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TURP


       M.A.Wadood Aref
TURP set
• Lens
• Resectoscope sheath 24-
  Fr or 27-Fr. (single flow
  or continous flow).
• HF resection electrodes:
  b...
Right position (lithotomy    Wrong position (extended
    position) (45 degrees)    lithotomy position) (90 degrees)


   ...
Sphincteric mechanism




The three components of the sphincter mechanism are:
 bladder neck
 intramural external sphinc...
The operation




                M.A.Wadood Aref
Basic skills for TURP




                        M.A.Wadood Aref
Cutting a chip
      1. lift the resectoscope
         to allow the loop to
         sink in
      2. keep it level as you...
Cutting a chip



• The shape of the chip       • Cutting the chip off
  is like a canoe. It is as     before the loop
   ...
Bleeding control



• Smaller vessel may be    • larger     vessel    is
  controlled         by      controlled          ...
Bleeding control




• When artery points straight at     • If localization of bleeding
  you all you can see is a red blu...
Prophylactic coagulation sites




5 o’clock       7 o’clock   10 o’clock

  Badenoch’s arteries

                        ...
Main Steps of TURP

1. Identification of landmarks.

2. Removal of most of adenoma (stepwise) by
   Mauermayer technique o...
Initial steps – Identification of bookmarks

• Lithotomy position.
• Blind trocar or visual
  insertion      of    the
  r...
Orientation




• The external sphincter is easily   • It is necessary to be aware of the position
  identifiable at the le...
Mauermayer Standard technique
             (1981)

• Resection in lobes (middle lobe & tissues lat.
  to veru. → Lt lobe→ ...
Endoscopic view                        Diagramatic view




• Resection begins at the proximal portion of the middle lobe ...
Endoscopic view             Diagramatic view




• Continue resecting the middle lobe from the 7 to 5
  o’clock positions....
Endoscopic view                             Diagramatic view




•   Resection at both sides of the verumontanum with part...
Endoscopic view                    Diagramatic view




Resection of Left lateral lobe (proximal part) in long cuts
next t...
Endoscopic view                Diagramatic view




Resection of Right lateral lobe (proximal part) in long cuts
next to e...
• Shape of surface (fossa) after resection proximal
  part of both lateral lobes in long cuts.
                           ...
• Resection of apical tissues carefully (do not exceed
  distal end of verumontanum)- finger in rectum can approximate
  t...
Nesbit Standard technique
                 (1943)

• Resection from proximal to distal (BN →
  midportion → apical tissue)...
1st stage: resect BN




• Resect BN in quadrants starting at 12 o’clock (until see circular
  fibers of BN)
2nd stage: resect midportion
    in quadrants, (superiorly to inferiorly) (until see fibers of prostatic capsule)




•   ...
2nd stage: resect midportion
    in quadrants, (superiorly to inferiorly) (until see fibers of prostatic capsule)




 (b...
2nd stage: resect midportion
     in quadrants, (superiorly to inferiorly) (until see fibers of prostatic capsule)




 (...
3rd stage: resect apical tissues




Residual tissue is carefully cleared on both sides immediately lateral
  to veru (do ...
Catheter application




                       M.A.Wadood Aref
Catheter at bladder neck                           catheter in prostatic fossa




•   place a 20 F three-way catheter for...
Catheter at bladder neck
                           Balloon catheter within the
                           bladder (with t...
catheter in prostatic fossa
 Balloon catheter within
 the prostatic fossa
• some surgeons
   advocate that method
   to co...
Skin traction
• some surgeons
  advocate traction to be
  maintained by a gauze
  swab tied round the
  catheter and pulle...
EARLY                    LATE
intra-op                  POST-OP                 POST-OP
   Haemorrhage          Urinary ...
Thank You


        M.A.Wadood Aref
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TURP step by step operative urology

TURP step by step operative urology series

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TURP step by step operative urology

  1. 1. TURP M.A.Wadood Aref
  2. 2. TURP set • Lens • Resectoscope sheath 24- Fr or 27-Fr. (single flow or continous flow). • HF resection electrodes: band electrode & roller electrode (coagulation). • Ellic evacuator • Electrolyte-free and sterile irrigation fluid. • Lubricant. • Optional suprapubic catheter (12-Fr) for continuous irrigation. ©
  3. 3. Right position (lithotomy Wrong position (extended position) (45 degrees) lithotomy position) (90 degrees) M.A.Wadood Aref
  4. 4. Sphincteric mechanism The three components of the sphincter mechanism are:  bladder neck  intramural external sphincter (just distal to the verumontanum)  levator ani. M.A.Wadood Aref
  5. 5. The operation M.A.Wadood Aref
  6. 6. Basic skills for TURP M.A.Wadood Aref
  7. 7. Cutting a chip 1. lift the resectoscope to allow the loop to sink in 2. keep it level as you cut the chip 3. depress the sheath to cut off the chip. M.A.Wadood Aref
  8. 8. Cutting a chip • The shape of the chip • Cutting the chip off is like a canoe. It is as before the loop enters the sheath wide and deep as the prevents any loop, and its length is possible damage to determined by the the telescope. travel of the loop. M.A.Wadood Aref
  9. 9. Bleeding control • Smaller vessel may be • larger vessel is controlled by controlled by coagulating its applying the loop just mouth. to one side of wall to seal the walls together. M.A.Wadood Aref
  10. 10. Bleeding control • When artery points straight at • If localization of bleeding you all you can see is a red blur. site is difficult consider • advance sheath, tilt it to squeeze ‘Bouncing bleeding’. vessel, coagulate just upstream. M.A.Wadood Aref
  11. 11. Prophylactic coagulation sites 5 o’clock 7 o’clock 10 o’clock Badenoch’s arteries M.A.Wadood Aref
  12. 12. Main Steps of TURP 1. Identification of landmarks. 2. Removal of most of adenoma (stepwise) by Mauermayer technique or Nesbit technique. 3. Tidying up & removal of apical tissue. 4. Catheter application M.A.Wadood Aref
  13. 13. Initial steps – Identification of bookmarks • Lithotomy position. • Blind trocar or visual insertion of the resectoscope sheath. • Urethrocystoscopy with identification of verumontanum, prostatic urethra, bladder neck and ureteral orifices. M.A.Wadood Aref
  14. 14. Orientation • The external sphincter is easily • It is necessary to be aware of the position identifiable at the level of the of the verumontanum to see that the membranous urethra. lower part of the cut is not extending below this level, otherwise damage to the sphincter mechanism may occur. M.A.Wadood Aref
  15. 15. Mauermayer Standard technique (1981) • Resection in lobes (middle lobe & tissues lat. to veru. → Lt lobe→ Rt → lobe apical tissues). • apical tissues last M.A.Wadood Aref
  16. 16. Endoscopic view Diagramatic view • Resection begins at the proximal portion of the middle lobe at the 6 o’clock position. • The resectoscope is placed just proximal to the verumontanum and the resection carried out always controlling the endpoint of each cut. M.A.Wadood Aref
  17. 17. Endoscopic view Diagramatic view • Continue resecting the middle lobe from the 7 to 5 o’clock positions. M.A.Wadood Aref
  18. 18. Endoscopic view Diagramatic view • Resection at both sides of the verumontanum with particular care of the position of the external sphincter (do not exceed distal end of verumontanum). • pull the resectoscope into the urethra, just distal to the verumontanum, and note that there is no falling and obstructing tissue. M.A.Wadood Aref
  19. 19. Endoscopic view Diagramatic view Resection of Left lateral lobe (proximal part) in long cuts next to each other to achieve smooth surface (fossa). • Which lobe first? depends on the preference of the surgeon. M.A.Wadood Aref
  20. 20. Endoscopic view Diagramatic view Resection of Right lateral lobe (proximal part) in long cuts next to each other to achieve smooth surface (fossa). M.A.Wadood Aref
  21. 21. • Shape of surface (fossa) after resection proximal part of both lateral lobes in long cuts. M.A.Wadood Aref
  22. 22. • Resection of apical tissues carefully (do not exceed distal end of verumontanum)- finger in rectum can approximate the apical tissues. M.A.Wadood Aref
  23. 23. Nesbit Standard technique (1943) • Resection from proximal to distal (BN → midportion → apical tissue). • apical tissues last. M.A.Wadood Aref
  24. 24. 1st stage: resect BN • Resect BN in quadrants starting at 12 o’clock (until see circular fibers of BN)
  25. 25. 2nd stage: resect midportion in quadrants, (superiorly to inferiorly) (until see fibers of prostatic capsule) • (a): Rt lobe upper quadrant (12 to 9 o’clock)
  26. 26. 2nd stage: resect midportion in quadrants, (superiorly to inferiorly) (until see fibers of prostatic capsule)  (b): Lt lobe upper quadrant (12 to 3 o’clock) 
  27. 27. 2nd stage: resect midportion in quadrants, (superiorly to inferiorly) (until see fibers of prostatic capsule)  (c): Rt lower quadrant (9 to 6 o’clock) & Lt lower quadrant (3 to 6 o’clock) 
  28. 28. 3rd stage: resect apical tissues Residual tissue is carefully cleared on both sides immediately lateral to veru (do not exceed distal end of verumontanum to preserve sphincter).  begin next to the veru → toward the 12 o'clock position
  29. 29. Catheter application M.A.Wadood Aref
  30. 30. Catheter at bladder neck catheter in prostatic fossa • place a 20 F three-way catheter for drainage; can be inserted with the finger in the rectum, pressing the prostatic tissue up to avoid damage to the bladder neck and trigone. • The balloon is inflated to 20 mL or 30 mL • the catheter can be left at bladder neck or withdrawn in the prostatic fossa. M.A.Wadood Aref
  31. 31. Catheter at bladder neck Balloon catheter within the bladder (with traction on BN to contract the fossa) • this is the preferred method by most of the surgeons because it allows the capsule to contract without much trauma to the urethra. M.A.Wadood Aref
  32. 32. catheter in prostatic fossa Balloon catheter within the prostatic fossa • some surgeons advocate that method to control bleeding (only for short time). • However, Prolonged traction with the balloon in prostatic fossa has the risk of traumatic injury & prevent fossa contraction leading to bleeding. M.A.Wadood Aref
  33. 33. Skin traction • some surgeons advocate traction to be maintained by a gauze swab tied round the catheter and pulled back onto the glans penis (for short time to avoid ischemia). M.A.Wadood Aref
  34. 34. EARLY LATE intra-op POST-OP POST-OP  Haemorrhage  Urinary retention  Retrograde  Urethral injury  Clot retention Ejaculation  Bladder injury  2ry Haemorrhage  UTI  TUR syndrome  Erectile Dysfunction  Epididymo-orchitis  Mortality  Bladder neck  Septicaemia stenosis  DVT  Urethral Stricture  PE  Incontinence  Re-operation  Mortality
  35. 35. Thank You M.A.Wadood Aref
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