Endoscopic Management of BPH

Endoscopic surgery is the mainstay of operative management for bladder outlet obstruction due to benign prostatic enlargement. The options range from resective and ablative techniques (TURP, photovaporization) to minimally invasive, ejaculation-preserving approaches (UroLift, TUIP), with the choice driven by gland size, anticoagulation status, and the patient's priorities around sexual function.

Transurethral Resection of Prostate (TURP)

Preoperative Considerations

• Anticoagulation: higher risk for postoperative transfusion, clot retention, and VTE, consider laser prostatectomy
• Counsel that retrograde ejaculation occurs in 62-78%
• Erections: 30% report improvement vs 20% report worsening, overall no change in sexual activity

Operative Technique

1. Dorsal lithotomy, genitals at edge of bed, optimize space between legs by spreading knees
2. Resectoscope: 30 degree lens, yellow sheath (26Fr), visual obturator
3. Confirm bi vs mono polar equipment and irrigation
4. Prep and drape patient
5. Set up light + camera cord and irrigation fluid with stopcock
6. Place sound in meatus to passively dilate urethra
7. Lubricate entire scope length (minimizes stricture formation)
8. Insert resectoscope, empty bladder, examine prostate, verumontanum, and ureteral orifices
9. Resect prostate starting with median lobe, then move anteriorly for lateral lobes
10. Reassess and repeat resection for adenoma as needed, shorter swipes near apex
11. Obtain hemostasis as needed
12. Remove chips with Ellik or Toomey syringe
13. Repeat obtaining hemostasis, reassess at lower pressure
14. Remove scope with bladder full (may see passive drainage), place 20Fr 3-way catheter and inflate with 30mL sterile water, irrigate to confirm placement and drainage

Operative Tips

• Bipolar vs monopolar: bipolar has no risk TUR syndrome but monopolar better at hemostasis, mainly surgeon preference
• Anesthesia: can consider spinal if high risk
• Bipolar settings: 200 resection, 120 vaporization
• Monopolar settings: 90 cut, 60 coag
• Chip length: avoid short chips, prolongs resection time and makes identifying bleeding more difficult
• Visualization: always keep 1/4 loop visible to maintain same resection depth
• Fulcrum: sweep hands in opposite direction of resection (think clock face), allows loop to resect entire depth of prostate (shaped like a bowl)
• Collecting chips: cut off top and bottom of suction bag to isolate chips then scoop directly into specimen cup
• TUR syndrome: more common in larger glands (> 45g) and longer surgeries (> 90min)
• Intraoperative erection: rare, may require phenylephrine injection

Expected Postoperative Course

• Void trial POD#1
• If patient passes, discharge POD#1 without catheter
• If patient fails, replace catheter, void trial in 3-5 days
• Stool softeners to prevent constipation (can cause hematuria from straining)
• Avoid physical activity causing perineal pressure for 4-6 weeks
• Intermittent hematuria and dysuria normal for 4-6 weeks
• 75-93% report improved voiding symptoms

Postoperative Complication Management

• Bleeding: fill balloon to 50-60mL, place catheter on traction, transfuse prn
• Bladder neck contracture: 2%, slowly decreasing flow rates, confirm with cystoscopy, open laterally until it accommodates cystoscope, can give methylene blue to identify obliterated opening
• Stricture: 4%, lubricate scope to prevent intraop, low rates with SP catheters over urethral catheters

Prostatic Urethral Lift (UroLift)

Preoperative Considerations

• Contraindicated if history urinary retention
• Perform cystoscopy to rule out presence of median lobe
• Perform sizing, less effective for glands > 80g
• Should have minimal effect on erectile and ejaculatory function (no tissue removed)

Operative Technique

1. Place patient in dorsal lithotomy position, prep/drape similar to TURP
2. Insert cystoscope, inspect bladder and prostate
3. Position device 1.5cm distal to bladder neck, visualizing verumontanum
4. Unlock safety
5. Compress against prostatic tissue at 2 or 10 oclock (anterolateral position)
6. Pull needle trigger (blue trigger)
7. Pull retraction trigger (gray trigger) to pull needle back
8. Move scope proximally towards bladder until silver line visible
9. Push urethral release button to cut suture
10. Usually place 4 implants, more if needed

Postoperative Management

• 1/3 failed immediate void trial and required catheter for ~1 day
• Up to 2% have inadequately placed implants and need removal due to encrustation
• Many patients will likely require a second treatment in the future due to tissue growth

Photovaporization (PVP, KTP)

Preoperative Considerations

• Useful for patients on active anticoagulation, but best if patients can be bridged
• Works best for prostates < 80-100g

Operative Technique

1. Position similar to TURP (see above), prep/drape
2. Set up separate laser irrigation cord, keep closed until ready to start surgery (will avoid running out of fluid)
3. Reverse trendelenberg to 6 degrees (forces bubbles into bladder to improve visualization)
4. Dilate meatus and lubricate entire scope length
5. Insert cystoscope into bladder, assess location of ureters and trigone relative to bladder neck
6. After inspecting, open laser and attach to irrigation fluid
7. Position laser so blue triangle is visible (can damage scope if laser too close)
8. Can rapidly zap entire prostate on 80 to superficially cauterize all tissue
9. Take down median lobe, either by creating lateral channels first or just working from one side to the other
10. Increase the energy level as needed (120+)
11. Maintain appropriate distance and timing, otherwise laser will coagulate and not vaporize
12. Obtain hemostasis as needed
13. Can consider giving 20mg IV furosemide to assist with diuresis
14. Place 18Fr 2-way or 22Fr 3-way (if concerned for bleeding)
15. Disposition: admit and perform void trial in AM, admit and discharge with catheter in AM for clinic void trial, or discharge from PACU with catheter for clinic void trial

Postoperative Management

• Maintain fluid intake to minimize hematuria
• Dysuria minimized by avoiding accidental tissue coagulation during surgery, can treat with NSAIDs and occasionally a steroid taper
• Transfusion need is rare

Transurethral Incision of Prostate (TUIP)

Preoperative Considerations

• Useful for younger patients who want to avoid retrograde ejaculation
• Size: best candidates are small glands (< 30g)
• Median lobe is not a contraindication

Operative Technique

1. Position similar to above
2. Insert resectoscope and examine prostate and bladder neck
3. Incise at 5 o'clock or 7 o'clock positions, unilaterally or bilaterally
4. Can incise with laser or hot knife
5. Incise down to surgical capsule (some incise down to periprostatic fat)
6. Obtain hemostasis
7. Insert catheter to monitor immediate urine appearance

Postoperative Management

• Can keep overnight or discharge immediately, with(out) catheter
• Retrograde ejaculation: 0-37%, less with unilateral incision

Reported Surgical Complications (from Campbell's)

	mTURP	bTURP	TUNA	TUMT	HoLEP	PVP	TUVP	TUIP
Temporary retention	4.3-6.8%	3.3-3.7%	23%	10-24%	2.7-5.9%	5.2-9.9%	2-9.8%	4.9-11.3%
UTI	4.1-6.2%	2.6-8.4%	4%	15-20%	0.9-2.7%	4.2-12%	0%	—
BNC	2-3.2%	0.5%	—	0%	1.2-1.5%	1.1-5%	0.5-1%	—
Stricture	3.4-4.1%	0.5-4.7%	0.5%	0-2%	1.9-4.4%	1-6.3%	1.9-3.3%	2.9-8.8%
Incontinence	0.6-1.5%	0-1%	—	—	0.9-1.1%	0-0.4%	0-2%	0.3-1.8%
Transfusion	2-4.4%	1.5-2.3%	rare	0%	0-1%	0%	0-0.5%	1.1%
Clot retention	4.9-7.2%	2.7-7.9%	—	1%	0%	0%	0-0.5%	—
Hematuria	3.5-15.7%	1%	6-28%	1-26%	0%	0.7%	0%	4.3%
Dysuria	0.8%	0%	8-14%	14%	1.2%	8.5-13.9%	2.9%	—
Urgency	2.2%	0.2%	10%	—	5.6%	0%	0%	—
Storage symptoms	—	—	—	18-31%	—	—	21%	—
Reoperation for BPE	0.5%	0.2%	19%	4%	0%	0.7-5.6%	2.4%	—
Reoperation other than for BPE	1.1%	0.2%	0%	—	1.9-2.8%	—	5.4%	9.6-18.4%
Capsular perforation	0.1%	0%	—	—	0.2%	0%	0%	—
Conversion to TURP	n/a	0%	n/a	n/a	0%	3.5%	0%	—
TUR syndrome	0.8-2.5%	0%	0%	0%	0%	0%	0%	—
Bladder mucosal injury	0%	0%	0%	—	3.3%	0%	0%	—