612 CHAPTER 16 Urological surgery and equipment

Transurethral resection of the prostate (TURP)

Indications

•Bothersome LUTS that fail to respond to changes in lifestyle or medical therapy

•Recurrent acute urinary retention

•Renal impairment due to bladder outlet obstruction (high-pressure chronic urinary retention)

•Recurrent hematuria due to benign prostatic enlargement

•Bladder stones due to prostatic obstruction

Postoperative care

A three-way catheter is left in situ after the operation, through which irrigation fluid (normal saline) is run to dilute the blood so that a clot will not form to block the catheter. The rate of inflow of the saline is adjusted to keep the outflow a pale pink rosé color and, as a rule, the rate of inflow can be cut down after about 20 minutes. The irrigation is continued for 712–24 hours.

The catheter is removed the day after (second postoperative day) if the urine has cleared to a normal color (trial without catheter [TWOC] or trial of void [TOV]).

Common postoperative complications and their management

Blocked catheter post-TURP

This is common. The catheter may become blocked with clot or a prostatic chip that was inadvertently left in the bladder at the end of the operation.

•Apply a bladder syringe to the end of the catheter to try to dislodge the obstruction.

•If this fails, withdraw some irrigant into the syringe and flush the catheter.

•If this fails, change the catheter. The obstructing chip of prostate may be found stuck in one of the eyeholes of the catheter.

•Pass a new catheter, on an introducer.

If the bladder has been allowed to become so full of clot that a simple bladder washout is unable to evacuate it all, return the patient to the operating room for clot evacuation.

Hemorrhage

Minor bleeding after TURP is common and will stop spontaneously. A simple system to allow communication between staff is to describe the color of the urine draining through the catheter as the same as a rosé wine (minor hematuria), a dark red wine (moderate hematuria), or frank blood (bright red bleeding, suggesting serious hemorrhage).

614 CHAPTER 16 Urological surgery and equipment

Transurethral resection of bladder tumor (TURBT)

Indications

•Local control of non-muscle-invasive bladder cancer (i.e., stops bleeding tumors)

•Staging of bladder cancer—to determine whether the cancer is nonmuscle invasive or muscle invasive, so that subsequent treatment and appropriate follow-up can be arranged

Postoperative care

A twoor three-way catheter is left in situ after the operation, depending on the size of the tumor and, therefore, on the likelihood that bleeding requiring irrigation will be required. As for TURP, normal saline is run through the catheter to dilute the blood so that a clot will not form to block the catheter. It is particularly important to avoid catheter blockage post-TURBT, since this could lead to distension of the bladder already weakened by resection of a tumor.

The period of irrigation is usually shorter than that required after TURP, and for small tumors the catheter may be removed the day after the TURBT. For larger tumors, remove it 2 days later.

Common operative and postoperative complications and their management

Bladder perforation during TURBT

Small perforations into the perivesical tissues (extraperitoneal) are not uncommon when resecting small tumors of the bladder. So long as you have secured good hemostasis and all the irrigating fluid is being recovered, no additional steps are required, except that perhaps one should leave the catheter in for 4 rather than 2 days.

Intraperitoneal perforations (through the wall of the bladder, through the peritoneum, and into the peritoneal cavity) are uncommon, but far more serious.

Is it an extraperitoneal or intraperitoneal perforation? Establishing this can be difficult. Both can cause marked distension of the lower abdo- men—an intraperitoneal perforation by allowing escape of irrigating solution directly into the abdominal cavity, and an extraperitoneal perforation by expanding the retroperitoneal space, with fluid then diffusing directly into the peritoneal cavity.

The fact that a suspected intraperitoneal perforation was actually extraperitoneal becomes apparent only at laparotomy when no hole can be found in the peritoneum overlying the bladder (the peritoneum over the bladder is not breached in an extraperitoneal perforation).

When there is no abdominal distension, the volume of extravasated fluid is likely to be low and, if the perforation is small, it is reasonable to manage the case conservatively. Achieve hemostasis and pass a catheter.

Make frequent postoperative assessments of the patient’s vital signs and abdomen (worsening abdominal pain, distension, and tenderness suggest the need for laparotomy).