TURP
PROSTATE SURGERY- TURP OR LASER
Benign prostatic hyperplasia (BPH), or benign prostatic hypertrophy is enlargement of the prostate gland. The word "benign" means the cells are not cancerous while “hyperplasia” indicates an increased number of prostate cells.
The prostate gland sits between the bladder neck and urinary sphincter and it encircles the urethra. It is common for the prostate gland to enlarge as a man ages and this results in significant urinary tract symptoms such as urinary frequency, urgency, and hesistancy, weak stream, and nocturia (waking up at night to go to bathroom). In severe cases, BPH will lead to frequent bladder infections, bladder stones formation, urinary retention and renal failure.
Transurethral resection of the prostate (TURP) gland is carried out primarily to relieve obstruction, improve quality of life and to treat any complications of BPH such as regular bleeding, urinary tract infections, renal impairment and bladder stones. It is not the type of operation that is usually carried out in the treatment of prostate cancer.
The operation is performed by passing a telescopic instrument in through the eye of the penis and down the urethra into the area of the prostate. The internal lining of the bladder is also routinely inspected. A special electric knife (or laser fiber) is used to cut (vaporize) pieces of the prostate out and these pieces can then be flushed out. At the end of the procedure, a catheter (a plastic tube that drains urine from the bladder) is placed and usually kept in place from anything between one to three days after the surgery.
Whilst the catheter is in place, irrigating fluid can be instilled at the same time as the urine drains into a bag. The nurses will change the irrigating fluid and bag at regular intervals.
The operation takes on average around 45-60 minutes to perform and the usual length of stay in hospital is in the vicinity of 2-3 days.
WHAT ARE THE MAIN ADVANTAGES OF LASER OVER CONVENTIONAL TURP APPROACH?
- Minimal invasive prostate surgery
- Safe in patient taking blood thinning medication
- Slightly higher cost
- Some patients report longer period of dysuria and urinary urgency
WHAT ARE THE MAIN ADVANTAGES OF LASER OVER CONVENTIONAL TURP APPROACH?
- Slightly higher cost
- Some patients report longer period of dysuria and urinary urgency
WHAT PREPARATION IS REQUIRED?
As TURP is performed under regional or general anaesthesia, you should have nothing to eat or drink for 6 hours prior to treatment. Regular medications can be taken with a sip of water with the exception of blood thinning agents (eg. warfarin, aspirin, clopidogrel) or non-steroidal anti-inflammatories which need to be stopped for 7-10 days. If you are having laser TURP, Dr Chung will discuss with you on the use of blood thinning agents. A mid stream urine (MSU) test is required to ensure the urine is sterile before treatment is undertaken.
What do I need to bring to surgery?
- All related available imaging such as KUB (kidneys, ureter, and bladder) x-ray, CT scan abdomen, or kidney ultrasound
- Your usual medications
WHAT HAPPENS IN THE OPERATING ROOM?
You will meet your anaesthetist prior to surgery who will take a thorough medical history. Your anaesthetist will discuss with you on the choice of anesthesia; namely spinal (regional) or general anaesthetic.
TURP is considered a safe procedure. Specific complications involve:
- Bleeding requiring longer duration of urinary catheter or clot retention; it is uncommon for patient to require blood transfusion
- Retrograde ejaculation- this refers to the absence of any fluid when you have a sexual orgasm
- Infection
- Irritative urinary symptoms namely urinary frequency, urgency and temporary urinary incontinence
WHAT PREPARATION IS REQUIRED?
Laparoscopic Nephrectomy / Robotic Nephrectomy are the minimal invasive surgery or the Key Hole surgery. It is a safe and effective way of removing kidney and the results are comparable with the open surgery. It has got the advantage of the minimal invasive surgery in the form of less pain, shorter hospital stay, smaller scar, better cosmesis, and early return to the work.
What to expect during you preoperative consultation?
In the first consultation with the surgeon, he usually reviews all the documents, images and investigation. He does a physical examination and Asses the fitness for the surgery. In case there is renal tumor, the surgeon would like to stage the disease. Once the date of surgery is finalized , he may advice you to do few test for the surgical fitness and meet an anesthetist and a physician.
What to expect prior to the surgery?
Usual preop investigation done are:
- Physical exam
- ECG (electrocardiogram)
- CBC (complete blood count)
- PT / PTT (blood coagulation profile)
- Comprehensive Metabolic Panel (blood chemistry profile)
- Viral Markers
- Urinalysis
- 2D Echo in elderly
Preparation for surgery
MEDICATIONS TO AVOID PRIOR TO SURGERY:
Aspirin, Warfarin, Clopidogrel and some other blood thinner need to be stopped prior to an elective surgery (5-7 days) after approval from the prescribing physician.
Patient is kept nill by mouth (NBM) at least 6 hours prior to the surgery.
The Operation: Laparoscopic nephrectomy / Robotic Nephrectomy is a Key hole surgery performed through 3-5 small incision on the abdomen through which various instruments and telescope is inserted after distending abdomen by a gas. The kidney is dissected all around the vessels and the ureter is clipped. The final specimen is retrieved after inserting in a plastic bag either extending a port or putting a separate incision (Pfannensteil)
Open ProcedureLaparoscopic Procedure
Although this procedure have stood test of the time , but like any other surgical procedure it also carries some risk of complication.
The usual blood loss is less than 100 cc and need for blood transfusion is seen in less than 5% of patients.
Infection:All the patient are give preop / intra op antibiotics and usually is continued 24-48 hours post surgery. The risk of the infection is less compared to open surgery, however it may happen.
Tissue / Organ Injury:Although the risk is small if done in experienced hand but in large tumor or a inflamed kidney there can be injury to the surrounding organs or vasculature requiring open conversion or other intervention.
Hernia :Hernias are quite rare because of the smaller size of incision , but may occur.
Conversion to Open Surgery :Conversion to open surgery is not the failure of the surgeon to do a key hole surgery but is a wise decision for the safety and better outcome of the patient. It may be needed if there is failure to progress because of dense adhesion to surrounding structure, or bleeding or injury to surrounding viscera.
During your hospitalization.
Patient is shifted to the recovery room after surgery, where he is kept for observation for 4-6 hours. If vitals and other parameters are normal, he is usually shifted to his room post surgery on the same day unless any other comorbities exist requiring ICU care.
- Postoperative Pain :There may be a transient pain in the shoulder which is due to the carbon dioxide insufflation. Wound is usually infiltrated with local anesthesia during surgery and post operatively patients receive adjuvant Intravenous analgesics in consultation with the anesthetist.
- Nausea : It may happen because of the medications or the anesthetic drugs.
- Urinary Catheter :Urinary pipe may be present for couple of days to monitor the urine output. It is usually removed by second postoperative day.
- Diet :Most of the patient are give clear liquids by evening and a normal diet next day once he starts tolerating the liquids well.
- Fatigue :Generalized weakness and fatigability can be there because of the anesthetist or other drugs. Usually subsides in 5-7 days.
- Incentive Spirometry : As many patient hold there breathing because of the pain which can result in some lung related complication. Incentive spirometery is advisable to expand the lung and prevent post
- Ambulation :Patient is ambulated on the eve of the surgery. Early mobilization reduces the risk of of blood clots in the leg veins , it also speed up the recovery and bowel movement.
- Hospital Stay :The usual hospital stay is 2-3 days in Laparoscopic / Robotic Nephrectomy
- Constipation / Gas Cramps :Patient can have mild abdominal distention and constipation due to the anesthetic drugs and other medications specially analgesics. Patient are usually given laxative and early mobilization helps in reducing the bowel discomfort.
- Pain Control :There may be mild incisional discomfort, and usual oral analgesics are sufficient to care of that.
- Showering :Patient can take shower 3 days post surgery, they can wet the surgical site but have to pad it dry immediately after taking the bath.
- Activity :Patient starts walking on the eve of surgery. He can climb stairs after a day. Patient should avoid exercise and gyming for 4-6 weeks. Usually they can resume there normal office work 2-3 weeks after the surgery.
- Diet :it is advisable to take low salt , low protein diet post kidney removal. Dietician and nephrologist should be consulted for the proper dietary advice.
- Pathology Results :The pathology report is usually available after 5-7 days of the surgery. Patient needs to review with the surgeon again with the histopathology report.
- Kidney/Liver Function Blood Tests and Xrays :Patients need to on regular follow up as advised by the surgeon.
