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Name:
TURP
Description:
TURP
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https://cadmoremediastorage.blob.core.windows.net/9acba8a3-4dd8-4a68-a429-2fa458083ccb/videoscrubberimages/Scrubber_1.jpg?sv=2019-02-02&sr=c&sig=RMv987J8iLwIdatMgPTG%2F8FZfigwMq3M0LBeDydwVtI%3D&st=2025-04-30T05%3A08%3A22Z&se=2025-04-30T09%3A13%3A22Z&sp=r
Duration:
T00H17M47S
Embed URL:
https://stream.cadmore.media/player/9acba8a3-4dd8-4a68-a429-2fa458083ccb
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/9acba8a3-4dd8-4a68-a429-2fa458083ccb/TURP - Madhu Agrawal.mp4?sv=2019-02-02&sr=c&sig=LfccXXp7tRyvzqQ4bU9fzMRRaRk%2BuEY72PH68EsmZYY%3D&st=2025-04-30T05%3A08%3A22Z&se=2025-04-30T07%3A13%3A22Z&sp=r
Upload Date:
2023-12-06T00:00:00.0000000
Transcript:
Language: EN.
Segment:1 Title.
[MUSIC PLAYING]
SPEAKER: Trans-Urethral Resection of Prostate, TURP, has been the gold standard for surgical removal of prostatic adenoma for a long time and will continue to remain so despite the advent of many minimally invasive alternative therapies. This is a procedure which has stood the test of time.
Segment:2 Indications of TURP.
SPEAKER: It is indicated in patients who present with moderate to severe lower urinary tract symptoms not responding to medical treatment, patients who present with recurrent or chronic retention of urine, and patients who have complications of BPH, including urinary tract infection, hematuria, bladder stones, and bladder diverticula, and so on.
Segment:3 Preoperative preparation.
SPEAKER: All patients, before operation, undergo detailed history and physical examination, including digital rectal examination, standard blood chemistry, including serum PSA, and ultrasound, abdominal as well as transrectal for prostate volume and residual urine, uroflowmetry in all patients who are passing urine, and urodynamic study pressure flow studies in patients who have neurological problems.
SPEAKER: All patients undergo detailed metabolic and systemic evaluation for any medical morbidities
Segment:4 Principles of monopolar and bipolar TURP.
SPEAKER: and treatment for infection. Now, monopolar TUR has been the gold standard procedure, but in recent years, bipolar TUR has increasingly replaced it because of certain advantages, although the technique is more or less the same. Now, according to simple electrophysiological principles, the bipolarity, TUR because of shorter pathway, offers less resistance and requires lower power settings for achieving the same results.
SPEAKER: And for this reason, the bipolar TUR offers an alternative to monopolar current with better tissue response as compared to the monopolar electrodiathermy. The prostatic fossa at the end of the procedure comes out cleaner. There is less tissue damage.
SPEAKER: The penetration of electric current in bipolar is less, and tissue healing is superior. In all other respects, the technique of TURP remains the same in both the procedures.
Segment:5 Instruments.
SPEAKER: The instrument used in the TURP is the standard 26-French Iglesias resectoscope. The inner sheath is 24 French.
SPEAKER: There is an operator, a 30 degree lens, and a working element. The bipolar working element differs from the monopolar working element in only one detail, that is a pathway for the returning current in the bipolar system and the returning current, which goes through the working element itself. And it must be understood that the current returns mostly through the working element and not through the sheath.
SPEAKER: Now, prostatic adenoma removal in TURP,
Segment:6 Principles of adenoma removal.
SPEAKER: transurethral resection, mostly works from inside out. And there are many techniques which are popular, among which Barnes is one of the most popular where the resection starts at the luminal level and goes towards the capsule. However, there are other techniques described which work on the principle of enucleation of the loop.
SPEAKER: And one of them is Nesbit's approach, which was described a long time back. But it has now come back into popularity because of the recent interest in the endoscopic enucleation procedures. In the Nesbit approach, the resection starts anteriorly, and it proceeds towards both lateral lobes one by one.
SPEAKER: Working along the capsule, first on one side and then
Segment:7 Positioning.
SPEAKER: on the other side, very similar to the endoscopic enucleation procedure. And the patient's position should be modified lithotomy in all TURPs and not the standard or extended lithotomy.
Segment:8 Surgical steps.
SPEAKER: Surgical steps, the first step is cystoscopy for evaluation of the anatomy as well as identification of the landmarks.
SPEAKER: And then, in Nesbit's technique, the resection starts at 12 o'clock position, the site of the anterior commissure. The resection of the lateral lobes starts one by one. For the right side, it goes anticlockwise from 12 o'clock to 7 o'clock. And on the left side, it moves from 12 o'clock to 3 o'clock and up to 5 o'clock clockwise. And once both lobes are detached from the capsule, they fall to the floor, and in the process are devascularized.
SPEAKER: And then they are resected quickly along with the medial loop. The procedure concludes by achieving hemostasis in the usual way and removal of the resected chips with an evacuator and the placement of a Foley catheter.
Segment:9 Case details.
SPEAKER: Now, the case, being demonstrative, is a 73-year-old male who presented with recurrent retention of urine. His clinical findings were unremarkable.
SPEAKER: The prostate was grade 2 on digital rectal examination, 48 ml in volume. The blood chemistry was within normal limits, and the serum PSA was 2.2. After management of other medical parameters and clinical evaluation, the patient was taken up for trans-urethral resection of prostate using a bipolar Olympus diathermy.
Segment:10 Cystourethroscopy and landmarks.
SPEAKER: The cystoscopy and identification of the landmarks, the verumontanum, the right ureteric orifice, trabeculated bladder, and the left ureteric orifice.
SPEAKER: The verumontanum, which is the distal limit for all resection,
Segment:11 Resection starts at 12 0’clock.
SPEAKER: and the resection starts at 12 o'clock position. The bipolar loop is color coded with each limb in a different color. The resection process is the same as monopolar. You can see a bright orange corona being generated when the electric current is passed through the loop, which is special to the bipolar system.
SPEAKER: The resection proceeds till the capsule is identified and long chips extending from the bladder neck up to the level of the veru can be resected. And then, resection for the right
Segment:12 Right lobe resection.
SPEAKER: lobe starting at 12 o'clock going down to 3, and then to 7 o'clock position, working along the capsule.
SPEAKER: The corona generated around the loop provides excellent cutting as well as hemostasis with very little resistance to the tissue. And it produces very little tissue coagulation and charring. So you can see clean, white floor and tissue identification.
SPEAKER: Identification of the capsule can be made easy this way. The resection proceeds along the capsule up to the level of 7 o'clock. And the lobe falls medially into the floor. Now, irrespective of the prostate size, this step remains the same. And in very large glands as well, the time taken in separating the lobe from the capsule does not alter significantly. .
SPEAKER: Hemostasis is achieved with this diathermy said is quite excellent. After the right lobe, the same process
Segment:13 Left lobe resection.
SPEAKER: is repeated on the left side starting at 12 o'clock moving to 1:00. And then along 3 o'clock to up to 5 o'clock position.
SPEAKER: The irrigating fluid being used is normal saline, and it is the saline, the sodium of the saline which is responsible for the orange glow of the corona. All the hemostasis is achieved at the level of the capsule, which allows coagulation of the blood vessels nicely, and one does not have to repeatedly coagulate the same blood vessel.
SPEAKER: There is very little charring, blackening of the floor. And the precision of the tissue resection is quite good with this system. Once both lobes are separated from the capsule, all around it
Segment:14 Completion at base.
SPEAKER: they are left attached only on the floor.
SPEAKER: And then they can be resected quickly since the blood supply is largely gone. And the resection proceeds quickly of both the lobes as well as the median lobe if it is present. The presence of prostatic calculi confirms the correct plane of the prosthetic capsule.
SPEAKER: This is a largely unedited video, and a moderate-sized prostate can be completely resected with this approach within a matter of few, 15 to 20 minutes only.
SPEAKER: Even in larger glands, the total operating time does not alter significantly, up to 150 gram prostate can be completed in a single session. And prostates larger than that can be done as two sessions doing one lobe at a time. At completion, one can see complete rounded fossa, prostatic fossa all around and complete resection of the adenoma tissue with reasonably good hemostasis.
Segment:15 Hemostasis and completion.
SPEAKER: Small bleeders can be coagulated directly, while large bleeders can be coagulated by putting pressure on their stem around the bleeding points. By reducing the irrigation flow, one can catch and stop even the smallest bleeding points and achieve near complete hemostasis allowing a very bloodless outcome.
SPEAKER: And many of these patients can be discharged from the hospital within 24 hours. The inflow can be reduced to the minimum and almost to zero to allow even the smallest bleeders to show up and coagulated before completion of the procedure.
SPEAKER: Now, this kind of capillary washing may not truly be necessary, but it helps in providing a completely bloodless field at the end of the operation.
SPEAKER: The procedure, as I mentioned earlier, for bipolar and monopolar TUR are almost identical. However, due to the benefits that we see with the bipolar technology, this bipolar technology has almost completely replaced the monopolar approach
Segment:16 Evacuation of chips.
SPEAKER: in our practice. And at the end, the standard approach to removal of the prosthetic chips in a relatively bloodless field.
SPEAKER:
Segment:17 Catheter placement.
SPEAKER: A three-way Foley catheter, usually 18 or 20 French, is placed in the bladder, and gentle traction may be applied if required, which is kept in for 2 to 4 hours. And the patient is sent home within 24 or 48 hours.
Segment:18 Bipolar resection - advantages.
SPEAKER: Now, the bipolar, as I said, is exactly the same as monopolar resection, so there is no separate learning curve. The benefit of saline is in negligible electrolyte imbalance. The hemostasis is excellent, so there is less bleeding. It is safer for cardiac patients. There is less spread of current.
SPEAKER: The tissue charring and coagulation is less, so postoperative dysuria is less, and healing is faster. And the duration of catheterization and hospital stay is significantly shorter.
Segment:19 Thanks!.
SPEAKER: Thank you.
Segment:1 Title.
[MUSIC PLAYING]
SPEAKER: Trans-Urethral Resection of Prostate, TURP, has been the gold standard for surgical removal of prostatic adenoma for a long time and will continue to remain so despite the advent of many minimally invasive alternative therapies. This is a procedure which has stood the test of time.
Segment:2 Indications of TURP.
SPEAKER: It is indicated in patients who present with moderate to severe lower urinary tract symptoms not responding to medical treatment, patients who present with recurrent or chronic retention of urine, and patients who have complications of BPH, including urinary tract infection, hematuria, bladder stones, and bladder diverticula, and so on.
Segment:3 Preoperative preparation.
SPEAKER: All patients, before operation, undergo detailed history and physical examination, including digital rectal examination, standard blood chemistry, including serum PSA, and ultrasound, abdominal as well as transrectal for prostate volume and residual urine, uroflowmetry in all patients who are passing urine, and urodynamic study pressure flow studies in patients who have neurological problems.
SPEAKER: All patients undergo detailed metabolic and systemic evaluation for any medical morbidities
Segment:4 Principles of monopolar and bipolar TURP.
SPEAKER: and treatment for infection. Now, monopolar TUR has been the gold standard procedure, but in recent years, bipolar TUR has increasingly replaced it because of certain advantages, although the technique is more or less the same. Now, according to simple electrophysiological principles, the bipolarity, TUR because of shorter pathway, offers less resistance and requires lower power settings for achieving the same results.
SPEAKER: And for this reason, the bipolar TUR offers an alternative to monopolar current with better tissue response as compared to the monopolar electrodiathermy. The prostatic fossa at the end of the procedure comes out cleaner. There is less tissue damage.
SPEAKER: The penetration of electric current in bipolar is less, and tissue healing is superior. In all other respects, the technique of TURP remains the same in both the procedures.
Segment:5 Instruments.
SPEAKER: The instrument used in the TURP is the standard 26-French Iglesias resectoscope. The inner sheath is 24 French.
SPEAKER: There is an operator, a 30 degree lens, and a working element. The bipolar working element differs from the monopolar working element in only one detail, that is a pathway for the returning current in the bipolar system and the returning current, which goes through the working element itself. And it must be understood that the current returns mostly through the working element and not through the sheath.
SPEAKER: Now, prostatic adenoma removal in TURP,
Segment:6 Principles of adenoma removal.
SPEAKER: transurethral resection, mostly works from inside out. And there are many techniques which are popular, among which Barnes is one of the most popular where the resection starts at the luminal level and goes towards the capsule. However, there are other techniques described which work on the principle of enucleation of the loop.
SPEAKER: And one of them is Nesbit's approach, which was described a long time back. But it has now come back into popularity because of the recent interest in the endoscopic enucleation procedures. In the Nesbit approach, the resection starts anteriorly, and it proceeds towards both lateral lobes one by one.
SPEAKER: Working along the capsule, first on one side and then
Segment:7 Positioning.
SPEAKER: on the other side, very similar to the endoscopic enucleation procedure. And the patient's position should be modified lithotomy in all TURPs and not the standard or extended lithotomy.
Segment:8 Surgical steps.
SPEAKER: Surgical steps, the first step is cystoscopy for evaluation of the anatomy as well as identification of the landmarks.
SPEAKER: And then, in Nesbit's technique, the resection starts at 12 o'clock position, the site of the anterior commissure. The resection of the lateral lobes starts one by one. For the right side, it goes anticlockwise from 12 o'clock to 7 o'clock. And on the left side, it moves from 12 o'clock to 3 o'clock and up to 5 o'clock clockwise. And once both lobes are detached from the capsule, they fall to the floor, and in the process are devascularized.
SPEAKER: And then they are resected quickly along with the medial loop. The procedure concludes by achieving hemostasis in the usual way and removal of the resected chips with an evacuator and the placement of a Foley catheter.
Segment:9 Case details.
SPEAKER: Now, the case, being demonstrative, is a 73-year-old male who presented with recurrent retention of urine. His clinical findings were unremarkable.
SPEAKER: The prostate was grade 2 on digital rectal examination, 48 ml in volume. The blood chemistry was within normal limits, and the serum PSA was 2.2. After management of other medical parameters and clinical evaluation, the patient was taken up for trans-urethral resection of prostate using a bipolar Olympus diathermy.
Segment:10 Cystourethroscopy and landmarks.
SPEAKER: The cystoscopy and identification of the landmarks, the verumontanum, the right ureteric orifice, trabeculated bladder, and the left ureteric orifice.
SPEAKER: The verumontanum, which is the distal limit for all resection,
Segment:11 Resection starts at 12 0’clock.
SPEAKER: and the resection starts at 12 o'clock position. The bipolar loop is color coded with each limb in a different color. The resection process is the same as monopolar. You can see a bright orange corona being generated when the electric current is passed through the loop, which is special to the bipolar system.
SPEAKER: The resection proceeds till the capsule is identified and long chips extending from the bladder neck up to the level of the veru can be resected. And then, resection for the right
Segment:12 Right lobe resection.
SPEAKER: lobe starting at 12 o'clock going down to 3, and then to 7 o'clock position, working along the capsule.
SPEAKER: The corona generated around the loop provides excellent cutting as well as hemostasis with very little resistance to the tissue. And it produces very little tissue coagulation and charring. So you can see clean, white floor and tissue identification.
SPEAKER: Identification of the capsule can be made easy this way. The resection proceeds along the capsule up to the level of 7 o'clock. And the lobe falls medially into the floor. Now, irrespective of the prostate size, this step remains the same. And in very large glands as well, the time taken in separating the lobe from the capsule does not alter significantly. .
SPEAKER: Hemostasis is achieved with this diathermy said is quite excellent. After the right lobe, the same process
Segment:13 Left lobe resection.
SPEAKER: is repeated on the left side starting at 12 o'clock moving to 1:00. And then along 3 o'clock to up to 5 o'clock position.
SPEAKER: The irrigating fluid being used is normal saline, and it is the saline, the sodium of the saline which is responsible for the orange glow of the corona. All the hemostasis is achieved at the level of the capsule, which allows coagulation of the blood vessels nicely, and one does not have to repeatedly coagulate the same blood vessel.
SPEAKER: There is very little charring, blackening of the floor. And the precision of the tissue resection is quite good with this system. Once both lobes are separated from the capsule, all around it
Segment:14 Completion at base.
SPEAKER: they are left attached only on the floor.
SPEAKER: And then they can be resected quickly since the blood supply is largely gone. And the resection proceeds quickly of both the lobes as well as the median lobe if it is present. The presence of prostatic calculi confirms the correct plane of the prosthetic capsule.
SPEAKER: This is a largely unedited video, and a moderate-sized prostate can be completely resected with this approach within a matter of few, 15 to 20 minutes only.
SPEAKER: Even in larger glands, the total operating time does not alter significantly, up to 150 gram prostate can be completed in a single session. And prostates larger than that can be done as two sessions doing one lobe at a time. At completion, one can see complete rounded fossa, prostatic fossa all around and complete resection of the adenoma tissue with reasonably good hemostasis.
Segment:15 Hemostasis and completion.
SPEAKER: Small bleeders can be coagulated directly, while large bleeders can be coagulated by putting pressure on their stem around the bleeding points. By reducing the irrigation flow, one can catch and stop even the smallest bleeding points and achieve near complete hemostasis allowing a very bloodless outcome.
SPEAKER: And many of these patients can be discharged from the hospital within 24 hours. The inflow can be reduced to the minimum and almost to zero to allow even the smallest bleeders to show up and coagulated before completion of the procedure.
SPEAKER: Now, this kind of capillary washing may not truly be necessary, but it helps in providing a completely bloodless field at the end of the operation.
SPEAKER: The procedure, as I mentioned earlier, for bipolar and monopolar TUR are almost identical. However, due to the benefits that we see with the bipolar technology, this bipolar technology has almost completely replaced the monopolar approach
Segment:16 Evacuation of chips.
SPEAKER: in our practice. And at the end, the standard approach to removal of the prosthetic chips in a relatively bloodless field.
SPEAKER:
Segment:17 Catheter placement.
SPEAKER: A three-way Foley catheter, usually 18 or 20 French, is placed in the bladder, and gentle traction may be applied if required, which is kept in for 2 to 4 hours. And the patient is sent home within 24 or 48 hours.
Segment:18 Bipolar resection - advantages.
SPEAKER: Now, the bipolar, as I said, is exactly the same as monopolar resection, so there is no separate learning curve. The benefit of saline is in negligible electrolyte imbalance. The hemostasis is excellent, so there is less bleeding. It is safer for cardiac patients. There is less spread of current.
SPEAKER: The tissue charring and coagulation is less, so postoperative dysuria is less, and healing is faster. And the duration of catheterization and hospital stay is significantly shorter.
Segment:19 Thanks!.
SPEAKER: Thank you.
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