Grade I benign prostate with outflow obstruction is best treated with -
• MC indication for surgery is symptoms interfering with quality of life (bothersome symptoms and symptoms of BOO).
• TURP (Gold standard) :
−− Cystoscopic removal of strips of prostatic tissue using diathermy loop. Two techniques; NESBIT technique (preferred maver mayer technique)
−− Best irrigant fluid is 1.5% glycine (Electrolyte solutions like NaCl are not compatible with electrocautery, so not used).
−− Glycine is composed of glycolic acid and ammonium, which can cause CNS (visual) toxicity.
TURIS: TUR in saline using bipolar cautery
• Verumontanum is the single most important anatomical landmark in TURP.
• Verumontanum lies immediately proximal to external sphincter and serve as the distal landmark for prostate resection to prevent injury to the external sphincter.
• Verumontanum: Distal landmark for prostate resection.
• Verumontanum: Landmark for proximal limit of external sphincter.
−− Risks of TURP: Retrograde ejaculation (75%)Q, impotence (5–10%) and incontinence (< 1%).
−− Complications: Bleeding, urethral stricture or bladder neck contracture, perforation of the prostate capsule with extravasation, and if severe, TUR syndrome.
TUR syndrome (Dilutional hyponatremia or water intoxication)
• TUR syndrome (Dilutional hyponatremia or water intoxication) resulting from a hypervolemic, hyponatremic state due to absorption of the hypotonic irrigating solution.
• Clinical Features: Nausea, vomiting, confusion, hypertension, bradycardia, and visual disturbances.
• The risk increases with resection times > 90 minutes or gland size > 75 gm.
• Treatment includes diuresis (furosemide) and in severe cases, hypertonic saline (3%) administration.
Late Complications of TURP
• Bladder neck stenosis (4%) > Urethral stricture (3.6%)
• Bladder neck stenosis is seen more often with small (< 30 gm) fibrotic prostates.
• Transurethral incision of the prostate (TUIP):
−− For posterior commissure hyperplasia (elevated bladder neck), involves two incisions using the Collins knife at the 5- and 7-o’clock positions.
−− The incisions are started just distal to the ureteral orifices and are extended outward to the verumontanum.
• TUIP lowers the incidence of bladder neck contracture when compared to TURP, so TUIP should be strongly considered in patients with smaller gland in place of TURP.
• TUIP is used for smaller (20 gm) prostate, young patients.
• Decreased incidence of retrograde ejaculation as compared to TURP.
• Open simple prostatectomy: Glands > 75 gm, concomitant bladder diverticulum or a bladder stone or if dorsal lithotomy positioning is not possible.
−− Suprapubic prostatectomy: Performed transvesically (Frayer’s) and operation of choice in dealing with concomitant bladder pathology (Bladder stones or diverticulum).
−− Retropubic prostatectomy (Millin’s): Transverse incision is made in surgical capsule of prostate and enucleation is done.
−− Perineal prostatectomy (Youngs): Abandoned now
• Carcinoma prostate originates in peripheral zone of prostate, so prostatectomy for BPH confers no protection for subsequent cancer.
Retropubic prostatectomy
Transurethral resection
Transvesical prostatectomy
Androgen therapy