Endoscopic Management of BPH

Anticoagulation plans prior to TURP, from Kavanagh 2011

Medications that decrease bleeding during TURP, from Kavanagh 2011

Transurethral resection of prostate (TURP)

Preoperative considerations

Operative technique

  1. Dorsal lithotomy, genitals at edge of bed, optimize space between legs by spreading knees
  2. Resectoscope: 30 degree lens, yellow sheath (26Fr), visual obturator
  3. Confirm bi vs mono polar equipment and irrigation
  4. Prep and drape patient
  5. Set up light + camera cord and irrigation fluid with stopcock
  6. Place sound in meatus to passively dilate urethra
  7. Lubricate entire scope length (minimizes stricture formation)
  8. Insert resectoscope, empty bladder, examine prostate, verumontanum, and ureteral orifices
  9. Resect prostate starting with median lobe, then move anteriorly for lateral lobes
  10. Reassess and repeat resection for adenoma as needed, shorter swipes near apex
  11. Obtain hemostasis as needed
  12. Remove chips with Ellik or Toomey syringe
  13. Repeat obtaining hemostasis, reassess at lower pressure
  14. Remove scope with bladder full (may see passive drainage), place 20Fr 3-way catheter and inflate with 30mL sterile water, irrigate to confirm placement and drainage

Operative Tips

Expected postoperative course

Postoperative complication management

Prostatic Urethral Lift (UroLift)

Preoperative considerations

Operative technique

  1. Place patient in dorsal lithotomy position, prep/drape similar to TURP
  2. Insert cystoscope, inspect bladder and prostate
  3. Position device 1.5cm distal to bladder neck, visualizing verumontanum
  4. Unlock safety
  5. Compress against prostatic tissue at 2 or 10 oclock (anterolateral position)
  6. Pull needle trigger (blue trigger)
  7. Pull retraction trigger (gray trigger) to pull needle back
  8. Move scope proximally towards bladder until silver line visible
  9. Push urethral release button to cut suture
  10. Usually place 4 implants, more if needed

Postoperative management

Photovaporization (PVP, KTP)

Preoperative considerations

Operative technique

  1. Position similar to TURP (see above), prep/drape
  2. Set up separate laser irrigation cord, keep closed until ready to start surgery (will avoid running out of fluid
  3. Reverse trendelenberg to 6 degrees (forces bubbles into bladder to improve visualization)
  4. Dilate meatus and lubricate entire scope length
  5. Insert cystoscope into bladder, assess location of ureters and trigone relative to bladder neck
  6. After inspecting, open laser and attach to irrigation fluid
  7. Position laser so blue triangle is visible (can damage scope if laser too close)
  8. Can rapidly zap entire prostate on 80 to superficially cauterize all tissue
  9. Take down median lobe, either by creating lateral channels first or just working from one side to the other
  10. Increase the energy level as needed (120+)
  11. Maintain appropriate distance and timing, otherwise laser with coagulate and not vaporize
  12. Obtain hemostasis as needed
  13. Can consider giving 20mg IV furosemide to assist with diuresis
  14. Place 18Fr 2-way or 22Fr 3-way (if concerned for bleeding
  15. Disposition: admit and perform void trial in AM, admit and discharge with catheter in AM for clinic void trial, or discharge from PACU with catheter for clinic void trial

Postoperative management

Transurethral Incision of Prostate (TUIP)

Preoperative considerations

Operative technique

  1. Position similar to above
  2. Insert resectoscope and examine prostate and bladder neck
  3. Incise at 5 o'clock or 7 o'clock positions, unilaterally or bilaterally
  4. Can incise with laser or hot knife
  5. Incise down to surgical capsule (some incise down to periprostatic fat)
  6. Obtain hemostasis
  7. Insert catheter to monitor immediate urine appearance

Postoperative management

Reported Surgical Complications (from Campbell's)

mTURP bTURP TUNA TUMT HoLEP PVP TUVP TUIP
Temporary retention 4.3-6.8% 3.3-3.7% 23% 10-24% 2.7-5.9% 5.2-9.9% 2-9.8% 4.9-11.3%
UTI 4.1-6.2% 2.6-8.4% 4% 15-20% 0.9-2.7% 4.2-12% 0% -
BNC 2-3.2% 0.5% - 0% 1.2-1.5% 1.1-5% 0.5-1% -
Stricture 3.4-4.1% 0.5-4.7% 0.5% 0-2% 1.9-4.4% 1-6.3% 1.9-3.3% 2.9-8.8%
Incontinence 0.6-1.5% 0-1% - - 0.9-1.1% 0-0.4% 0-2% 0.3-1.8%
Transfusion 2-4.4% 1.5-2.3% rare 0% 0-1% 0% 0-0.5% 1.1%
Clot retention 4.9-7.2% 2.7-7.9% - 1% 0% 0% 0-0.5% -
Hematuria 3.5-15.7% 1% 6-28% 1-26% 0% 0.7% 0% 4.3%
Dysuria 0.8% 0% 8-14% 14% 1.2% 8.5-13.9% 2.9% -
Urgency 2.2% 0.2% 10% - 5.6% 0% 0% -
Storage symptoms - - - 18-31% - - 21% -
Reoperation for BPE 0.5% 0.2% 19% 4% 0% 0.7-5.6% 2.4% -
Reoperation other than for BPE 1.1% 0.2% 0% - 1.9-2.8% - 5.4% 9.6-18.4%
Capsular perforation 0.1% 0% - - 0.2% 0% 0% -
Conversion to TURP n/a 0% n/a n/a 0% 3.5% 0% -
TUR syndrome 0.8-2.5% 0% 0% 0% 0% 0% 0% -
Bladder mucosal injury 0% 0% 0% - 3.3% 0% 0% -

References