Transurethral resection of the prostate

Operative visualisation

Operative steps

1. Unlock camera, then cystoscopy Unlock the camera from the head of the resectoscope before any loop rotation, so the view stays true while the instrument turns inside the urethra. Enter in one continuous movement into a single bladder cavity, confirming the dome and both side walls come into view without a second hold-up. Complete a slow, full circumferential cystoscopy with the bladder partly filled, reading the shape of the cavity before any cutting begins. A rushed survey is how a second pathology or unexpected anatomy is missed before the first pass is ever made.
2. Check both UOs Sweep the trigone deliberately and identify exactly two ureteric orifices, one each side of the midline. Fix their relationship to the bladder neck and to any median lobe before the loop is energised, and carry that map for the whole case. Where a median lobe crowds the trigone, confirm both clear jets of urine rather than trusting a single glance. An orifice resected in error announces itself weeks later as a silent, obstructed kidney.
3. Check the verumontanum Withdraw under vision from the bladder until the verumontanum rises at 6 o'clock, and centre it on the screen. This is the fixed distal-limit station: every later pass is measured against it, and the memorised relationship of veru, neck and lobes is the map for the whole resection. Note its height and the tissue crowding it before any cutting begins. Everything distal to this point belongs to the external sphincter.
   where it bites: Never resect or coagulate the verumontanum. The external sphincter lies immediately distal.
4. Median lobe: proximal passes from the bladder neck Using bipolar cut at the film reference setting of 200 W in 0.9% normal saline, seat the loop at the bladder neck and begin on the proximal median lobe. Withdraw through the proximal part of the median lobe in a controlled stroke, with repeated passes towards the planned capsular plane. The bladder neck is the depth reference for the whole lobe, which is why the sequence begins here.
5. Median lobe: cumulative distal passes Continue through the distal part of the median lobe, still withdrawing from bladder neck towards the verumontanum so every stroke keeps the same direction and reference. Stop each pass safely proximal to the veru, because the distal limit declared at the start governs the median lobe exactly as it later governs the apex. Confirm the generator-specific settings and local protocol before the distal passes begin, since a setting found wrong mid-pass is found late.
6. Patient-right release: seat at 11, then slowly down to 9 Seat the curved tip of the U at the 11 o'clock entry and hold it still before any current flows, so the first cut starts from a placed position rather than a moving one. Begin at the bladder neck on screen-left, then come down slowly: the tip indexes 11, then 10, then 9 o'clock in one unhurried descent. The release is confirmed by the connected patient-right lobe peeling off the wall and revealing the muted fibrous-rose capsule along the line travelled. The slow descent keeps the release in one sheet, because a rushed descent tears through adenoma in one place and leaves it attached in another.
7. Return to the distal-limit station, loop fully closed Withdraw the resectoscope to the fixed forward operative station just proximal to the verumontanum, closing the loop fully before the move. Bring the camera optical axis inside the curve of the U so the working view sits at the distal end of the channel rather than floating in the bladder. From this station the view looks forward along the resected field towards the bladder neck, and every later release and retrieval returns to the same position. Keep looking towards the bladder neck: reversing or drifting from the station is how the distal limit is quietly lost.
8. Patient-right lobe drops Hold the closed loop exactly where it is and wait after the release completes, without reversing the camera or advancing. The broad patient-right lobe, detached at the capsule, settles under gravity and irrigation into the median-lobe defect and out of the working line. The check is visual: the lateral wall that was full is now empty, and the fallen lobe lies across the floor of the channel. The waiting is part of the manoeuvre, because cutting a lobe that is still settling means cutting it again once it lands.
9. At the end, looking back: hook at 8 o'clock From the fixed distal station the forward view already contains the bladder neck, so retrieval begins in the same position the release ended on. Extend the loop out towards the neck, rotate its curved U-tip to 8 o'clock, and hook the dropped free edge of the fallen patient-right lobe where it lies adjacent to the bladder neck. The hook must catch the free edge rather than the wall behind it, read from the pale cut surface of the edge against the darker lobe. Only once the loop is visibly around tissue does current enter the plan.
10. Massive chunks from the caught edge Apply current only after the loop is confirmed in contact with the caught edge, because a loop energised in air burns without cutting and fogs the view. Take the dropped lobe in three massive chunks: deep, long strokes pulled steadily towards the camera through broad lateral tissue extending to the bladder neck. Each stroke travels the full length of the lobe in one movement, which keeps the cut plane flat and leaves a single readable bed. Fragmented, hesitant cutting produces a ragged floor in which residual adenoma and bleeding points are both harder to find.
11. Patient-left release: seat at 1, then slowly down to 3 Mirror the manoeuvre on screen-right: seat the curved tip of the U at the 1 o'clock entry and hold before cutting, exactly as on the first side. Descend slowly through 1, then 2, then 3 o'clock so the tip indexes the wall in one continuous descent while the connected patient-left lobe is released to the capsule. The muted fibrous-rose capsule should appear along the full length of the descent, confirming the plane runs at the same depth as the right side. Working the mirror image keeps the two beds symmetrical, which is what the final haemostasis sweep then reads easily.
12. Return to the fixed distal-limit station Return the scope to the same fixed forward station just proximal to the verumontanum, closing the loop before the move. Re-establish the memorised distal limit by confirming the veru rises at 6 o'clock in the same relationship to the surrounding tissue as at the first check. The bladder-neck view is held throughout, so release, settle and retrieval run inside one continuous visual frame rather than a series of re-found positions. This return is also where any residual ridge of unreleased tissue declares itself against the resected floor.
13. Patient-left lobe drops Pause after completing the release and give the left lobe the same waiting time, without reversing the camera or moving the loop. The detached lobe settles under gravity and irrigation into the channel, falling across the floor towards the median-lobe defect its counterpart already occupies. Confirm the drop by the emptied left lateral wall and the presence of both fallen lobes in the working view. Resecting before the drop completes risks cutting the lobe twice, once where it hung and once where it lands.
14. At the end, looking back: hook at 4 o'clock Mirror the previous retrieval within the fixed forward view: extend the loop out towards the bladder neck and rotate the curved U-tip to 4 o'clock. Hook the fallen patient-left lobe's dropped free edge where it rests adjacent to the bladder neck, catching the pale cut edge rather than the wall behind it. Confirm the loop has encircled tissue before any current is applied, the same contact rule as the first side. A symmetric retrieval leaves the two lateral beds flat and comparable for the final sweep.
15. Massive chunks from the caught left edge Remove the broad left lobe in three massive chunks with long, complete withdrawal strokes through the lobe, each stroke pulled the full distance towards the camera. The depth check runs through every stroke: cut down to, but not through, the capsule, reading the muted fibrous-rose plane as the stop line. Three deliberate strokes leave a single flat bed on which every bleeding point can later be found.
16. Hold the distal safety limit Before treating the apex, hold the same fixed forward station just proximal to the verumontanum and confirm the veru is still the distal border of the view. The apex is where the external sphincter and the veru converge, so the declared limit matters more here than anywhere else in the case. Do not reverse the bladder-neck view to see the apex: the apical work is done from the same station, with the loop brought out to the tissue rather than the scope pushed towards the sphincter. The deliberate pause at the station is what separates a planned apex from an accidental one.
17. Final 12 o'clock apical resection Turn the complete U upside down and place its curved tip at 12 o'clock on the apical roof. Pull each short apical cut towards the camera across the top of the field, keeping every stroke proximal to the verumontanum and re-reading the veru after each cut. Short strokes are the discipline here, because apical tissue sits closest to the sphincter and a long stroke cannot be stopped mid-course. The film shows tissue evacuation in the final Ellik sequence.
18. Ellik, reassess and selectively resect if needed Advance the sheath into the bladder, stop the inflow and let the field settle, then inspect the dependent base where the chips have collected and hold that angle. Keep the sheath in place, attach the Ellik and open the evacuation channel for three controlled cycles, watching tissue rather than irrigant leave each time. Withdraw the Ellik, restore the working view and reassess the channel, which now sits slightly narrower and gently oozing from the resected beds. Selectively resect remnant tissue only where a distinct ridge or lobe remnant is visible, rather than re-cutting the beds for appearance.
19. Button diathermy: bladder neck and median-lobe bed After Ellik evacuation and any selective re-cut, retract and hide the cutting loop so the working channel carries the button electrode alone. Use the button electrode at the film reference setting of 120 W, rolling it in short, overlapping strokes so each point of tissue is coagulated once and seen to blanch. Treat the bladder neck by clock face first, working systematically around the ring so no sector is skipped or treated twice. Move to the median-lobe bed second, since the neck bleeds first and the bed reads best once the neck is dry.
20. Button diathermy back to the veru and lateral-bed check Continue systematic button haemostasis backwards along the channel all the way to the verumontanum, working in the same sector order so the whole surface is covered once the veru is reached. The endpoint is effluent running rose rather than red, with no arterial spurter anywhere in the field. Inspect both lateral beds deliberately and treat the two demonstrated surface bleeders selectively, coagulating the identified vessels rather than painting the whole bed. Selective treatment preserves viable tissue, which is what keeps post-operative slough and irritative symptoms down.

Complications and immediate saves

Use the operative film to locate each danger moment, 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