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1. TURP Technique
Eko Indra Pradono

2. INTRODUCTION
• Transurethral resection of the
prostate (TURP) is a commonly
performed surgical treatment for
benign prostatic hyperplasia
• TURP surgically treat moderate- to-
severe LUTS in men with prostate
size of 30-80 mL

3. INDICATION
Strong Indications for Surgery
• Recurrent urinary retention
• Acute urinary retention
• Recurrent haematuria refractory to medical treatment with 5-alpha reductase
inhibitors
• Bladder stones
• Renal insufficiency.

4. INDICATION
Relative Indications
• Morphological changes in bladder or upper urinary tract secondary to bladder outlet
obstruction
• Constant and increasing postvoid residue (PVR) greater than 100 ml
• Recurrent urinary infection secondary to bladder outlet obstruction
• The final decision also depends on the patient’s willingness for surgery

5. Contraindications
Absolute :
- Active urinary tract infection
- Uncorrected coagulopathy
Relative :
- Large bladder stone (two-stage procedure, cystolitholapaxy and TURP)
- Anaesthetic contraindications
- Acute renal insufficiency secondary to bladder outlet obstruction

6. Pre-operative
• Stop any ‘bleeders drugs’
• Informed consent
• No shaving necessary
• Antibiotics

7. Operating Suite

8. The re-sterilizable funnel for the collection of
irrigation fluid (views showing its attachment b to the
operating table)

9. Positioning
POSITIONING

10. The Sets
• Resectoscope 24-Fr single-flow or 27-Fr/24- Fr
continuous-flow rotatable resectoscope with 12° or 0°
optics.
• Video camera with rotatable camera head
• HF resection electrodes: band electrode (preferred)
• Thin loop (optional for precision cuts) and roller
electrode (coagulation)
• 100-ml bladder syringe
• 20-Fr irrigation catheter
• Optional suprapubic catheter (12-Fr) for continuous
irrigation during resection
• Lubricant
• Electrolyte-free and sterile irrigation fluid, positioned at a
height of 50–60 cm above the pubic symphysis

11. TECHNIQUE

12. TURP Technique Principle
Do safety and efficiently
Work in low pressure
Achieve good hemostasis
Systematic approach of TURP

13. Main Steps of TURP
1. Identification of landmarks
2. Removal of most of adenoma
3. Bleeding control
4. Tidying up & removal of apical tissue
5. Catheter application

14. Urethrocystoscopy
• Verumontanum
• Kissing lobes
• Bladder neck
• Ureteral orifices
• Bladder trabeculation ; sacculation,
diverticula
• Bladder capacity

15. CUTTING
TECHNIQUE
Nesbit
Barnes
‘Like a canoe’
as wide and deep as the loop, as long as its travel

16. Varying depths of cut. Shallow (a), normal (b), and deep (c) cuts

18. Cuttingwithpredeterminedendpoint

19. TheCutwithPredeterminedStartingPoint

20. TheExtendedCut

21. RetrogradeCutting

22. EntrapmentCutting

23. HEMOSTATIC

24. • Smaller vessel may be
controlled by coagulating its
mouth
• Larger vessel is controlled by
applying the loop just to one
side of wall to seal the walls
together
• Perform hemostatic
procedure particularly in 2,
10, 5 and 10 o’clock
HEMOSTATIC
TECHNIQUE

25. CHIPS EVACUATION
Milo Ellik’s
• Get rid all the air
• Gently
• Inflow valve left open  ‘safety
valve’

26. Catheter Placement

27. TURP Methods
NesbitBarnes
Alcock &
Flocks
Mauermayer Blandy

28. Nesbit’s Method
• Start from 12 o’clock
• Lateral lobe will be resected from the top to the bottom
• Median lobe will be the last to resect

29. Nesbit’s Method

30. Nesbit’s Method

31. Alcock and Flocks’ Method
• Start from 9 and 3 o’clock
• Then, it depends on the situation

32. Mauermayer’s Method
• Alcock & Flocks’ modification
• Start from median lobe
• Then, resect 9 and 3 o’clock
• This method is recommended for
beginners and could be used for
large/small adenoma

33. Blandy
Identification of landmark
Resect middle lobe
Control the Flock Arteries and resect
lateral lobes

34. Barnes’ Method
• Start from median lobe
• Lateral lobe will be resected from the bottom to the top

35. Barnes’ Method

41. Post operative
• POD 0:
• Irrigation is running freely, is no darker than vin rose, and fully conscious
 send to wards
• POD 1 – 2: Early mobilization
• When the effluent is clear, little brownish blood  discontinue irrigation
• POD 3: Remove the catheter
Failure to void after removing the catheter:
• Uncomfortable
• Detrusor failure
• Insufficient tissue resection

42. Postoperative Care
• When the irrigation fluid becomes clear  catheter traction can be
released up to 4 h
• Continue irrigation of the bladder overnight
• If there is no complication  catheter can be removed 2 days POD
• Common complications: bleeding (macroscopic haematuria),
undermining the bladder neck, inadvertent peritoneal puncture,
capsular perforation
• Going Home POD 3

43. Complications
INTRA OP EARLY POST OP POST OP
Haemorrhage
Urethral injury
Bladder Injury
TUR syndrome
Mortality
Urinary Retention
Clot retention
UTI
Epididymo-orchitis
Septicaemia
DVT
PE
Retrograde Ejaculation
Secondary Haemorrhage
Erectile Dysfunction
Bladder neck stenosis
Urethral Stricture
Incontinence
Re-operation
Mortality

44. Reference
• Mauermayer, Wolfgang. Transurethral surgery. Springer Science & Business Media,
2012.
• John P. Blandy. Transurethral Resection. 2005
• Hohenfellner. Manual Endourology for Residents. 2005
• Marszalek M, et al. Transurethral Resection of the Prostate. EAU. 2019
• Hamid ARAH. TUR-P techniques. Presented on Simulative Training on Basic
Endourology ICTEC. 2018 Mar 8

45. THANK YOU