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Thursday, October 7, 2021

Transurethral resection of the prostate (TURP), Transurethral resection of bladder tumour (TURBT)


Transurethral resection of the prostate (TURP). Tissue is removed from the prostate using a resectoscope (a thin, lighted tube with a cutting tool at the end) inserted through the urethra. Prostate tissue that is blocking the urethra is cut away and removed through the resectoscope.

Indications TURP

1: Bothersome LUTS which fail to respond to changes in lifestyle or
medical therapy.

2; Recurrent acute urinary retention.

3: Renal impairment due to BOO (high-pressure chronic urinary retention).

4: Recurrent haematuria due to BPE.

5: Bladder stones due to prostatic obstruction.


Administration of Enema Nursing Procedure

Post-operative care TURP

A 3-way catheter is left in situ after the operation, through which irrigation fluid (normal saline) is run to dilute the blood so that a clot will not form to block the catheter. The rate of inflow of the saline is adjusted to keep the outflow a pale pink rosé colour and as a rule, the rate of inflow can be cut down after about 20min. The irrigation is continued for 12–24h. The catheter is removed the day after (second post-operative day) if the urine has cleared to a normal colour (TWOC or trial of void (TOV)).

Common post-operative complications and their management TURP

Blocked catheter post-TURP


The catheter may become blocked with clot or a prostatic ‘chip’ that was inadvertently left in the bladder at the end of the operation.

  • Apply a bladder syringe to the end of the catheter to try to dislodge the obstruction.
  • If this fails, withdraw some irrigant into the syringe and flush the catheter.
  • If this fails, change the catheter. The obstructing chip of prostate may be found stuck in one of the eyeholes of the catheter.
  • Pass a new catheter on an introducer.
If the bladder has been allowed to become so full of clot that a simple bladder washout is unable to evacuate it all, return the patient to the theatre for clot evacuation.


Minor bleeding after TURP is common and will stop spontaneously. A simple system to allow communication between staff is to describe the colour of the urine draining through the catheter as the same as a rosé wine (minor haematuria), a dark red wine (moderate haematuria), or frank blood (bright red bleeding, suggesting serious haemorrhage). The rosé urine requires no action. Dark red urine should be managed by increasing the flow of irrigant and by applying gentle traction to the catheter (with the balloon inflated to 40–50mL), thereby pulling it onto the bladder neck or into the prostatic fossa to tamponade bleeding for 20min or so. This will usually result in urine clearing. An attempt at controlling heavier bleeding by these techniques may be tried, but at the same time, you should make preparations to return the patient to theatre because it is unlikely that bleeding of this degree will stop. The bleeding vessel(s), if seen, is controlled with diathermy. If bleeding persists, open surgical control is required—the prostatic capsule is opened, the bleeding vessels sutured, and the prostatic bed packed. Post-operative bleeding requiring a return to theatre occurs in 0.5% of cases.

Serious or frequently occurring complications of TURP

1: Temporary mild burning on passing urine, urinary frequency, haematuria.

2: Retrograde ejaculation in 75% of patients.

3: Failure of symptom resolution.

4: Permanent inability to achieve an erection adequate for sexual activity.

5: UTI requiring antibiotic therapy.

6: Ten percent of patients require redo surgery for recurrent prostatic obstruction.

7: Failure to pass urine after the post-operative catheter has been removed.

8: In 10% of patients, prostate cancer is found on subsequent pathological examination of the resected tissue.

9: Urethral stricture formation requiring subsequent treatment.

10: Incontinence (loss of urinary control)—may be temporary or permanent.

11: Absorption of irrigating fluid causing confusion and heart failure (TUR syndrome).

12:  Very rarely, perforation of the bladder requiring a temporary urinary catheter or open surgical repair.

Alternative therapy: observation, drugs, catheter, stent, laser prostatectomy, open operation.

Transurethral resection of bladder tumour (TURBT)

Indications TURBT

1: Local control of non-muscle-invasive bladder cancer (i.e. stops bleeding tumours).

2: Staging of bladder cancer: to determine whether the cancer is nonmuscle- invasive or muscle-invasive so that subsequent treatment and appropriate follow-up can be arranged.

Post-operative care of TURBT

A 2- or 3-way catheter is left in situ after the operation, depending on the size of the tumour and, therefore, on the likelihood that bleeding requiring irrigation will be required. As for TURP, normal saline is run through the catheter to dilute the blood so that a clot will not form to block the catheter.

It is particularly important to avoid catheter blockage post-TURBT since this could lead to distension of the bladder already weakened by resection of a tumour. The period of irrigation is usually shorter than that required after TURP and for small tumours, the catheter may be removed the day after the TURBT. For larger tumours, remove it 2 days later.

Common postoperative complications and  management of TURBT

Bladder perforation during TURBT

Small perforations into the perivesical tissues (extraperitoneal) are not uncommon when resecting small tumours of the bladder and so long as you have secured good haemostasis and all the irrigating fluid is being recovered, no additional steps are required, except that perhaps one should leave the catheter in for 4 rather than 2 days.

Intraperitoneal perforations (through the wall of the bladder, through the peritoneum, and into the peritoneal cavity) are uncommon but far more serious.

Is it an extraperitoneal or intraperitoneal perforation? Establishing this can be difficult. Both can cause marked distension of the lower abdomen an intraperitoneal perforation by allowing the escape of irrigating solution directly into the abdominal cavity and an extraperitoneal perforation by expanding the retroperitoneal space, with fluid then diffusing directly into the peritoneal cavity. The fact that a suspected intraperitoneal perforation was actually extraperitoneal becomes apparent only at laparotomy
when no hole can be found in the peritoneum overlying the bladder (the peritoneum over the bladder is not breached in an extraperitoneal perforation).

When there is no abdominal distension, the volume of extravasated fluid is likely to be low and if the perforation is small, it is reasonable to manage the case conservatively. Achieve haemostasis and pass a catheter. Make frequent postoperative assessments of the patient’s vital signs and abdomen (worsening abdominal pain, distension, and tenderness suggest the need for laparotomy).

Where there is marked abdominal distension, whether the perforation is extraperitoneal or intraperitoneal, explore the abdomen, principally to drain the large amount of fluid (which can compromise respiration in an elderly patient) by splinting the diaphragm, but also to check that loops
of bowel adjacent to the site of perforation have not been injured at the same time. Failing to make the diagnosis of an intraperitoneal perforation, particularly if the bowel has been injured, is a worse situation to be in than performing a laparotomy for a suspected intraperitoneal perforation, but
then finding that the perforation was ‘only’ extraperitoneal.

Open bladder repair

Pfannenstiel incision or lower midline abdominal incision, open the bladder, evacuate the clot, control bleeding, and repair the hole. Open the peritoneum and inspect small and large bowel for perforations. Leave a urethral catheter and a drain in place.

Blocked catheter post-TURBT

The catheter may become blocked with clot. Use the same technique for unblocking it as for TURP, but avoid vigorous washouts of the bladder because of the risk of bladder perforation.


Minor bleeding after TURBT is common and will stop spontaneously. The only ‘technique’ for controlling it is to ensure that an adequate flow of irrigant is maintained (to dilute the blood and thereby, preventing clots from forming). If bleeding persists, return the patient to theatre for endoscopic

TUR syndrome

Uncommon after TURBT unless the tumour is large and the resection, therefore, long.

Serious or frequently occurring complications of TURBT

Common complications TURBT

1: Mild burning on passing urine.

2: Additional treatment (intravesical chemotherapy or immunotherapy) may be required to reduce the risk of future tumour recurrence.

3: UTI.

4: No guarantee of bladder cancer cure.

5: Tumour recurrence is common.

Rare complications TURBT

1: Delayed bleeding requiring removal of clots or further surgery.

2: Damage to drainage tubes from the kidney (ureters) requiring additional therapy.

3: Development of urethral stricture.

4: Bladder perforation requiring a temporary urinary catheter or open surgical repair.

Alternative treatment: open removal of the bladder; chemotherapy, radiation.

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