Transurethral resection of the prostate

Indications for prostatectomy have been described in detail in open prostatectomy. The choice of transurethral or other means of prostatectomy depends on many different factors. Treatment of diseases: prostate cancer prostatic hyperplasia Indication Indications for prostatectomy have been described in detail in open prostatectomy. The choice of transurethral or other means of prostatectomy depends on many different factors. Benign prostatic hyperplasia (1) large adenoma: open prostate resection is appropriate, can quickly and completely remove hyperplastic glands. (2) Moderate-sized adenoma: both open prostatectomy and transurethral resection of the prostate can be performed. A frail patient with better tolerance after surgery is better, and the postoperative wake-up activity is faster. The choice of the two methods depends mainly on the personal experience of the urologist and his proficiency in transurethral resection. Transurethral resection should not last more than 1 hour. Regardless of the method used, it is required to remove as much gland tissue as possible. (3) small adenoma: should be removed through the urethra, because this prostate is deep in the pelvis. 2. Prostatic stones: The large adenoma with stones is located between the gland and the capsule, and open resection is feasible. Small and medium adenomas with stones, feasible transurethral resection, and the formation of fibrous tissue can increase the difficulty. 3. Prostatitis and prostate cancer: glands with prostatitis, prostate cancer or clinical diagnosis of fibrosis should undergo transurethral resection, and an appropriate separation gap may not be found due to open surgery. Large glands containing small cancerous lesions can often be removed, but are not easily diagnosed before surgery. Prostatic granuloma is often mistaken for cancer and resection; however, if a biopsy can be used to confirm the diagnosis before surgery, surgery can be avoided because dysuria can disappear automatically after steroid treatment. 4. Bladder neck obstruction: more common in older women. Contraindications 1. Prostatic hyperplasia is too large. 2. Prostatic hyperplasia with bladder stones. 3. Prostatitis with severe urethritis. 4. The diameter of the urethra is too small, and it is difficult to insert the instrument. Preoperative preparation In addition to the degree of obstruction, urine culture, hemoglobin and blood type determination, and blood matching are required. Intravenous pyelography is also needed to check for obstruction, upper urinary tract malformation and prostate size. The ureter is hook-shaped. It is a reliable sign of x-ray when the prostate is very large; the stone can be seen in the prostate; the base of the irregular bladder suggests a cancerous lesion in the prostate. When there is an infection in the urine, antibiotics should be given properly, and patients with anemia should receive blood transfusions. When there is chronic urinary retention and severe renal failure, slow bladder decompression, catheterization for a period of time, and even hemodialysis may be required before surgery. Many patients have concerns about whether prostatectomy has an effect on sexual function. It should be explained to all patients, especially those under the age of 60. Prostatectomy often causes retrograde ejaculation, which leads to infertility, and prostatectomy does not reduce sexual function unless the former is already present. Surgical procedure 1. Position: The position of the stone is cut, and a drainage liquid tray can be connected to the lower end of the operating table to receive the drainage liquid. A sieve is placed in the tray of the drainage fluid to receive the cut prostate tissue piece. Send a biopsy. 2. Check the instrument: Before each electric resection, it is necessary to repeatedly check and test the electric cutting device. If you are satisfied, you can perform this operation. See transurethral resection of bladder tumor. 3. Urethral cystoscopy: urinary cystoscopy must be performed before surgery, and a comprehensive understanding of the urethra, the entire bladder, the bladder neck, the posterior urethra, the prostate and the external sphincter. According to the thickness of the urethra, the 27th or 24th resectoscope is used. According to the size of the prostate, it is decided to perform the prostate surgery. 4. Insert the resectoscope to find out the important signs: first test the urethral tube diameter with a metal probe. Inject more lubricant. Then insert the sheath of the resectoscope with the mirror core, pull out the mirror core, and insert the surgical mirror of the electric resectoscope. Marks were identified with a 30° beveled mirror in the prostatic urethra and bladder neck. The main hallmark of transurethral resection of the prostate is fine sputum. Never remove it. Fine sputum is still an important sign even if the patient has to undergo another resection in the future, such as residual gland re-proliferation or tumor development. Place the tip of the resectoscope just under the fine sputum. Pay attention to the extent to which the leaves on both sides of the prostate protrude into the urethra on both sides, whether the leaves on both sides touch and press, and whether the bladder entrance can be seen. Push the resectoscope and estimate the size of the leaves on both sides. The size of the two sides is uneven or irregular. The latter suggests the possibility of tumor. In the neck of the bladder, it is also estimated that the prostate protrudes into the bladder or has a middle lobe. If so, the angle between the convex side and the middle leaf on both sides should be further clarified and the length of the two sides of the sweat should be determined. The position of the two ureteral orifices should be confirmed to avoid damage during the electric cutting. Be familiar with all of these signs before performing the first undercut. The neck of the bladder must be removed with the prostate. If there is no electric resection, there will still be obstruction after surgery. 5. Cut the front groove: The purpose of cutting out the front groove is to determine the exact length of the front side of the side leaves and deep cut the side grooves into the envelope. The remaining lateral leaf resection (cutting the lateral groove and obstructing the adenoma entity) can refer to the full-length electric cut strip of the leaf, which can remove a large amount of prostate tissue in a short time. However, you must not cut long strips in the front groove. The front groove should be cut to the fine level. If the patient's right side leaf is first cut, the two pieces are cut from the 10 points of the bladder neck to reveal the ring-shaped muscle line of the bladder neck, and then the depth of the groove is deepened. On the cutting surface of the electric cutting, different shapes may be formed due to different pathologies. If the prostatic hyperplasia of the prostate tissue is cut, it is in the form of fine particles. The next step is to carefully extend the groove to the fine level, but not to pass. Stretching delay, only one small piece at a time, the position of the fine boring should be checked again and again between the two electric cuts. When cutting the last strip, the tip of the resectoscope should be placed just at the lower edge of the fine boring. Then, rotate the electric mirror and hold it firmly so that the last strip is not damaged. Deepening this groove starts from immediately below the bladder neck, where the annular fibers terminate, where the glandular tissue begins. The glandular tissue should be removed in a small piece. At the same time, the narrowed band should be removed until the groove is cut flat from the bladder neck to the fine, and the full length of the envelope is revealed. This layer of capsule is actually a pseudo-envelope of the prostate. The junction between the pseudocapsule and the adenoma is the separation plane of open prostatectomy, and transurethral resection of the prostate should also be used as an interface. In the case of electric cutting, the envelope can be identified by its specific structural form. Unlike the annular fibers of the bladder neck, the fibers are interlaced, but the general direction of the fibers is still annular. The anterior groove is made at the leading edge of the lateral lobes, so there is no need to remove too much glandular tissue in the anterior groove before the envelope is revealed. 6. Cutting side groove: The purpose of cutting the side groove is to determine the outer range of the electric cut. When the gland tissue is cut in this way, most of the blood supply can be cut off, so that the body of the side leaf can be quickly removed. Without excessive bleeding. When cutting the front groove, the electric mirror should be turned to the front to face the groove, and when the side is cut, the electric mirror should be gradually turned to face the rear, and the rest of the electric cutting is This is done with the resectoscope facing the rear. When cutting the side groove, the first piece of the side groove should be first cut at the outer edge of the dorsal gland tissue of the front groove, and then one piece is continuously cut into pieces, and the groove is deepened until the envelope is formed. At first, it is best for beginners to keep the resectoscope stationary, so that the length of each piece can be limited to the extent of the rotation of the electric cutting ring. Later, with the accumulation of experience, it can be used to move the resectoscope and gradually cut out. Longer strips. When the large blood vessels of the capsule are bleeding, the blood should be stopped well before continuing the electric cutting. Most of the bleeding points are just below the bladder neck. The prostate artery is mostly at 7-8 or 4-5. 7. Electric cutting of the lateral leaf body: If the side groove is cut correctly, the entity of the lateral blade will not encounter many problems. This part of the electric cutting is as simple as the electric cutting of the middle part of the prostate. Before starting to cut each piece, make sure that the electric sputum is placed on the glandular tissue, and then cut the electric sputum to the full depth, and continue the electric cutting until the mucosa in the lower part of the lateral lobes can be seen. To. All these electric cutting operations need to be performed in the prostate cavity, and should not be mistaken into the bladder, cutting the triangle area, the ureteral fistula or the two ureteral orifices. Before the contralateral lateral leaf is cut, the larger bleeding point should be electrocoagulated to stop bleeding. The electric cutting step of this leaf is completely similar to the electric cutting of the previous leaf: firstly, a front groove is cut from the neck of the bladder to a fine level, and the front groove is deepened until the envelope is completely exposed. Then, the side groove on the left side is electrically cut out to the envelope, and the groove is repeatedly deepened until 5 o'clock; the body of the side leaves is electrically cut by the long and deep strips until only one segment of the tissue is connected behind. Since the contralateral side leaves have been resected, after the left side groove is cut out, the left remaining prostate tends to fall to the opposite prostate cavity, so this part of the prostate body needs to be electrically cut on the opposite side of the prostate cavity. The fine sputum can be covered by the remaining side leaves, and the fine base can often be seen under the lateral leaves. Large bleeding from the prostate should be stopped before the middle cut. 8. Electric mid-cut: Once the lateral leaf entity is removed, the middle lobe is isolated in the field of view. Some urologists prefer to remove the middle lobe before cutting the lateral lobe. Before cutting the middle lobe, the ring muscle fibers on both sides of the middle lobe should be seen first, and the middle lobe protrudes between the 5 and 7 points of the bladder neck ring. Verify both ureteral ports again to avoid injury. Then place the electric cut on the middle leaf (that is, in the bladder), and cut the middle leaf according to the long piece. When cutting, use the full depth of the cut and stop above the protruding fine. When cutting the middle lobe, it is necessary to proceed from one side to the other until the annular fibers of the bladder neck are all exposed. Finally, it is necessary to cut the back of the bladder neck ring until the posterior wall forms a flat slope. Stop bleeding again. When the middle lobe does not increase, it should be cut behind the bladder neck until this level shows the annular fiber, forming a complete bladder neck ring. If the bladder neck has been cut, there is no need to cut the back of the bladder neck; keep the bladder neck at 4 and 8 points intact. 9. End of the electric cut: After most of the electric cuts are completed, all the pieces still to be cut are the front piece of tissue, the missing side leaves and the left and middle leaves around the fine. Although it is smaller in size than the tissue that has been removed, it is extremely important to remove all of these residuals; because: 1 doing so often improves the rate of urine flow; 2 when all non-viable tissue is removed, post-operative infection The incidence can be reduced; 3 this operation reduces the chance of re-accumulation. First, the resectoscope should be turned to the front to remove the glandular tissue between the two front grooves [Fig. 1 (8)]. Glandular tissue is removed from the neck of the bladder until the ring fibers are revealed and the bladder neck ring is completed. Cut a small piece of gland tissue down to the fine level, and carefully extend the electric cut like the original groove before electric cutting. Then observe the outer part of the prostate cavity, you can observe: the pseudo-envelope contraction, so that the residual part of the gland tissue protrudes into the lumen; often there are large pieces of tissue that have been missed, but now can be seen protruding into the prostate cavity . All these residuals should be cut off electrically. Then cut the 10 to 7 o'clock area on the right side of the patient and the 2 to 5 o'clock area on the left side of the patient again. Resection of residual tissue at the tip of the prostate requires lifting the electrical sputum upwards to make up the prostate tip tissue. It can also be removed with the aid of a digital rectal examination. After the electric cut is completed, the bladder neck is observed from the fine sputum, and the whole appearance is a wide open loop. 10. Empty gland tissue strips: When each gland tissue is cut, the flushing force can flush the strip into the bladder and accumulate in the bottom of the bladder to form a small pile. Sometimes, due to insufficient flushing force, small strips can accumulate in the prostate cavity, blurring the field of view. In this case, the cut should be stopped and emptied. When emptying, first use the electric cutting mirror to see the position of the small strip pile, and place the tip of the electric cutting mirror just on the small strip pile, pull out the surgical mirror of the electric cutting mirror, and connect the ellik flusher to the sheath. The ellik irrigator must be filled with rinsing fluid, which reduces the attractiveness of the bubbles. Squeeze the rubber ball of the ellik irrigator, then loosen the rubber ball, and repeat the operation, it can be seen that a large number of small pieces of gland tissue break into the glass ball cavity of the irrigator. All these small strips were collected and weighed and sent for pathological examination. 11. Test urine flow: When the electric cut is completed and all the obstruction has been relieved, the bladder should be filled with the flushing fluid, and then the electrosurgical sheath is pulled out from the urethra. Shortly after the pullout, the urine flow can be discharged from the full bladder. Note. When the bladder is pressurized on the pubic bone, such as good urine flow, it often proves that the electric cut is sufficient. 12. Hemostasis: Carefully inspect each part of the prostate cavity and electrocoagulate the blood vessels at each location. The cut artery is often protruded from the cut surface of the prostate for a short period of time. This condition is relatively easy to electrocoagulate, and the electric cut of the resectoscope is required to press the end of the bleeding artery, the base thereof or the place where the nutritional artery is located. Either way, as long as the compression of the electric sputum can stop the bleeding of the artery. Electrocoagulation must be operated accurately. Generally, it can stop bleeding with one touch. When it is inaccurate, it can destroy the protruding part and still bleed from the bottom or even deep inside the capsule. The second stop of bleeding is always more difficult than the first. 13. Insert the balloon catheter: use a balloon silicone catheter drainage, usually with 20, urethral stricture, urethral external incision, use the 18th, performed perineal external urethrotomy Then the catheter is inserted through the perineal stoma, and the catheter should not be inserted behind the triangle to form a false passage. The catheter balloon is filled with 15-20 ml of fluid and the catheter is then connected to a continuously closed drainage system. complication (1) intraoperative and postoperative bleeding: Recent postoperative hemorrhage (within 7 days after surgery): more common, mainly intraoperative electrocoagulation of vasospasm detachment or removal of prostate tissue fragments blocking the urinary catheter, overfilling and swelling of the bladder during irrigation, resulting in prostatectomy Secondary bleeding. It is usually controlled by balloon catheter compression, dredge of the catheter and hemostasis medication. In a few cases, it is necessary to go to the operating room again to stop bleeding with a resectoscope. Long-term postoperative bleeding (7 to 30 days after surgery): Most of the wounds due to prostate cutting did not heal, and the wounds were detached. Mild bleeding gives oral antibiotics a large amount of drinking water, generally can disappear on their own; if there is more bleeding, you need to go to the hospital to take out the blood clot again, and then re-infuse the three-chamber balloon catheter for continuous washing can be cured. (two) bladder neck contracture It was manifested as difficulty in urinating after a few months after surgery, mostly due to stenosis caused by postoperative bladder neck scar contracture. It is feasible to confirm the cystoscopy. Treatment should be performed with a transurethral cold knife or a hook electrode. (three) urethral stricture Mainly manifested as postoperative urinary thinning, bifurcation, and even dysuria and other symptoms. The main reason is that the patient's urethral orifice is small, and the electrosurgical sheath is thicker, causing a urethral fistula or a sheath sheath pull during surgery, causing damage to the urethral mucosa. The vast majority can be cured by regular urethral dilatation. (4) Urinary incontinence Most of them are temporary urinary incontinence, which is manifested by the inability of the urine to control itself and flow out of the urethra. Most of them disappear after training through the anal sphincter, but some need to be observed for 3 to 6 months or even 1 year. A very small number of permanent urinary incontinence, mainly caused by damage to the external urinary sphincter during surgery, is an annoying complication. At present, the InVance male urethral sling system has certain curative effect, but the cost is relatively expensive. (5) TURP syndrome TURP syndrome is a clinical syndrome characterized by excessive blood volume, hemodilution and hyponatremia caused by a large amount of electrolyte-free washing fluid entering the venous system during electric resection, usually after the surgery is completed and several hours after surgery. Within the patient, the patient may have significant fluctuations in blood pressure and heart rate, difficulty breathing, headache, irritability, nausea and vomiting, and even disturbance of consciousness. Laboratory tests showed a decrease in blood sodium and a decrease in plasma osmotic pressure. Its occurrence is related to the perforation of the prostate capsule, the sinus incision around the prostate, the high pressure of the irrigation fluid, and the long operation time. If the surgeon actively takes preventive measures, early detection, and early treatment, it can generally effectively control the condition. (6) Other complications For example, postoperative urinary frequency, urgency, urinary pain irritation, postoperative impotence and retrograde ejaculation, epididymitis.