Doronio, Jylme Keziah M.

BSN 4B

TURP
Transurethral Resection of the Prostate

Anatomic and Physiologic Overview

In the male, several organs serve as parts of both the urinary tract and thereproductive system. Disorders
in the male reproductive organs may interfere withthe functions of one or both of these systems. As a result,
diseases of the malereproductive system are usually treated by a urologist. The structures in the
malereproductive system include the testes, the vas deferens (ductus deferens) andseminal vesicles, the penis,
and certain accessory glands, such as the prostateglands and Cowper’s gland (bulbourethral gland).

Definition
TURP is a surgical procedure involving the removal of prostate tissue using a resectoscope inserted
through the urethra.

Purpose/Indication of TURP
TURP has been long considered the “gold standard” surgical treatment forobstructing BPH specifically
when the major glandular enlargement exists in themedial lobe that directly surrounds the urethra. A relatively
small amount of tissuemust require resection so that excess bleeding will not occur and the time required
tocomplete the surgery will not be prolonged. TURP may be performed with the patientunder general or spinal
anesthesia.
A resectoscope is passed through the urethra. Tiny pieces of tissue are cutaway, and the bleeding points
are sealed by cauterization. The bladder and urethraare continuously irrigated during the procedure, allowing
visualization of theresection. Repeated irrigation and drainage of these fluids ensure that resectedtissue and
debris are removed from the bladder. Sterile, isotonic solution is selectedhowever, normal saline is avoided
because of its suboptimal conductivity properties.Also, hypotonic solution such as water must never be used.

Contraindication
Some relative contraindications include unstable cardiopulmonary status and a history of uncorrectable
bleeding disorders. Patients with a recent myocardialinfarction or coronary artery stent placement should not
have elective TURP surgeryfor a least 1 month because of the increased risk of cardiovascular events and
othercomplications. A reasonable minimum delay of 3 months is suggested, but waiting atleast 6 months after
any significant myocardial event is optimal before performing anelective TURP.
Patients who cannot be safely taken off blood thinners such as Plavix wouldalso not be candidates for
elective TURP surgery. If surgery is needed, they may be treated with a Greenlight or vaporization laser surgery
instead.
Patients with myasthenia gravis, multiple sclerosis, or Parkinson disease in whom the external sphincter
is dysfunctional and/or the bladder is severely hypertonic should not have a TURP because intractable
incontinence invariably would result. Patients who have had major pelvic fractures that involved damage to the
external urinary sphincter also should not undergo a TURP for similar reasons.
Patients who have recently completed definitive radiation therapy for prostate cancer are not candidates
for TURP because of the unacceptably high rate of urinary incontinence reported. If a TURP is absolutely
necessary, it should be delayed at least 6 months after definitive radiation therapy. Alternatives to TURP in such
a situation include drainage with a Foley or suprapubic catheter, intermittent self-catheterization, and various
other less-invasive prostatic surgical procedures.
Patients with prostate cancer who are considering brachytherapy (radioactive seed implantation) or
cryotherapy as part of their definitive treatment should not undergo a TURP because the resected tissue would
be necessary for optimal needle, probe, and seed placement. The patient would also have an increased risk for
incontinence.
An active urinary tract infection is another contraindication for TURP surgery. Usually, the surgery can be
rescheduled following a course of appropriate antibiotics.

Complication

1. TURP Syndrome – Patient can develop water intoxication, known as transurethral resection (TUR)
syndrome, as a result of excessive irrigating solution being absorbed during surgery. It is characterized
by hyponatremia, hypervolemia, hemolysis and acute renal failure. Cerebral edema may result, which
creates a medical emergency. Clinical manifestations include agitation, acute delirium, bradycardia,
tachypnea, and vomiting.

2. Incontinence – Persistent incontinence after TURP affects 1% to 2% Clients with overactive detrusor
contractions (overactive bladder), voiding frequency, and sensory urgency initially may note an increase
in the frequency of urinary leakage or de novo incontinence. Pharmacotherapy combined with pelvic
muscle rehabilitation and fluid and dietary control may be required to control overactive bladder that has
been “unmasked” by removal of obstructive prostatic tissue.

3. Retrograde ejaculation – Because the veru montanum is destroyed during most prostate surgery,
antegrade (forward) ejaculation cannot occur. Instead, semen goes into the bladder during ejaculation
and is voided with the next urination, creating cloudy urine. This effect is harmless, but sexual function
may be impaired unless the client is advised of this anticipated effect and reassured that it is expected to
alter fertility potential but not libido or erectile function.

4. Thrombophlebitis - Because patients undergoing prostatectomy have a high incidence of deep vein
thrombosis (DVT) and pulmonary embolism, the physician may prescribe prophylactic (preventive)
low-dose heparin therapy. The nurse assesses the patient frequently after surgery for manifestations of
DVT and applies elastic compression stockings to reduce the risk for DVT and pulmonary embolism.

5. Excessive bleeding - The immediate dangers after a prostatectomy are bleeding and hemorrhagic
shock. This risk is increased with BPH because a hyperplastic prostate gland is very vascular. Bleeding
may occur from the prostatic bed. Bleeding may also result in the formation of clots, which then obstruct
 urine flow. The drainage normally begins as reddish-pink and then clears to a light pink within 24 hours
after surgery. Bright-red bleeding with increased viscosity and numerous clots usually indicates arterial
bleeding. Venous blood appears darker and less viscous. Arterial hemorrhage usually requires surgical
intervention (e.g., suturing of bleeders or transurethral coagulation of bleeding vessels), whereas venous
bleeding may be controlled by applying prescribed traction to the catheter so that the balloon holding the
catheter in place applies pressure to the prostatic fossa. The surgeon applies traction by securely taping
the catheter to the patient’s thigh.

6. Infection – Urinary tract infections and epididymis are possible complications after prostatectomy. It
is mostly due to poor irrigation or introduction of bacteria by poor aseptic technique during installation
of irrigating system and urinary catheters. Intravenous or oral antibiotics are administered in the first few
days after surgery. The patient is encouraged to increase fluid intake to promote flushing of the system,
help prevent urinary stasis and decrease the chance of infection. The nurse reviews the symptoms of UTI
(fever higher than 37.6oC, chills, painful urination, back or flank pain and general malaise) which the
patient should report to the physician.

Nursing Management

Preoperative Care
• Reducing anxiety. Establish communication with the patient to assess his understanding of the
diagnosis and of the planned procedure. Preoperative teaching - Include attention to expectations about
the procedure, such as anticipated changes in voiding and sexual function.

• Preparing the patient. Properly assess the patient’s health history, contraindications and other
preoperative assessment. Client taking any drug or supplement with anticoagulant effects should be
discontinued before the surgery. Obtain informed consent.

• Providing Instruction.

Postoperative Care

• Maintaining fluid balance. The urine output and the amount of fluid used for irrigation must be
closely monitored. Monitor electrolyte imbalance as well. Frequently assess the client’s output (must
include records of intake and output, amount of instilled with the irritation. Monitor for retention.

• Relieving pain. Ensure catheter patency and prevent catheter dislodgement. Administer

medication as prescribe. Offer warm compresses to the pubis or sitz bath to relieve spasm.
Encourage to ambulate.
 • Monitor for bleeding. Monitor vital signs and laboratory results. Implement strategies to stop
bleeding and to prevent or reverse hemorrhagic shock. If blood loss is extensive, fluids and blood
component therapy may be given.

• Prevent infection. Careful aseptic technique should be used when irrigating the bladder. Proper
care of the catheter is important. Monitor for signs of local and systemic infection. Maintain closed
drainage system unless manual irrigation is required. Encourage fluid intake, ambulation and deep
breathing. Rectal procedures should be avoided.

• Manage temporary incontinence. Keep in his mind that these problems are just temporary and have
time to be resolve. Be understanding to the patient and assist him in cleansing the perineal area. Counsel
about the use of containment devices, urethral clamps and absorbency products. Encourage muscle
exercises.

Self Care

• Provide teaching. Includes catheter and wound management, activities that are limited based on
orders (heavy lifting, strenuous activity for 4-6 weeks, prolonged sitting except during meals, sexual
activity, and driving or riding in an automobile at least 2 weeks.

• Prevent injury Advise not to strain during defecation for at least 6 weeks. Docusate sodium,
prune juice, and milk of magnesia. Increase amount of fluid intake. Avoid or limit alcohol and other
bladder stimulant such as caffeine. Smoking should be discouraged because coughing puts strain on the
surgical area.

• Teach pelvic muscle rehabilitation Men with post prostatectomy incontinence who practiced
repeated pelvic muscle contractions with or without behavioural biofeedback or electrical stimulation
several times a day reported decreased incontinence following treatment.

• Arrange Follow Up Patient should report any elevated temp., unusual bleeding, manifestation of
wound infection or UTI and obstructed urinary flow.