Transurethral resection of the prostate (TURP) is a surgical procedure to remove parts of the prostate gland through the urethra, primarily indicated for benign prostatic hyperplasia with symptoms. The surgery is performed using a resectoscope and typically lasts 30-60 minutes, with potential complications such as TURP syndrome due to excessive irrigation fluid absorption. Early recognition and prompt treatment of complications are crucial, as the procedure is commonly performed on elderly patients with coexisting diseases.

1. TRANSURETHRAL RESECTION OF PROSTATE
PRESENTER-DR LALTHLAMUANA
DNB RESIDENT GENERAL SURGERY
DATE:21/5/24

2. INTRODUCTION
• A transurethral resection of the prostate (TURP) is surgery to remove parts of the prostate
gland through the penis.
• No incisions are needed.
• The surgeon reaches the prostate by putting an instrument into the end of the penis and through
the urethra
• This instrument is called a resectoscope it contains a lighted camera and valves that control
irrigating fluid.

3. INDICATION FOR TURP
• Benign prostatic hyperplasia with symptoms should be treated with
medication, until complications make surgery necessary:
• Recurrent urinary retention
• Recurrent urinary tract infection
• Recurrent hematuria
• Bladder stones
• Chronic kidney disease due to insufficient bladder emptying
• Large diverticula of the bladder

4. ANATOMY OF PROSTATE GLAND
• Pyramidal shaped organ
• Lies below urinary bladder & located infront of the rectum, posterior to the pubic symphysis & superior
to the perineal membrane
• Normal weight- 20 g
• Encircles urethera as it emerges from base of bladder
• It Is enclosed within a capsule composed of collagen, elasten & large no. of smooth muscles
Microscopic anatomy
Transitional.1 -
Central.2 -
periphery zone. 3

5. ANATOMY OF PROSTATE GLAND
:Transional zone
.This is the area surrounding the prostatic urethra-
.It is were the BPH occurs
:Central zone
It is the area surrounding the ejaculatory duct
:Peripheral zone
This zone covers the posterior & lateral zone aspects of the prostate. It is the most common area
affected by chronic prostatitis & adenocarcinoma

6. ANATOMY OF PROSTATE GLAND
• The Prostate Gland is rich in blood supply, mainly from inferior vesical artery
• The prostatic venous plexus drains into internal iliac vein & communicates with the vertebral
plexus, thereby allowing neoplastic spread to vertebrae
• The prostatic vessels & the autonomic innervations run between the layers of the lateral
prostatic fascia & the prostate
• Arteries and veins penetrate the capsule and branch inside the gland
• The venous sinuses adjacent to the capsule are particularly large

7. ANATOMY OF PROSTATE GLAND
• Nerve Supply
Sympathetic(T12-L2) input via the hypogastric nerve and parasympathetic(S2-S4) input via the
pelvic nerve.

8. SURGICAL PROCEDURE
TURP - performed by inserting a-
• Resectoscope through urethra
• Prostatic tissue is resected into pieces with an electrically powered cutting-
• Coagulating metal loop
• Pieces washed out by irrigating solution
• Prostatic capsule preserved-
• If violated,-
large amounts of irrigating fluid is absorbed into circulation, periprostatic
and retroperitoneal spaces

9. SURGICAL PROCEDURE
• Surgery normally takes 30-60 mins
• Depending on size of gland and experience of surgeon
• Position- Lithotomy position
• At the end of surgery- a 3-lumencatheter placed to allow continuous
irrigation using normal saline for upto 24 hours after surgery

10. BASIC SKILLS FOR TURP

35. IRRIGATION FLUIDS
Properties of ideal Irrigation Solution Transparent-
• Allows visualization.
• Isotonic.
• Electrically non conductive- allows diathermy to work.
• Non-hemolytic.
• Non metabolised.
• Non-toxic.
• Inexpensive.
• Easy to sterilize

36. IRRIGATION SOLUTION

37. COMPLICATIONS OF IRRIGATION FLUIDS
Glycine
• Normal plasma glycine levels are 13 to 17 mg/L
• Transient blindness is attributed to glycine toxicity
• Glycine is a major inhibitory-transmitter acting in the spinal cord and brain—stem
• Glycine also has been implicated in the myocardial depression and hemodynamic changes associated
with TURP syndrome
• Ammonia Toxicity-Absorption of glycine can result in CNS toxicity because-of oxidative bio-
transformation of glycine to ammonia

38. COMPLICATIONS OF IRRIGATION FLUIDS
Mannitol
-Rapidly expands blood volume and causes pulmonary edema in cardiac-patients
-Glucose Causes severe hyperglycemia in diabetic patients
Distilled Water is electrically inert and inexpensive and has excellent optical properties.
-Extremely Hypotonic.
-When absorbed into the circulation in large amounts plain water causes Hemolysis, Shock, and Renal
failure.
-Thus Isotonic fluids are preferred- these solutions are kept slightly
hypotonic to preserve transparency.

39. ANESTHETIC TECHNIQUES
• Spinal anesthesia is the most frequently used anesthetic for TURP and is believed to be
the technique of choice by many.
• A spinal anesthetic provides adequate anesthesia for the patient and good relaxation of the
pelvic floor and the perineum for the surgeon.
• General anesthesia may be necessary in patients who require ventilatory or
hemodynamic support, have a contraindication to regional anesthesia, or refuse regional
anesthesia.

41. COMPLICATION OF TURP

42. TURP SYNDROME
• TURP syndrome is a term applied to a constellation of symptoms and signs
caused primarily by excessive absorption of irrigating fluid.

43. MANIFESTATIONS OF THE TURP
Syndrome:
• Acute hypo-osmolality
• Acute hyponatremia
• Congestive heart failure
• Pulmonary edema
• Hypertension
• Hypotension
• Solute toxicity:
Hyperglycinaemia (glycine)
Hyperammonaemia (glycine)

44. INVESTIGATIONS REQUIRED FOR DIAGNOSIS
• Serum Sodium- levels below 120mEq/l,symptomatic
• ECG – QRS widening, ST segment elevation, T wave inversion
( below sodium levels of 115 mEq/l)
• Hyperammonemia ( by-product of glycine metabolism) 100 micromol /L can lead
to changes in consciousness.
• A blood ammonia level of 200 micromol /L is associated with coma and
convulsions

45. MANAGEMENT OF TURP SYNDROME
• Initial management follows the airway, breathing and circulation-
(ABC-guidelines)
• Awake patients need to be sedated and ventilated
• Anesthetised patients with mask airways may need intubation

46. MANAGEMENT OF TURP SYNDROME
• Initial management of fluid overload and hyponatraemia involves stopping IV fluids
• .Inj frusemide 40mg IV to promote diuresis
• Patients should be closely monitored on an intensive care unit
• Hypertonic saline solutions ( 3% or 5%( should be used to increase the serum sodium level by
about 1 mmol/l/hour (not exceding an ncrease of 20mmol/l in the first 48 hours of therapy
• Sodium levels should be checked every few hours.
• Therapy with-hypertonic saline should be stopped when symptoms cease or the sodium level
reaches 124-132mmol/l
• Rapid correction has been implicated as a cause of central pontine(myelinolysis, which causes
irreversible brain damage

47. • Convulsions should be acutely treated with a benzodiazepine (e.g.- 9
(. diazepam 5-10mg( or small doses of thiopentone (25 - 100mg
In the presence of intractable seizures, the sodium level may be
corrected more rapidly at a rate of up to 8-10mmol/l/hour for the first
4 hours of therapy

48. SUMMARY
TURP is a procedure carried out on a predominantly elderly population with a higher incidence of coexisting disease • -
TURP is a common operation performed in an elderly population with many co-
morbidities.
• - 7% sustain major complications and about 1% die perioperatively.
• - The main challenges are blood loss and TURP - Syndrome due to excessive
absorption of irrigation solution.
• TURP syndrome is a rare but potentially fatal complication
• Early recognition- and prompt treatment are essential
• Blood loss is difficult to quantify and may be significant.