Surgical Treatment (TURP)

Indications For Surgery

• Surgery is usually indicated for obstructive or irritative symptoms of BPH that may not be relieved by medical management.
• A significant decrease in urine flow rate (<10cc/sec) or significant residual volumes (>100 - 150cc). This includes men with acute or chronic urinary retention, who will usually have a catheter in situ due to inability to pass urine.
• Recurrent urinary infections, bladder stones, haematuria.
• BPH is a disease that is progressive. Surgery is advised before complications arise.

Transurethral Resection Of The Prostate (TURP)

• The procedure usually takes less than an hour to perform and is usually performed under spinal anaesthesia. General anaesthesia may be used, if necessary.
• The patient is placed in the lithotomy position (with the legs elevated and spread).
• The bladder is filled with a saline solution.
• A cystoscope, which is a special telescope, is inserted into the penis and passes up the urethra, until it reaches the prostatic portion of the urethra.
• A special wire loop, called the resectoscope, is then inserted into the urethra. The resectoscope has electrical current passing through the loop that acts to cut the prostate tissue. The resectoscope shaves off "chips" of the enlarged prostate gland. The shaving starts at the margin of the bladder outlet and progresses into the prostatic part of the urethra up to the verumontanum with careful preservation of the external urinary sphincter.
• The ejaculatory ducts that open on the verumontanum and carry spermatic secretions are preserved. The voluntary external sphincter lies below the verumontanum. This sphincter will also be preserved, to allow control of urination.
• At the end of the procedure, the bladder outlet remains open and unobstructed. The bladder is irrigated to flush out any blood clots and prostatic chips. The prostate chips are sent for histopathology to check for prostate cancer.
• A catheter is left in place to drain the bladder and a continuous bladder washout with saline fluids.
• The Gyrus bipolar TURP is a new technique which uses saline fluid irrigation which is safer and reduces risk of TUR syndrome.

Gyrus TURP

A newer technique currently being used by Urology Associates. This involves bipolar diathermy resection of the prostate which has the proven advantages of :-

1. Allowing the use of normal saline irrigation fluid during the prostate surgery, which is safer than the glycine irrigation used with standard TURP.
   This allows safer resection of larger prostates which may otherwise require open surgery, and avoids the TUR syndrome associated with glycine irrigation.
2. There is less bleeding both during and after the TURP surgery.
   Gyrus bipolar TURP forms a safer seal of bleeders than standard TURP.
3. It allows superficial vaporisation of the prostatic tissue, while shaving away prostate chips, thus leaving less tissue debris at the end of the procedure. Prostate tissue is available for histopathology testing.

Urology Associates now routinely use this technique for prostate resection, backed up by several meta-analyses which prove the advantages of Bipolar TURP with saline.

Postoperative Care (TURP)

• Blood tinged urine may be present at the end of the procedure. A continouous bladder washout with saline fluids is routine after TURP surgery to prevent blood clots forming in the bladder.
• The catheter is kept in until the urine clears, which is usually 24 - 48 hours. Patients usually stay in the hospital during this time.
• Occasionally, patients who are unable to void postop TURP, will be discharged home with the bladder catheter attached to a leg bag, which is subsequently removed at Suite 51 by our Urology nurse.
• Men do not usually experience much pain after the operation and can usually commence walking and driving as soon as they leave hospital.
• Antibiotics are usually given for a several days to a week after the operation to prevent infection.
• Blood Thinning Medications (Anticoagulants) are routinely stopped prior to a TURP, and restarted after TURP, on the advice of the Urologist and Cardiologist. Please ask for specific instructions about any anticoagulation medications.
• About 8% of patients will require a repeat TURP or opening of a scar or stricture (narrowing) during the remainder of their lives. This will depend on the initial size of the prostate, the natural healing process and the skill of the surgeon performing TURP.

After The Operation

• You will be closely monitored for the first few hours.
• If you have had a spinal anaesthetic, your legs are likely to feel numb or heavy for up to 4 hours.
• If you have had a general anaesthetic you may experience drowsiness, which can take some hours to wear off.
• You will be staying in bed for the rest of the day.
• You will have a catheter draining urine from the bladder and from this a continuous bladder wash out will flush out any blood.
• You will have an intravenous drip to provide you with fluids until the next day.
• You can eat and drink when you feel up to it.
• Normal medications will resume (except for Aspirin, Warfarin and anti inflammatory drugs). In some cases it is necessary to have antibiotics.
• Your nurse will assist you with washing, cleaning your teeth and any other personal care needs you may have.
• Minimal discomfort is expected after this operation, so any pain or discomfort should be discussed with your nurse so she can assess the situation.

Post Operative Day 1

• The day following your surgery your bladder wash out system and intravenous drip will be removed after consultation with your surgeon.
• The surgeon may ask for you to have a follow-up blood test.
• Your catheter may be removed depending on the colour of your urine.
• You may shower sitting down with supervision; pay special attention to cleaning around the tip of your penis.
• At this stage it is very important to drink approximately 2-3 litres of fluid a day to flush any blood or debris out of your bladder. If you have been advised for medical reasons not to drink a lot of fluid, please discuss this with your surgeon.
• Gentle walking around the ward is encouraged, this helps prevent complications.

Post Operative Day 2

• Depending on the colour of your urine and after review by your surgeon, your catheter will be removed by your nurse.
• It may be some time before you pass urine but when you do you will find several things:
• • Some burning or stinging
  • Urgency - needing to pass urine in a hurry
  • Frequency - needing to pass urine often
  • Incontinence - loss of control of urine associated with needing to pass urine in a hurry and often
  • Blood in the urine and passing of small blood clots
  • These are normal and will gradually settle down.
• You will be instructed to pass urine into a jug in the bathroom so the nurses can measure volumes and observe the colour.
• You may eat and drink as normal. A high fibre diet is advised to prevent constipation and avoid straining.
• Continue drinking 2-3 litres a day.
• You may shower independently and be as mobile as possible.

Post Operative Day 3

• If you are passing urine without difficulty and following review by your surgeon, you may go home.
  Some people may need to stay for another day but this will be discussed at the time.
• Management of ongoing urgency, frequency and incontinence of urine will be discussed prior to discharge.
• If you were taking any aspirin or anti-inflammatory drugs before your surgery, you will need to ask your surgeon when these can be recommenced.
• Discharge time is usually between 8.00am - 10.00am, but other arrangements can be discussed with your nurse if required.
• You will be given written information regarding new medication and follow up appointments.