Cystoscpy + turp

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Here is a thorough, textbook-based overview of Cystoscopy and TURP.

Cystoscopy

Definition

Direct endoscopic visualisation of the urethra and bladder using a cystoscope. The entire lower urinary tract from the urethral meatus to the bladder can be inspected, and with progressively longer instruments (ureteroscope) the ureters and renal pelvis can also be visualised. - Bailey and Love's Short Practice of Surgery, 28th Ed.

Types

Type	Anaesthesia	Primary role
Flexible cystoscopy	Local (lidocaine gel)	Diagnostic; poorly tolerated in young males due to angulated male urethra
Rigid cystoscopy	General or spinal	Diagnostic + operative; preferred for surgical procedures

Available telescope angles: 0°, 12°, 30°, and 70° lenses.

Indications

Haematuria (macroscopic or microscopic, not explained by UTI)
Bladder tumour - diagnosis, staging (TURBT), surveillance
Recurrent UTIs
Overactive bladder (OAB) refractory to treatment
Suspected vesicovaginal fistula
Lower urinary tract symptoms (LUTS) due to BPH / bladder outlet obstruction
Foreign body, bladder stone
Urethral stricture assessment
Pre-TURP - mandatory cystourethroscopy before resection to exclude concomitant bladder tumour, stone, or stricture
Intraoperative check after pelvic/incontinence surgery (injury exclusion)
Berek & Novak's Gynecology; Bailey and Love's

Cystoscopic images

Normal urethra on urethroscopy:

Normal bladder mucosa with right ureteric orifice (yellow arrow) and interureteric bar (red arrow):

Normal bladder mucosa with ureteric orifice

TURP (Transurethral Resection of the Prostate)

Definition and Status

TURP is the gold standard surgical treatment for bladder outlet obstruction (BOO) caused by benign prostatic hyperplasia (BPH). Among all BPH therapies, TURP produces the largest decrease in urinary symptoms, the largest increase in urinary flow rate, and the largest decrease in voiding pressure. - Hinman's Atlas of Urologic Surgery

Indications

Symptomatic BPH refractory to medical therapy (alpha-blockers, 5-alpha reductase inhibitors)
Acute urinary retention (refractory)
Recurrent haematuria from BPH
Bladder stones / diverticula secondary to BOO
Renal impairment from BOO
Prostate cancer patients not suitable for radical prostatectomy (palliation of obstruction)
Concomitant prostatic calculi release - Campbell-Walsh-Wein Urology; Bailey and Love's

Preoperative

Prophylactic IV antibiotics (single dose before resection)
Cystourethroscopy must be performed before any cutting begins - to exclude bladder tumour, stone, or stricture
Gentle meatal/fossa navicularis dilation if needed (Van Buren sounds, 18 Fr upward)

Patient Positioning

Dorsal lithotomy position, perineum at the table edge to allow the resectoscope to angle upward for anterior prostatic access.

The Resectoscope

A specialised endoscopic instrument with an electrode capable of both cutting and coagulating. Available in monopolar and bipolar configurations:

Monopolar: requires non-conductive (electrolyte-free) irrigant (glycine 1.5%, sorbitol 3.3%, mannitol 5%) - risk of TUR syndrome
Bipolar: uses normal saline irrigant - eliminates risk of dilutional hyponatremia

Cutting devices: thin loops (cleaner cut, less coagulation), thick loops, rollers/roller balls/buttons (desiccation, better haemostasis for larger glands).

Surgical Steps (Key Landmarks)

Cystourethroscopy to survey the entire urothelium
Pass resectoscope sheath into bladder
Median lobe resection first (if enlarged) - resected down to circular bladder neck fibres
Bladder neck and prostatic floor resected toward verumontanum
Anterior prostate resected at 12 o'clock
Lateral lobes taken down
Verumontanum is the key distal landmark - must NOT be resected (risk of sphincter damage and incontinence)
Chips irrigated out; haemostasis achieved; 3-way catheter placed

Hinman's Atlas of Urologic Surgery

Anaesthesia

Spinal (regional) or general anaesthesia - outcomes equivalent
Historically spinal was preferred because an awake patient allows early detection of TUR syndrome
Today, bipolar TURP with saline and less aggressive resection makes general anaesthesia widely acceptable

Irrigating Solutions

Solution	Osmolality (mOsm/L)	Advantages	Disadvantages
Distilled water	0	Best visibility	Haemolysis, haemoglobinuria, hyponatraemia
Glycine 1.5%	200	Less TUR syndrome risk	Transient visual disturbance, hyperammonaemia
Sorbitol 3.3%	165	Similar to glycine	Hyperglycaemia, possible lactic acidosis
Mannitol 5%	275	Isosmolar, not metabolised	Osmotic diuresis, volume expansion
Normal saline (0.9%)	~308	Eliminates hyponatraemia risk	Only usable with bipolar TURP

Barash Clinical Anesthesia, 9e; Miller's Anesthesia, 10e

TUR Syndrome

Definition

Symptomatic hyponatraemia + hypervolaemia resulting from absorption of hypotonic, electrolyte-free irrigant through open venous sinuses during TURP (or TURBT, hysteroscopy, ureteroscopy).

Complicates 10-15% of TURP procedures
Onset: 15 minutes to 24 hours after start of resection

Risk Factors

Prolonged resection (> 1 hour)
Increased intravesical pressure
Hypotonic irrigant
Open venous sinuses (large gland, capsular tear)

Clinical Features

System	Features
CNS	Nausea/vomiting, visual disturbance (glycine toxicity), confusion, agitation, seizures, reduced consciousness
CVS	Hypertension, then hypotension; bradycardia
Biochemical	Hyponatraemia (Na+ < 120 mEq/L in severe cases), hypo-osmolality

The classic CNS signs are due to acute serum hypoosmolality causing brain oedema rather than hyponatraemia per se.

Prevention

Use bipolar TURP with normal saline irrigant (eliminates hyposmolar risk)
Monitor fluid balance - halt if > 1000 mL absorbed (males)
Limit intravesical pressure < 15-25 mmHg
Limit resection duration to < 1 hour unless carefully monitoring for syndrome
Regional anaesthesia allows neurological monitoring in awake patient

Management

Severity	Na+	Treatment
Mild	> 120 mEq/L	Fluid restriction + furosemide (loop diuretic)
Severe	< 120 mEq/L	3% NaCl IV at < 100 mL/hr; stop when Na+ > 120 mEq/L
Seizures	Any	IV magnesium (counteracts glycine's NMDA excitation)
Normal osmolality	Any	Haemodialysis preferred over hypertonic saline

Avoid rapid correction - risk of central pontine myelinolysis (demyelination)
Terminate procedure, ensure oxygenation and circulatory support, ECG, electrolytes/ABG
Miller's Anesthesia 10e; Barash Clinical Anesthesia 9e; Morgan & Mikhail's Clinical Anesthesiology 7e

Key Differences: Monopolar vs Bipolar TURP

Feature	Monopolar	Bipolar
Irrigant	Non-conducting (glycine/sorbitol)	Normal saline
TUR syndrome risk	Yes	Eliminated (no hyponatraemia)
Haemostasis	Good	Good
Laser TURP	-	No requirement for non-conductive fluid; less blood loss; lower transfusion rates

Comparison with TUIP (Transurethral Incision of Prostate)

TUIP: no tissue removed; 1-2 incisions from bladder neck to verumontanum - widens the prostatic channel
Ideal for younger men, prostate < 30 g, no significant lateral lobe hypertrophy, primary bladder neck obstruction
Not gold standard; less durable than TURP for larger glands; not suitable when median lobe is obstructive

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