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BPH with LUTS: Complete Clinical Approach for the Urology Resident

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1. ANATOMY FIRST - Know Your Prostate Zones

• Transitional zone - where BPH arises (nodular hyperplasia here)
• Peripheral zone - where 70% of prostate cancers arise (palpable on DRE)
• Central zone - surrounds ejaculatory ducts
• Anterior fibromuscular stroma - no glandular tissue

In BPH, the transitional zone enlarges nodularly, compressing the peripheral zone into a "false capsule." When the central zone is involved, a middle lobe projects upward into the bladder.

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2. UNDERSTANDING LUTS - Classification

• BPH can exist with no symptoms and no BOO
• BOO can exist with no symptoms
• LUTS can be present without BPH (other causes)

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3. PATHOPHYSIOLOGY

1. Static (mechanical) component: Enlarged transitional zone physically narrows the prostatic urethra
2. Dynamic component: Alpha-1 adrenoceptors in prostatic smooth muscle and bladder neck increase muscle tone → increased outlet resistance

• Detrusor overactivity → storage symptoms
• Eventually decompensation → large residual volumes → chronic retention

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4. HISTORY TAKING

A. Symptom Assessment - IPSS

1. Incomplete emptying
2. Frequency (voiding <2 hours)
3. Intermittency
4. Urgency
5. Weak stream
6. Straining to void
7. Nocturia

• 0-7: Mild (watchful waiting)
• 8-19: Moderate (medical therapy)
• 20-35: Severe (consider surgery)

B. Ask Specifically About

• Duration of symptoms and progression
• Haematuria (terminal haematuria can be BPH; frank haematuria needs full evaluation)
• Acute urinary retention episodes
• Urinary tract infections (recurrent UTIs suggest high residual volumes)
• Overflow incontinence or enuresis (suggests chronic retention)
• Sexual function (erectile dysfunction - relevant for medication choice; ejaculatory dysfunction)

C. Medications Review

• Alpha-agonists (nasal decongestants, pseudoephedrine) - increase bladder neck tone
• Anticholinergics (antihistamines, tricyclics, some antipsychotics) - impair detrusor
• Diuretics - worsen frequency/nocturia

D. Past History

• Urethral trauma/instrumentation (stricture)
• Previous pelvic surgery
• Neurological conditions: Parkinson's, multiple sclerosis, diabetes, spinal cord disease (all can cause LUTS mimicking BPH)
• Cerebrovascular disease

E. Frequency-Volume Diary

• Identifying polyuria/nocturnal polyuria
• Establishing functional bladder capacity
• Differentiating overactive bladder from BOO

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5. PHYSICAL EXAMINATION

Abdominal Examination

• Palpate/percuss for a distended bladder above the pubic symphysis - may be visible in chronic retention (loss of suprapubic skin crease)
• Identify any renal mass
• Scars from previous surgery

Digital Rectal Examination (DRE)

• Size - rough estimate (normal ~20 mL, enlarged may be 30-100 mL+); only the posterior half is palpated so DRE underestimates size
• Consistency - BPH is rubbery/smooth
• Symmetry - BPH is generally symmetric
• Median sulcus - may be obliterated with enlargement
• Surface - hard/irregular nodule raises suspicion for prostate cancer
• Tenderness - warm, tender, boggy prostate = prostatitis

Neurological Examination

• Lower limb power, tone, reflexes
• Anal sphincter tone
• Mental status
• Any signs of cord compression (retention can be the presenting feature of cauda equina)

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6. INVESTIGATIONS

Essential (for every patient)

Additional (based on clinical picture)

• Q-max >15 mL/s with voided volume >200 mL = normal
• Q-max 10-15 mL/s = equivocal
• Q-max <10 mL/s = strongly suggests BOO (but can also be weak detrusor)
• Voiding pressures >80 cmH2O = high; <60 cmH2O = normal

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7. DIFFERENTIAL DIAGNOSES TO EXCLUDE

• Prostate cancer - hard/nodular DRE, elevated PSA; biopsy if suspicious
• Urethral stricture - history of STI, urethral trauma, catheterisation; poor stream from young age; diagnosed on urethrogram/cystoscopy
• Bladder cancer - haematuria; urine cytology, cystoscopy
• Overactive bladder (OAB) - dominant storage symptoms, small voided volumes, urgency incontinence; urodynamics shows detrusor overactivity
• Neurogenic bladder - Parkinson's, MS, spinal cord disease, diabetes; neurological examination and history
• Bladder neck dyssynergia - younger men; urodynamics needed
• Detrusor underactivity - elderly men; poor stream + large PVR but low voiding pressure on urodynamics; surgery will not help
• Prostatitis - acute or chronic; tenderness, fever, perineal/pelvic pain

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8. MANAGEMENT

Step 1 - Assess Severity and Bother

Step 2 - Lifestyle Modifications (all patients)

• Reduce fluid intake in evening (reduces nocturia)
• Avoid caffeine and alcohol
• Double voiding technique
• Bladder retraining (timed voiding)
• Treat constipation
• Review and stop offending medications

Step 3 - Medical Therapy

Alpha-1 Adrenoceptor Blockers (Alpha-blockers) - FIRST LINE

5-Alpha-Reductase Inhibitors (5-ARIs) - For large prostates

Combination Therapy (Alpha-blocker + 5-ARI)

• Dutasteride + Tamsulosin (or their combination pill) is the best-evidence combination
• Indicated for men with moderate-severe symptoms AND prostate volume >30-40 mL
• More effective than either drug alone for symptom relief and reducing disease progression
• The alpha-blocker handles the immediate dynamic component; 5-ARI shrinks the prostate over months

Phosphodiesterase-5 Inhibitors (PDE5i)

• Tadalafil 5 mg daily - improves LUTS and IPSS; also treats concomitant erectile dysfunction (very useful in BPH patients)
• Less effective than alpha-blockers for improving flow rates
• Can be combined with alpha-blocker

Antimuscarinics / Beta-3 Agonists - For dominant storage symptoms

• Antimuscarinics: Solifenacin 5-10 mg, Tolterodine, Oxybutynin, Fesoterodine
• Beta-3 agonists: Mirabegron 25-50 mg, Vibegron 75 mg
• Caution: Use with care if PVR >200 mL (risk of precipitating acute retention)
• Can be added to tamsulosin in inadequate responders

Step 4 - Surgical Indications

Absolute / Strong Indications (must operate):

1. Acute urinary retention (refractory to trial without catheter, or recurrent)
2. Chronic retention with renal impairment - PVR ≥200 mL + hydronephrosis + abnormal creatinine
3. Recurrent UTIs secondary to significant PVR
4. Bladder stones secondary to BOO
5. Recurrent haematuria from vascular BPH not responding to 5-ARI

Elective Indications:

• Severe symptoms (IPSS ≥20) not responding to medications
• Q-max <10 mL/s + PVR 100-250 mL
• Patient preference after failed/refused medical therapy

Surgical Options:

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9. COMPLICATIONS OF UNTREATED BPH

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10. FOLLOW-UP PLAN

• At 3 months after starting medical therapy: reassess IPSS, QoL, uroflowmetry, PVR
• PSA recheck at 6-12 months on 5-ARI (expect 50% reduction; if not, suspect cancer)
• Annual review if stable on medical therapy
• Patient education about: drug side effects, timeline of response, signs requiring urgent review (acute retention, worsening renal function, haematuria)

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Quick Reference Summary

BPH/LUTS Patient → History (IPSS, voiding diary) → Examination (abdomen, DRE, neurology)
→ Investigations (UA, creatinine, uroflowmetry + PVR, PSA, USS)
→ Exclude: Ca prostate, stricture, bladder Ca, neurogenic, OAB

IPSS 0-7 → Watchful waiting + lifestyle
IPSS 8-19 → Alpha-blocker ± 5-ARI (if prostate >30-40 mL or PSA >1.5)
IPSS ≥20 → Medical therapy; surgery if refractory
Absolute surgical indications → Retention, renal impairment, recurrent UTI/stones, bleeding

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• Goldman-Cecil Medicine, Ch. 114 - Benign Prostatic Hyperplasia, pp. 1316-1322
• Bailey and Love's Short Practice of Surgery (28th ed.), Ch. 84 - BPH, pp. 1543-1548
• Campbell-Walsh-Wein Urology (12th ed.) - BPH chapters

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TURP - Complete Exam-Ready Guide for Urology Residents

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1. DEFINITION & CONTEXT

Examiner question: "Why is TURP called the gold standard?" Answer: It has the longest evidence base, most validated outcomes data, best improvement in urinary flow rates and symptom scores, and all newer procedures compare themselves to TURP in trials.

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2. ANATOMY CRITICAL TO THE PROCEDURE

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3. INDICATIONS FOR TURP

Absolute / Strong Indications (must not delay):

1. Acute urinary retention - failed trial without catheter (TWOC), or recurrent AUR
2. Chronic retention with upper tract obstruction - bilateral hydronephrosis + renal impairment
3. Recurrent UTIs due to significant post-void residual (PVR)
4. Bladder stones secondary to bladder outlet obstruction
5. Recurrent haematuria from BPH unresponsive to 5-ARI therapy

Elective Indications:

• IPSS ≥ 20 with failed/refused medical therapy
• Moderate symptoms (IPSS 8-19) with significant bother after medical failure
• Q-max < 10 mL/s + PVR 100-250 mL
• Patient preference after weighing alternatives

Prostate Size Consideration:

• TURP is ideal for 30-80 g prostates
• For > 80-100 g: consider HoLEP or open/robotic simple prostatectomy
• Very small gland with BOO: consider TUIP (transurethral incision of prostate) instead

Examiner question: "What is the size limit for TURP?" Answer: Conventionally 80 g. Beyond this, resection time increases disproportionately (>1 hour), increasing risk of fluid absorption and TUR syndrome. HoLEP has no size restriction.

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4. CONTRAINDICATIONS

Absolute:

• Untreated UTI (risk of bacteraemia/sepsis from irrigant entering venous sinuses)
• Uncorrected coagulopathy
• Urethral stricture preventing passage of resectoscope (treat stricture first)
• Patient unfit for anaesthesia

Relative:

• Prostate > 80-100 g (increased surgical risk)
• Small bladder capacity (risk of perforation)
• Prior pelvic surgery/radiation (anatomy distorted)
• Desire to preserve antegrade ejaculation (counsel about retrograde ejaculation; consider alternatives like Urolift)

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5. PRE-OPERATIVE WORKUP

History:

• IPSS score and QoL score
• Sexual function (SHIM questionnaire) - baseline for post-op comparison
• Medications: anticoagulants/antiplatelets (must stop: aspirin 7 days, clopidogrel 5-7 days, warfarin 5 days - bridge with LMWH if high-risk cardiac/AF patient)
• Diabetes (affects healing, infection risk)

Examination:

• DRE - prostate size, consistency (exclude cancer)
• Abdominal exam - palpable bladder
• Focused neurology

Investigations:

Consent - what to tell the patient (must be comprehensive):

• Retrograde ejaculation (~65-90% of patients)
• Erectile dysfunction (~5-10%)
• Urinary incontinence (temporary stress incontinence ~5%; permanent <1%)
• Urethral/bladder neck stricture (2-4%)
• Bleeding requiring transfusion (~2%)
• TUR syndrome (<1% with bipolar, ~2% with monopolar)
• Risk of re-operation (10-15% at 10 years)
• Continued irritative LUTS post-op (may persist 4-6 weeks)
• Failure to void after catheter removal (~5%)

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6. ANAESTHESIA

1. Spinal/regional anaesthesia (preferred) - advantages:
   • Patient remains conscious - allows early detection of TUR syndrome (confusion, restlessness are first signs; awake patient communicates symptoms)
   • Lower risk of deep venous thrombosis (sympathetic block causes vasodilation)
   • Equivalent outcomes to GA
   • Block level needed: T10 (level of bladder sensation)
2. General anaesthesia - used when:
   • Patient refuses spinal
   • Contraindication to spinal (coagulopathy, spinal pathology, patient refusal)
   • Anticipated long procedure
   • Disadvantage: masks early TUR syndrome signs

Examiner question: "Why is spinal anaesthesia preferred for TURP?" Answer: The conscious patient can report early symptoms of TUR syndrome (confusion, nausea, visual disturbance) before they become severe. Under GA, TUR syndrome may only be detected when cardiovascular or respiratory signs appear, by which time it is more advanced.

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7. PATIENT POSITIONING

• Lithotomy position - legs in stirrups
• Pressure areas: protect heels, common peroneal nerve at fibular head, popliteal fossa
• Compartment syndrome of the legs (from prolonged lithotomy) - change stirrup position if >2 hours
• Brachial plexus injury (if arms extended)
• DVT prophylaxis: TED stockings, pneumatic compression devices

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8. INSTRUMENTS - KNOW EVERY COMPONENT

• Cutting current: High-frequency alternating current causes vaporisation (tissue cutting)
• Coagulation current: Lower frequency; coagulates bleeding vessels without cutting

Examiner question: "Why can't you use saline with monopolar TURP?" Answer: Saline (NaCl) is an electrolyte conductor. In monopolar diathermy, current must travel from the active electrode through tissue to a return/ground pad. Saline would conduct and disperse the current throughout the irrigating fluid rather than concentrating it at the cutting loop - the loop would not generate enough current density to cut tissue. Bipolar diathermy completes the circuit locally between two electrodes within the resectoscope, so saline works fine.

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9. IRRIGATING SOLUTIONS - CRITICAL TOPIC

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10. SURGICAL TECHNIQUE - STEP BY STEP

• Insert 0° telescope through urethra and into bladder
• Inspect urethra for stricture
• Inspect bladder: exclude tumour, stones, diverticula; note ureteric orifices (landmarks)
• Inspect prostate: size, lobe configuration (note middle lobe, lateral lobe enlargement), bladder neck

• Lubricate generously
• Advance resectoscope sheath under vision
• Note verumontanum position (your critical distal landmark)

• Start at 6 o'clock position - create a groove down to the capsule (establishes landmark for depth)
• Proceed to 5 o'clock and 7 o'clock grooves
• Resect lateral lobes (systematic sweeping movements from bladder neck to verumontanum)
• Resect median/middle lobe last (resecting middle lobe first collapses the field and reduces visibility)
• Working within the surgical capsule (whitish, circular fibres) at all times

• Systematically coagulate visible bleeding points
• Reduce irrigation pressure to identify low-pressure bleeders
• Check for arterial bleeders (bright red spurting) - coagulate these immediately
• Check at the end of procedure with reduced irrigation flow to ensure haemostasis

• Resected chips (tissue fragments) are evacuated with an Ellik evacuator (bulb syringe that creates turbulence in the bladder to suction out chips)
• Send all chips for histopathology (unsuspected prostate cancer found in 8-10% of TURP specimens)

• Three-way 22Fr Foley catheter
• Continuous bladder irrigation (CBI) started with normal saline to wash out blood and prevent clot retention
• Catheter removed typically at 24-48 hours post-op (earlier if urine clears)

Examiner question: "Why do you send all TURP chips for histopathology?" Answer: Incidental prostate cancer (pT2 disease) is found in approximately 8-10% of TURP specimens. This has therapeutic implications - if significant cancer is found, the patient needs staging and potentially radical treatment.

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11. TUR SYNDROME - THE MOST FEARED COMPLICATION

Definition:

Mechanism of Fluid Entry:

1. Open prostatic venous sinuses (primary route) - the periprostatic venous plexus becomes exposed during resection
2. Capsular perforation (extravasation into retroperitoneum, then absorbed)
3. Bladder perforation into peritoneal space (rarer)

Factors Increasing Risk:

• Prolonged resection (>60 min is critical threshold)
• Large prostate with extensive venous sinus exposure
• High irrigation fluid pressure (height of bag)
• Capsular perforation
• Low venous pressure at irrigation-blood interface (hypotension)
• Large prostate volume resected

Clinical Features by Serum Na+ Level:

• Nausea, vomiting
• Restlessness, confusion
• Visual disturbance (blurred vision, transient blindness - specific to glycine)
• Headache
• Hypertension (early, from volume loading)

• Hypotension
• Bradycardia
• Pulmonary oedema (dyspnoea)
• Cardiovascular collapse

Additional Glycine-Specific Toxicity:

• Transient blindness - glycine structurally similar to inhibitory neurotransmitter GABA → retinal/brainstem inhibition. Pupils minimally reactive. NOT cerebral oedema.
• Hyperammonemia - glycine metabolised to ammonia → encephalopathy, coma lasting 24-48 hours post-op

Treatment of TUR Syndrome:

1. Stop surgery immediately - abandon procedure, insert catheter
2. Call anaesthesiologist urgently
3. Furosemide IV (40-80 mg) - promote water diuresis
4. Restrict fluids - stop any hypotonic IV fluids
5. Serum electrolytes urgently - check Na+ level
6. Oxygen via face mask / consider intubation if severe
7. Hypertonic saline (3% NaCl) infusion - ONLY if:
   • Na+ < 120 mEq/L, OR
   • Symptomatic severe hyponatremia (seizures)
   • Rate of correction: max 1-2 mEq/L/hour; target: raise Na+ to 120 mEq/L then allow slow correction
   • Never correct faster than 8-10 mEq/L in 24 hours - risk of osmotic demyelination syndrome (central pontine myelinolysis)
8. ITU/HDU monitoring if severe

Examiner question: "How do you prevent TUR syndrome?" Answer: (a) Use bipolar TURP with saline - eliminates hyponatremia risk; (b) Limit resection time to <60 minutes; (c) Keep irrigation bag height low (minimise hydrostatic pressure); (d) Achieve rapid haemostasis; (e) Avoid capsular perforation; (f) Use spinal anaesthesia so patient can report early symptoms; (g) Monitor for early signs and stop promptly.

Examiner question: "Why does glycine cause visual disturbance but not cerebral oedema?" Answer: Glycine is structurally similar to inhibitory neurotransmitters (GABA, glycine receptors in the retina and brainstem). It inhibits neurotransmission in the retina and optic pathway causing transient blindness and minimally reactive pupils. This reverses as glycine is metabolised. Cerebral oedema would cause raised ICP with papilloedema and slower onset - that is not the mechanism here.

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12. ALL COMPLICATIONS OF TURP - CLASSIFIED

Intraoperative:

Immediate Post-operative (within 24-48 hours):

Early Post-operative (first few weeks):

Late Complications:

Examiner question: "What is the most common complication of TURP?" Answer: Retrograde ejaculation, occurring in 65-90% of patients. It must be specifically discussed in pre-operative counselling.

Examiner question: "A patient returns at 12 days post-TURP with haematuria. What is happening and how do you manage?" Answer: This is secondary haemorrhage due to sloughing of the post-TURP necrotic eschar (similar to a post-tonsillectomy bleed). Management: (1) admit patient; (2) catheterise and start CBI; (3) cross-match blood; (4) most cases settle with irrigation; (5) if haemorrhage continues or bladder fills with clots despite irrigation, return to theatre for cystoscopy, clot evacuation, and formal coagulation.

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13. MONOPOLAR vs BIPOLAR TURP - EXAM FAVOURITE

Examiner question: "What is the advantage of bipolar TURP?" Answer: Normal saline is used as irrigant. Since saline is isotonic, any absorbed fluid causes only volume overload - not dilutional hyponatraemia. This eliminates the metabolic component of TUR syndrome (the hyponatremia, glycine toxicity, hyperammonemia) while only the haemodynamic overload risk remains. Bipolar also eliminates the risk of diathermy burns at the return electrode pad site.

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14. OUTCOMES OF TURP

• IPSS improvement: 70-80% reduction in symptom score
• Peak flow rate (Q-max) improvement: Increases by 100-150% (e.g., from 8 mL/s to 16-20 mL/s)
• PVR reduction: Significant
• Patient satisfaction: >80% satisfied
• Re-operation rate: ~10-15% at 10 years (main reason: BPH regrowth, bladder neck contracture)
• Mortality: <0.1% in modern series (historically 0.5-1%)
• Blood transfusion rate: ~2% in modern series

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15. POST-OPERATIVE CARE

• CBI with normal saline via 3-way Foley until urine runs clear (usually 12-24 hours)
• Analgesia: NSAIDs (avoid if renal impairment) + paracetamol
• Monitor: urine output, colour, haemoglobin, electrolytes (especially Na+)
• Mobilise early - DVT risk
• Remove catheter at 24-48 hours (when urine clear); ensure adequate void and check PVR
• Discharge home same day or next day in uncomplicated cases

• Avoid strenuous activity for 2-4 weeks
• Avoid sexual intercourse for 4-6 weeks
• Increased fluid intake (dilutes urine, reduces clot risk)
• Expect mild haematuria, frequency, dysuria - normal for 4-6 weeks
• Return immediately if: heavy haematuria, clot retention, fever, inability to void

• Stop anticoagulants can be restarted at 24-48 hours (liaise with haematology for high-risk patients)
• Alpha-blockers: can be stopped post-TURP (obstruction relieved)
• 5-ARIs: stop post-TURP

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16. TURP vs ALTERNATIVES - EXAMINER LOVES THIS

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17. QUICK VIVA FIRE-ROUND - Q&A

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SUMMARY CARD

TURP = Gold standard endoscopic BPH surgery
Ideal prostate size: 30-80 g
Position: Lithotomy | Anaesthesia: Spinal preferred (detect TUR syndrome early)
Irrigant: Glycine (monopolar) | Saline (bipolar - preferred)
Key landmark: VERUMONTANUM - never resect distal to it
Resection sequence: 6 o'clock groove → lateral lobes → median lobe last
Chip evacuation: Ellik evacuator | Send ALL chips to histology
Post-op: 3-way Foley + CBI until clear → remove 24-48h

MOST COMMON complication: Retrograde ejaculation (65-90%)
MOST FEARED complication: TUR syndrome → hyponatremia → confusion → seizures → VF
Treatment of TUR syndrome: STOP surgery → furosemide → restrict fluids → hypertonic saline if Na <120
Bipolar advantage: Uses saline → no hyponatraemia TUR syndrome
Re-operation rate: ~10-15% at 10 years

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Techniques of TURP - Complete Guide

"The actual technique is probably not as important as planning it carefully and executing it precisely so that the operation is complete and the surgeon remains oriented throughout the procedure."

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THE THREE UNIVERSAL STAGES IN ALL TECHNIQUES

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THE PRINCIPAL TECHNIQUES

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1. NESBIT TECHNIQUE (1943/1951) - The Classic Standard

Nesbit's Three Formal Stages:

• Resectoscope positioned at the midpoint of the prostate
• Begin at the 12 o'clock position (anterior, roof of prostate)
• Resect intravesical prostatic tissue, bladder neck, and immediately adjacent proximal prostatic tissue
• Work clockwise from 12 → 3 → 6 → 9 → 12
• This stage removes the anterior (ventral) portions and the proximal adenoma
• Key effect: early control of perforating urethral blood vessels at the roof, devascularising the lateral lobes

• Systematic resection of lateral lobes (3-9 o'clock on each side)
• Because the anterior and proximal tissue was removed in Stage 1, the lateral lobe bulk falls posteriorly under gravity
• This makes the posterior and posterolateral tissue easier to visualise and resect
• Proceed from 12 o'clock down to 6 o'clock on each side
• Resect to the surgical capsule (circular white fibrous tissue - the plane boundary)

• Most critical and delicate stage
• Remove remaining apical tissue around the verumontanum
• Again start at 12 o'clock anteriorly, using the verumontanum as the primary landmark
• Short, controlled strokes to avoid going beyond/distal to verumontanum
• A finger in the rectum (by assistant) can help feel the extent of remaining apex tissue

12 o'clock proximal → clockwise proximal resection → lateral lobes fall back
→ systematic lateral lobe resection → apical resection around verumontanum

• Early devascularisation (roof cut first controls main vessels → less bleeding overall)
• Lateral lobes released and fall posteriorly → easier to resect bulky tissue
• Surgeon always oriented by the intact capsule landmarks
• Widely taught; most urologists trained on this

• Bulk lateral lobe tissue may impede view during capsular bleeding control until removed
• Partially resected lateral lobes (inevitable mid-procedure) tend to bleed

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2. MAUERMAYER TECHNIQUE (1985)

Sequence:

• Resect the middle lobe (if present) at the prostatic floor
• Create a channel between 5 and 7 o'clock at the floor of the prostatic urethra
• This opens up the bladder neck drainage, improves irrigation flow and visual clarity immediately

• With good irrigation now established (floor open), resect lateral lobes systematically
• Proceed from floor upward, resecting ventral (anterior) portions as well

• Careful apical resection around verumontanum

Middle lobe (5-7 o'clock channel) → lateral lobes + ventral parts → apical region

• Immediate improvement in irrigation drainage (floor opened first)
• Excellent early visibility
• Particularly suited when there is a prominent middle/median lobe obstructing the bladder neck (the most bothersome obstruction is relieved first)
• If middle lobe is intravesical, removing it first prevents it from flopping over the bladder neck and obstructing vision

• Starting at 6 o'clock without devascularising the roof first → can encounter more bleeding from lateral lobe vessels early on
• Less systematic devascularisation compared to Nesbit

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3. MILNER TECHNIQUE (1941)

Sequence:

• If median lobe enlarged, resect it first to open the bladder neck and clear the field

• Begin with a deep full-length groove at the extreme lateral position (9 o'clock for the left lobe, or 3 o'clock for right lobe)
• The groove goes from bladder neck to verumontanum level, full depth to capsule
• This groove runs the entire length of the prostate at the thickest lateral point
• Then systematically resect the entire lobe in sequence - anterior portions first, allowing remaining tissue to fall posteriorly
• Complete the entire lobe before moving on

• Mirror the procedure on the opposite side
• Again, full-length groove first, then systematic completion

• Resected similarly to Nesbit technique
• Dr. Milner used the Stern-McCarthy resectoscope (2-handed instrument) so he could not place a finger in the rectum - he relied on resecting the posterior lobe to a slightly concave surface

• Tissue around verumontanum is resected carefully
• Scope is inverted; remaining tissue 11-1 o'clock resected with straight strokes parallel/proximal to verumontanum

Middle lobe (if present) → full-length groove at 9 or 3 o'clock → complete one entire lateral lobe
→ full-length groove opposite side → complete second lateral lobe → posterior lobe → apex

• Immediate attack on the bulk lateral lobe tissue → faster tissue removal, better irrigation and scope mobility early
• One-lobe-at-a-time approach: can stop surgery midway (after one lobe) if needed (bleeding, time limit, TUR syndrome developing) - the completed side is already fully haemostatic
• Full-length groove at thickest point (9 or 3) means any inadvertent early capsular perforation occurs at minimal clinical risk (thickest point of capsule)
• Less bleeding in practice because perpendicular resection to capsule gives rapid access to main vessels for immediate coagulation
• Avoids problem of bulk lateral lobe tissue impeding vision

• Appears to "violate" Nesbit devascularisation principle (no early 12 o'clock cut)
• Requires skill - the speed of resection is key to controlling bleeding
• Steeper learning curve to master

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4. BARNES TECHNIQUE

Sequence:

• Begin resection at the posterior lobe (6 o'clock)
• This immediately establishes good irrigation flow into the bladder (floor open)
• Ensures thorough posterior lobe resection (which can be difficult later when floor fills with chips and clots)
• Then proceed to lateral lobes and ventral portions
• Apex last

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5. ALCOCK TECHNIQUE

Sequence:

• Resect along the floor and sides to undermine the base of each lateral lobe
• The undermined lateral lobes then fall into the prostatic fossa
• Resect the fallen lobe tissue
• Works on principle of gravity-assisted prolapse of tissue into the field

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6. FLOCKS TECHNIQUE

• Creates a posterior sulcus first, exposing the capsule posterolaterally
• Proceeds to remove lateral lobe tissue working anteriorly
• Establishes posterior capsule landmark early

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COMPARISON TABLE - AT A GLANCE

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UNIVERSAL PRINCIPLES APPLYING TO ALL TECHNIQUES

1. Cystoscopy first - inspect urethra, bladder, note ureteric orifices, assess prostate configuration
2. Verumontanum = absolute distal boundary - never resect distal to it
3. Ureteric orifices - identify and protect during bladder neck/middle lobe resection
4. Surgical capsule = endpoint of resection (circular white fibrous tissue)
5. Haemostasis at each stage - do not leave active bleeders and proceed
6. Resection time ≤60 minutes - if not complete, stage the procedure
7. Ellik evacuator for chip clearance before each new stage (improves visibility)
8. Systematic approach - always have a plan; disorientation is the surgeon's greatest enemy

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APICAL RESECTION - SPECIAL MENTION

• It is the most critical step for functional success - inadequate apex resection = persistent obstruction
• It is the most dangerous step - external sphincter lies just distal to verumontanum

• Resect with short controlled strokes at the apex
• Use verumontanum as constant reference - the loop should never go distal to its distal edge
• The scope can be inverted (rolled) to reach the anterior apex (11-1 o'clock tissue above the verumontanum) using short straight strokes parallel to the veru
• Rectal finger by assistant: the finger can guide depth of remaining tissue at the apex
• Some urologists use the cold-cut technique (cut current only, no coagulation) for the very last apical tissue to avoid thermal spread to the sphincter

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EXAMINER Q&A ON TECHNIQUES

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TURP Techniques - Complete Table + Blandy Technique in Detail

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WHO WAS JOHN BLANDY?

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THE BLANDY TECHNIQUE - Full Detail

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BLANDY'S THREE UNIVERSAL STAGES (applies to his whole technique)

"In all methods there are three stages: 1. Establishing the landmarks. 2. Removing the main bulk of tissue. 3. Tidying up." - Blandy

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STAGE 1: ESTABLISHING LANDMARKS

• Ureteric orifices (bilateral) - must be visualised and protected throughout
• Verumontanum - the sacred distal landmark; never cut distal to it
• Bladder neck - proximal limit
• Anterior commissure (12 o'clock) - reference for orientation
• Surgical capsule - circular fibres; endpoint of resection

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STAGE 2: REMOVING THE MAIN BULK

STEP 1 - Resect the Middle Lobe First

• The middle/median lobe is resected first (if present)
• Take systematic, even cuts to reduce the mound of the middle lobe flat
• The correctly resected middle lobe shows a "cobweb appearance" under the bladder neck - this is the endpoint
• After resecting the middle lobe, specifically control Badenoch's arteries at 5 and 7 o'clock (these are the main arterial feeders to the floor of the prostate at the bladder neck level - named after A.J. Badenoch, a British urologist)

STEP 2 - First Method for Lateral Lobes (standard-sized prostate)

• Rotate resectoscope to bring the anterior commissure to 12 o'clock
• Take one or two careful chips at 1 o'clock - the object is to liberate the lateral lobe from the capsule anteriorly
• Remember: the prostate is very thin anteriorly at 12 o'clock - only 1-2 chips expose the capsule here
• Deepen the trench laterally - as you proceed, the left lateral lobe falls backwards into the space vacated by the resected middle lobe (gravity-assisted)
• At this point you will encounter the "arteries of Flocks" at 2 o'clock (Rubin Flocks first described the arterial anatomy of the prostate in 1937 - the main arterial supply enters at the 2 and 10 o'clock positions at the bladder neck). These must be carefully coagulated before proceeding further
• Once the lateral lobe has fallen inwards, resect the fallen lump of tissue - it is now free of the capsule and easier to remove
• Repeat mirror procedure on the opposite side

• For a really bulky prostate, begin with prophylactic coagulation of the main prostatic arteries at 10, 2, 5 and 7 o'clock using the rollerball electrode before taking any tissue
• This pre-emptive devascularisation reduces bleeding during the subsequent bulk resection
• Then proceed to resect middle lobe, followed by lateral lobes as above

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STAGE 3: TIDYING UP (THE APICAL RESECTION)

• The apical tissue at 2 and 10 o'clock (anterolateral apex) is trimmed carefully
• A finger in the rectum by the assistant can lift the apical tissue up toward the resectoscope loop - making it easier to resect without going distal to the verumontanum
• Trim the tissue adjacent to the verumontanum with great care

"In removing the tissue adjacent to the verumontanum, err on the side of caution. A gram or two of adenoma in this situation does not cause outflow obstruction, and a damaged sphincter can never be restored."

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KEY BLANDY ANATOMICAL FEATURES TO KNOW

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BLANDY'S TECHNIQUE FOR VERY LARGE PROSTATES (>50 g)

"Thanks to the instruments of today there is virtually no limit to the size of prostate that can be resected transurethrally so long as the surgeon can keep clearly orientated and maintain concentration and patience... it is hardly more difficult to remove 100 g than 40 g, since the steps of the operation are the same even though they take a little longer."

1. Prophylactic rollerball coagulation at 10, 2, 5, 7 o'clock first (devascularise before cutting)
2. Resect very bulky middle lobe - keep the mound flat and even
3. Proceed with lateral lobes systematically as above
4. Consider staged TURP if time limit approaching (>60 min rule)

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COMPLETE COMPARISON TABLE OF ALL TURP TECHNIQUES

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HOW THE TECHNIQUES RELATE TO EACH OTHER

                    WHERE TO START
                         │
           ┌─────────────┼──────────────┐
        12 o'clock    5-7 o'clock    9/3 o'clock    Post sulcus
        (Anterior)    (Floor/Middle)  (Extreme lat)  (Posterior lat)
           │              │               │               │
         NESBIT       MAUERMAYER        MILNER          FLOCKS
         BLANDY*       BLANDY*          (one lobe
        (step 2)      (step 1)         at a time)
           │
        6 o'clock
        (Posterior)
           │
         BARNES
           │
      Undermine base
           │
         ALCOCK

*Blandy = hybrid: starts with middle lobe (like Mauermayer/Barnes), 
          then uses anterior commissure approach (like Nesbit) for lateral lobes

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COMMON THREAD - THE ARTERIES YOU MUST KNOW

Examiner question: "What are Badenoch's arteries and when do you encounter them?" Answer: Badenoch's arteries are paired vessels entering the prostate at 5 and 7 o'clock at the level of the bladder neck. They are the main blood supply to the floor of the prostate. In Blandy's technique, they are specifically coagulated after the middle lobe resection is complete to secure haemostasis of the floor before proceeding to lateral lobe resection.

Examiner question: "What are Flocks' arteries?" Answer: Described by Rubin Flocks in his 1937 paper on prostatic arterial distribution. They enter at 2 and 10 o'clock at the bladder neck and are the dominant arterial supply to the lateral lobes. In Blandy's technique, as the anterior commissure cut is made and the lateral lobe falls backwards, these vessels are encountered and must be coagulated before resecting the fallen lobe tissue.

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QUICK MEMORY AID

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