Minimal Invasive Transurethral Resection of the Prostate 10

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10 Minimal Invasive Transurethral Resection of the Prostate

Jan Fichtner

Introduction – 90 Anaesthesia – 90 Indications – 90 Contraindications – 90 Instruments – 90

Operative Technique (Step by Step) – 90 Operative Tricks – 90

Postoperative Care – 90 Image Gallery – 91

Hohenfellner_L4F-2sp.indd 89

Hohenfellner_L4F-2sp.indd 89 23.06.2005 17:56:4423.06.2005 17:56:44

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Introduction

While standard transurethral resection of the prostate (TUR-P) remains the gold standard for surgical treatment of BPH in selected patients with significant comorbidity and subsequently elevated operative risk factors, the questions of a minimal invasive alternative to standard TUR-P may arise.

For this indication a variety of primarily no- nablative treatment options (laser, thermo, cryo, TUNA, etc.) have been described with limited results and significant associated costs.

A minimal TUR-P (MINT) with the aim of creating a prostatic channel with resection of limited tissue during a short intervention (10 min) is described in a modification of the original Nesbit technique. The resection is limited to the anterior tissue from the 11 o’clock to the 1 o’clock position without involvement of the lateral and median lobes. This resection technique, in cont- rast to the one described by Flocks, allows creation of a channel sufficient for bladder emptying and avoids protruding lateral lobes. Apart from the short operative duration, the risk of bleeding with this technique is very low.

Anesthesia Spinal anaesthesia.

Indications

▬ Recurrent urinary retention.

▬ Recurrent urinary tract infection secondary to bladder outlet obstruction.

▬ In patients with high anesthesiologic risk (ASA III–IV).

Contraindications

▬ Uncorrected coagulopathy.

▬ Associated bladder stones.

▬ Acute renal insufficiency.

Instruments

▬ A 24-Fr resectoscope with 0° optic.

▬ Video camera with rotatable camera head

▬ A 20-Fr irrigation catheter.

▬ Lubricant.

▬ Optional trocar cystostomy for low pressure resection.

Operative Technique (Step by Step)

▬ Lithotomy position.

▬ Blind trocar or visual insertion of the resectoscope sheath.

▬ Urethrocystoscopy with identification of verumontanum, prostatic urethra, bladder neck and ureteral orifices.

▬ Fixation of the sheath at the level of the verumontanum with the left hand and rotation of the loop to the 12 o’clock position.

▬ Eversion of the loop and beginning of the resection at the bladder neck and 12 o’clock.

▬ Immediate hemostasis with the back-gliding loop over the exposed tissue.

▬ Creation of a tunnel by additional resection at the 11 and 1 o’clock position.

▬ Optional bladder neck incision at the end of the procedure.

Operative Tricks

▬ Resection with slowly gliding loop achieves an optimal coagulation effect

▬ The surgeon’s left hand is of importance for securing the sheath at the verumontanum and avoidance of sphincter damage.

Postoperative Care

▬ Irrigation for 12–24 h.

▬ Catheter removal with clear irrigation after 24 h.

▬ Removal of suprapubic tube with residual urine below 50 cc.

90 Chapter 10 · Minimal Invasive Transurethral Resection of the Prostate

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Chapter 10 · Minimal Invasive Transurethral Resection of the Prostate ⁹¹

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Image Gallery

⊡ Fig. 10.3. First resection at the 12 o’clock position ⊡ Fig. 10.4. Resulting anterior channel

⊡ Fig. 10.2. Rotation of the loop to the 12 o’clock position

⊡ Fig. 10.1. Small amount of anterior tissue

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92 Chapter 10 · Minimal Invasive Transurethral Resection of the Prostate

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⊡ Fig. 10.6. Minimal invasive transurethral resection of the prostate: Channel formation from 11–1 o’clock position (left and right top). Final endoscopic view (right bottom)

⊡ Fig. 10.5. Completion of the voiding channel following resection from 11 to 1 o’clock