Transurethral resection of the prostate: the resection through the scope

Operative visualisation

UrOops3D · UroRef · © Nity G

Operative steps

1. Before the scope: consent, position, the stack The consent conversation names the specific things: retrograde ejaculation in most men, bleeding that may need transfusion or a return to theatre, infection, a catheter for a day or two, the small risks of incontinence and stricture, the chance of needing a second procedure years later, and TUR syndrome if the resection is monopolar. An MSU is clear or treated, the anticoagulation plan is written down, and antibiotics go in at induction. The patient is in lithotomy in Lloyd-Davies supports with the buttocks just over the end of the table, the legs padded at the peroneal nerve, the diathermy plate on the thigh. On the stack: the camera and light lead, the irrigation line from a bag hung no higher than sixty centimetres above the patient, the outflow to a bucket, and the generator set for the electrode in use. A rectal examination under anaesthetic tells the surgeon the size of the gland before the scope goes in.
2. The instrument: what a resectoscope is A 26 French continuous-flow sheath with an inner and outer channel, so irrigant runs in through one and out through the other and the bladder never fills. Into the sheath goes either the visual obturator for passing it, or the working element: a spring-loaded trigger that moves the loop in and out along a rack, carrying a 30 degree telescope and the electrode. The loop is a fine wire on two supports; when the trigger is squeezed the loop comes toward the sheath, and cutting happens on that pull, never on the push. A bipolar system cuts in normal saline, with the return electrode on the loop itself; a monopolar one needs a non-conducting irrigant, 1.5 per cent glycine, and the plate on the thigh. On the trolley beside it: the Ellik evacuator, a Toomey syringe, a 22 French three-way catheter with a 30 ml balloon, and a specimen pot for the chips.
3. Urethroscopy and cystoscopy The sheath is passed under vision with the visual obturator, following the lumen and not the resistance: the bulbar urethra, then the external sphincter as a closed ring that opens as the scope approaches, then the verumontanum at six o'clock and the prostatic urethra with the lateral lobes kissing in the midline and the median lobe as a mound on the floor at the bladder neck. Into the bladder: the air bubble sits at twelve o'clock and gives orientation, the trigone is the raised triangle on the floor, and both ureteric orifices are found at its corners and their distance from the bladder neck noted. The walls are surveyed for stones, tumour and diverticula. Only when the surgeon has seen the sphincter, the veru, the neck and both orifices does the working element go in.
   where it bites: a ureteric orifice that sits close behind a large median lobe is the one that gets resected; find it before the first cut, not after.
4. The landmark hold The scope rests with the lens just on the bladder side of the verumontanum and the loop parked at six o'clock. From here the surgeon can see the veru below the lens, the bladder neck as a ring ahead, and the lateral lobes either side. This is the reference position; every time orientation is lost, the scope comes back to it. The rule that runs the whole operation is that nothing distal to the veru is cut, because the external sphincter lies two centimetres beyond it, and nothing deeper than the surgical capsule is cut, because the venous sinuses and the periprostatic fat lie beyond that.
5. The median lobe, from the neck toward the veru The first cuts go into the median lobe at six o'clock, starting at the bladder neck and working back toward the verumontanum in short strokes, each one adjacent to the last so the bed stays flat. Each stroke is the same: the loop is pushed out beyond the tissue on the bladder side, current comes on, and the trigger draws it back through the adenoma toward the sheath and the veru; the chip lifts off and floats away. The capsule does not move: each chip takes a layer of adenoma off it, and it is uncovered where the tissue has gone. The tissue changes as the depth increases: the adenoma is granular and pale, and when the loop reaches the surgical capsule the bed shows criss-crossing white fibres like the inside of a coconut. That is the floor. The lobe is levelled to it from the neck to a point just proximal to the veru, and the bladder neck fibres are seen as a transverse ring at the top of the trench.
   where it bites: a deep central trench with two shoulders is the commonest mistake; keep the bed flat so that both lateral lobes have a defect to fall into.
6. The right lobe: release along eleven, ten, nine A lateral lobe comes out in two moves. First it is released: a trench is cut from the bladder neck to the level of the veru along the roof of the lobe at eleven o'clock, and deepened to the capsule, then the same at ten and at nine. As the trench reaches the capsule the lobe, no longer held at its roof, drops into the median defect. Second it is taken: the loop is passed behind the dropped lobe at about eight o'clock and hooked into it so that each stroke takes a full-length chip from the neck to the apex, and the lobe comes away in adjacent flat chips until the capsule shows across the whole sector. The apical part of the lobe, beside the veru, is left for the apical step.
   where it bites: the capsule is thinnest at the apex and laterally at nine and three o'clock; fat seen at the bottom of a trench means the loop has gone through it.
7. The left lobe: the mirror at one, two, three The same two moves on the other side: release along one, two and three o'clock from the neck to the veru, let the lobe drop, hook it at four o'clock and take it in adjacent chips. Before starting the second lobe the surgeon comes back to the landmark hold and looks again at the veru and the neck, because a bleeding field and a changed shape make it easy to lose the level. One sector is finished, and its bleeding controlled, before the next is opened.
8. The apex, from twelve o'clock, and the tissue beside the veru What remains is a shelf of tissue at twelve o'clock, where the two lobes met at the roof, and the apical tissue on either side of the verumontanum. The roof is taken with the loop turned over, its bend at twelve o'clock, and short strokes drawn back toward the veru. The apical tissue is taken the same way as every other part of the gland: the loop is put out over the tissue on the bladder side and each stroke is drawn back toward the veru, ending at it and never carried beyond it. A small apical remnant is accepted; a sphincter is not. The sphincter is checked without turning the view round: the scope is withdrawn into the bulbar urethra, still looking forward, and the sphincter is seen to close as a ring ahead of the lens with the veru beyond it.
   where it bites: the loop never goes distal to the verumontanum; the external sphincter is the next structure.
9. Chips out: the Ellik The telescope and working element come out of the sheath and the Ellik evacuator goes on, its bulb full of irrigant with no air. Squeeze and release: the chips are drawn out of the bladder into the glass chamber and settle, and the process is repeated until the return is clear. A Toomey syringe does the same for a few remaining chips. The scope goes back in to check every chip is out and to look at the bed and the bladder for a chip lodged behind the neck. The chips are drained, weighed, and sent for histology in formalin; the house officer writes the weight on the form and the op note.
10. Haemostasis With the resection finished the loop is exchanged for the button or roller electrode, or the loop is used on coagulation. The irrigation is slowed and the bed inspected sector by sector. Arterial bleeders spurt in a jet across the field and are coagulated at their point, not sprayed across the bed; venous sinuses ooze dark blood and bleed more when the pressure falls, and are not chased, because coagulating a sinus opens it further. The irrigant is turned off for a moment and the field watched: what fills it now is what the catheter has to control. Bleeding at the bladder neck at five and seven o'clock, where the arteries enter, is checked last.
11. The catheter, and what to write A 22 French three-way catheter goes in over the bed with the balloon filled to 30 ml in the bladder, irrigation connected and running until the effluent is rosé rather than red. Traction, with the balloon pulled down onto the bladder neck and the catheter taped to the thigh, is used for venous ooze and released within a few hours. The op note records the resection weight, the resection time, the irrigant used and the deficit, the electrode used, whether the sphincter and orifices were seen intact, the catheter size and balloon volume, and the irrigation plan. On the ward the house officer watches the colour of the bag, the bladder for clot retention, and the sodium if the resection was monopolar.

Complications and immediate saves

Trigger each of these live in the Animation tab, then read the save: the first move, the escalation trigger, and the line that goes in the op note.

FRCS viva questions

The examiner stems this scene prepares you for. Try to answer out loud first, then reveal, and learn the discriminator, the detail that turns a pass into a strong pass.

Evidence and guidance