
expect the need to take it easy for 1st 8 weeks

risk is less than 1 in 1,000 and is usually related to post-op infection or cardiac complications

a rare complication in < 1% of cases due to excessive absorption of fluid used to wash the prostatic area during the procedure
causes nausea, bloating of abdomen, disorientation, dizziness, headache, bradycardia and can be life threatening with seizures, pulmonary oedema and coma

this may require re-insertion of a 3 way catheter and bladder washouts if clots and retention occur

this will require IDC to be replaced and occurs in 2%
it may require an IDC for some weeks until the bladder muscles regain normal function

this is common initially but should settle
persistent may require physiotherapy after 4 weeks to improve pelvic floor and bladder sphincter control

occurs in around 5-10%, but most have better erectile function than pre-op as no longer require BPH medications

this is the usual and expected outcome following TURP and occurs in 90%
this is due to damage to the nerves or muscles surrounding the neck of the bladder
this does not affect the sensation of orgasm but will affect fertility
it is sometimes possible to reduce the risk when performing a TURP by leaving prostate tissue near the urethra intact