Transurethral resection

The transurethral resection (TUR) is a urologic surgical technique , wherein the diseased tissue from bladder or prostate is removed. The operation is performed endoscopically through the urethra without an external incision and usually under general anesthesia . Colloquially, the TUR is also known as planing .

technology

The TUR is the oldest procedure in minimally invasive surgery . It is performed with the help of a resectoscope . A modern backwash resectoscope consists of an outer shaft that is atraumatic in the urethra and has a channel for the supply of liquid and one for suction. The inner shaft contains the optics including the transport dog for the longitudinal movement of the resection loop. The light source and a video camera are connected to the optics.

A wire loop through which an electrical current flows is used for the TUR . This removes diseased tissue in the urinary bladder or prostate layer by layer. Tissue that has been removed is usually examined histologically . Any bleeding that occurs is electrically obliterated ( cauterization ). The physical principle corresponds to that of high-frequency surgery . During the operation, a rinsing liquid is continuously introduced via the resectoscope and suctioned off in a controlled manner; this creates constant bladder filling and good visibility. This solution is semihypoosmolar and electrolyte- free in the classic monopolar resection . The lack of electrolytes is due to the need for low conductivity. The rinsing solutions typically consist of 1.5 percent glycine (theoretical osmolarity 299 mosmol / L) or a mixture of 1 percent sorbitol and two percent mannitol (theoretical osmolarity 164 mosmol / L). At the end of the operation, the resected tissue is rinsed out and, once the bleeding has stopped, an irrigation catheter is inserted. In addition to the classic monopolar resection, which requires the use of electrolyte-free rinsing fluids and is therefore associated with the risk of a so-called "TUR syndrome" (see below), there are now also bipolar resectoscopes. Newly developed high-frequency generators allow isotonic saline solution to be used as a rinsing liquid.

Application types

Transurethral resection of the bladder

The transurethral resection of the urinary bladder (TURB or TUR-B) is used to treat superficial bladder cancer . Several liters of physiological saline solution are usually required to flush the bladder postoperatively . The various urine bags are usually used for the subsequent supply . Local instillations of BCG or mitomycin are also used if subsequent resections are required .

Transurethral resection of the prostate

Transurethral resection of the prostate (TURP or TUR-P) is a standard procedure for removing obstacles to urinary flow through the prostate. Only the inner part of the prostate that is facing the urethra is removed. The peripheral prostate tissue and the organ capsule remain, the seed mounds and urethral sphincter are still spared . It is mostly used to treat the benign enlargement of the prostate ( benign prostatic hyperplasia ). A TUR-P can also be used for other flow obstacles, e.g. B. by prostate cancer .

Complications

In addition to general surgical or anesthetic risks (infection, bleeding, scars, cardiovascular disorders, thrombosis, etc.), there are also special risks of TUR:

• TUR syndrome (monopolar TUR): volume load and electrolyte shift (sodium deficiency) as a result of hypotonic irrigation fluid floating in lead to cardiovascular stress and even acute right heart failure . Symptoms are nausea , vomiting , confusion, and restlessness .
• Stress incontinence : An injury to the external sphincter can lead to incontinence. Urge incontinence , often observed after catheter removal, can be caused by irritation of the bladder, infection or postoperative edema and usually subsides over a period of three months.
• Injury to the ureter or urethra: narrowing of the urethra ( strictures ) can form. In rare cases, the junction of the ureters can be injured, resulting in urinary retention in the kidneys.
• Injury to the prostate capsule with leakage of fluid into the small pelvis
• Bladder neck sclerosis
• Inflammation of the testicles or epididymis
• Retrograde ejaculation in about 65% of the operated
• impotence is rarely observed.

history

The prerequisites for the TURB as an operating technique were created by Max Nitze's development of the electrically illuminated cystoscope from 1879 onwards. Later, Nitze also developed surgical cystoscopes and introduced cauterization for the removal of bladder tumors.

Although Ambroise Paré was already removing obstacles to the flow of urine through the urethra with a sharp hollow probe in the 16th century, the modern TURP developed later than the TURB. A precursor method of today's TURP was the transurethral punch resection of the prostate ("cold punch"), which was introduced in 1909 by Hugh Hampton Young (1870-1945). In 1913, George Luys performed the first coagulation of smaller prostate adenomas with the help of high-frequency current ( forage de la prostate ).

In 1926 Max Stern (1873–1946) combined Young's punch instrument with a cystoscope and electric loop and introduced the term resectoscope . He created the prototype of today's resectoscope. With the improvements made by Joseph McCarthy (1874-1965) in 1931 , the instrument became known as the Stern-McCarthy resectoscope .

In the 1970s, continuous flushing was popularized by José Iglesias de la Torre (1904–1979). However, Iglesias' instrument was based on preliminary work by Hans Joachim Reuter (1923-2003) in cooperation with the Storz company, which was initially not mentioned .

See also

• Resection : generally the surgical removal of tissue from an organ or a tumor.
• HF surgery (high frequency surgery): Presentation of the physical principles of electroresection and hemostasis.

Individual evidence

1. ^ DKFZ information
2. Jump up ↑ Veeratterapillay R, Heer R, Johnson MI, Persad R, Bach C: High-Risk Non-Muscle-Invasive Bladder Cancer-Therapy Options During Intravesical BCG Shortage. , Curr Urol Rep. 2016 Sep; 17 (9): 68, PMID 27492610
3. ↑ Ślusarczyk A, Zapała P, Zapała Ł, Piecha T, Radziszewski P: Prediction of BCG responses in non-muscle-invasive bladder cancer in the era of novel immunotherapeutics. , Int Urol Nephrol. 2019 Jul; 51 (7): 1089-1099, PMID 31154583
4. ↑ http://www.urologielehrbuch.de/turp.html D. Manski, www.urologielehrbuch.de, section TURP
5. ↑ L.Brandt B. Lazica Pathophysiology and Therapy of the TUR Syndrome in: R. Purschke Refresher Course- Current Knowledge for Anesthesiologists Springer 1993 pages 28–34 ISBN 978-3-540-57197-1
6. ↑ JN Cornu, S. Ahyai, ​​A. Bachmann, J. de la Rosette, P. Gilling, C. Gratzke, K. McVary, G. Novara, H. Woo, S. Madersbacher: A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update. In: European urology. Volume 67, number 6, June 2015, pp. 1066-1096, doi : 10.1016 / j.eururo.2014.06.017 , PMID 24972732 (review), PDF .
7. ↑ Mebust WK. Transurethral prostatectomy. Urol Clin North Am. 1990; 17 : 575-84. PMID 2197768
8. ↑ Young HH. A new procedure (punch operation) for small prostatic bars and contracts of the prostatic orifice. J Am Med Assoc. 1913; 60 : 253.
9. ^ Luys G. Traitement de l'hypertrophie de prostate par la voie endouréthrale. Clinique. 1913; 44 : 693.
10. ^ Iglesias JJ, Fiore G. Iglesias resectoscope with simultaneous irrigation, suction and low intravesical pressure. In: Eur Urol . 1975; 1 : 251-254. PMID 61120

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Web links

• TUR prostate and laser therapy: two therapies in comparison