Transurethral resection of the prostate

Benign prostatic hyperplasia is a prostate adenoma (adenoma). Proliferating adenomas compress normal prostate tissue into a capsule called a surgical capsule, and open surgical fingers separate in this gap. At present, in the developed countries, the traditional open surgery is rarely used to remove the prostate. Transurethral resection of the prostate (TURP) has become one of the routine surgical methods. Only a small number of patients with hyperplasia of the prostate are estimated to be more than 50g, and open surgery is considered. Since the 1980s, TURP has been carried out in many large and medium cities in China. This method has the advantages of small impact on patients and quick recovery, but requires special equipment and equipment, such as resection mirrors and high-frequency electrosurgical knives. Treatment of diseases: benign prostatic hyperplasia Indication Transurethral resection of the prostate is applicable to: Symptoms with obvious symptoms, enlarged prostate, and fine urine flow have surgical indications. If the symptoms are mild, the prostate is large or small, and the urine flow rate is normal, the treatment is conservative. Symptoms are obvious, the prostate is not large, but the urine flow rate value proves that the bladder outlet obstruction should also undergo transurethral resection of the prostate. The choice of patients undergoing transurethral resection of the prostate is preferably under 80 years of age, the size of the prostate is estimated to be below 45 g, and the surgery ends within 90 minutes. It has been suggested that it should be performed before the appearance of significant residual urine (>50ml), that is, when the bladder contraction compensatory function is better, mainly determined by the degree of obstruction rather than the size of the prostate. Preoperative preparation Most patients with benign prostatic hyperplasia are elderly, usually with coronary artery, valve and hypertensive heart disease, as well as cerebrovascular disease, chronic lung disease, renal insufficiency, and diabetes. Be sure to carefully understand and properly treat these diseases before surgery. There should be no obvious blood disease, and the coagulation function is basically normal. Prepare blood according to the general condition and the size of the prostate. Anticoagulants and vasodilators were discontinued 5 days before surgery to explain possible complications and postoperative considerations to patients and their families. Surgical procedure 1. Initial examination of cystoscopy Check the bladder for lesions, pay special attention to the bladder diverticulum, and if possible, extend the endoscope into it. Check the location of the triangle, the ureteral orifice, and their relationship to the proliferative prostate. Triangular hypertrophy may be mistaken for benign prostatic hyperplasia, which can be used to damage the ureteral orifice. The mid-lobe hyperplasia can cover the triangle. It must be accurately judged by a mirror (Storz 135°), followed by an examination to understand the increase of the leaf and its extent. And the extent of penetration into the bladder. Usually the prostatic urethra increases from the normal 2 to 3 cm to 4 to 6 cm. After the lateral lobe hyperplasia, the urethral cavity becomes a gap, and the distance from the top to the base increases. It must be noted that the lateral leaves protrude inward, sometimes squeezing and covering the fine The size range of the middle lobe hyperplasia is easy to judge, while the lateral lobe is more difficult. 2. Insert the electric mirror A 24F or 27F resection mirror is used depending on the size of the patient's urethra. If 24F can not pass, the urethral opening of the urethra can be performed first, and the metal urethral probes 20F, 24F, and 27F are successively expanded. The mid-lobular hyperplasia is obvious, and the obturator with movable bending at the head end is applied. First straighten, as usual, when the posterior urethra cannot advance, then retreat later, the obturator head end is bent forward, guiding the mirror sheath into the bladder. Exit the obturator and place the resection operator and 30° mirror. Intravesical infusion of liquid at least 300ml. 3. Suprapubic bladder puncture At 1 cm above the pubic symphysis, 10% of lidocaine was intradermally injected into the dermis, and then the needle was punctured vertically to the bladder. The anesthetic solution was pushed while the needle was pulled back, and the liquid was withdrawn. A 5mm straight incision is made in the skin, and the Trocar of the Reuter pubic suction device is inserted vertically into the bladder. The side tube (safety alarm tube) overflows the bladder fluid, the puncture needle is pulled out, the indwelling sleeve is inserted, and the catheter is inserted. The porous suction tube is inserted into the cannula instead (note that one puncture must be performed, and if the puncture is performed twice, the intravesical fluid overflows to the outside of the bladder through another perforation). Above the Reuter suction device, the gauze is placed between the holder and the skin to avoid electric shock and electric shock when cutting, and accidentally injure other tissues. 4. Excision of tissue First, the electric cutting ring was extended to the end, and the distal end exceeded the prostate 2 cm. The relationship between the electric cutting circle and the prostate tissue was visually observed. Then it is appropriate to properly pull the electric cutting ring to a distance of 1 cm from the prostate. To make the tissue larger, you can move the mirror sheath together to increase the length of the slice. The electric cutting circle passes the tissue too slowly, and the tissue piece is easy to stick to the electric cutting ring, but can be released after the subsequent cutting. If the slice is large, it is stuck in the circle and must be taken out when it cannot be removed. In addition to the middle of the prostate or the neck of the bladder, the prostate tissue is a globular adenoma. Therefore, the resection should be shallow-deep-shallow, and the tissue section is small. Each area can begin to be deep and then gradually cut so as not to cut through the surgical envelope. When cutting to the tip of the prostate, the sheath is placed on the upper edge of the external sphincter. After seeing the fine sputum, the fine sputum is marked on the sides and above the plane, and the electric cutting ring is pushed forward from the sphincter. Rachel, so as not to accidentally injure the external sphincter. During the electric cutting process, the fluid in the bladder is kept at a medium volume (about 200 ml), especially at the beginning and end of the electric cutting. Otherwise, the boundary between the edge of the prostate fossa and the front of the bladder and the side wall is difficult to distinguish, and it is easy to be accidentally injured. If the prostate protrudes significantly into the bladder (2cm) to cover the triangle of the bladder, the amount of bladder content must be filled to 300-400ml, so that the ureteral fistula and the ureteral orifice of the bladder are kept at a considerable distance from the cut prostate tissue (more than 1cm). In order to avoid accidental injury. When the benign prostatic hyperplasia of the bladder neck is cut to the annular fiber, it should not be cut again, otherwise it will cause postoperative bladder neck contracture, and the bladder prostate joint is very thin, and deep cut may cause perforation. After the excision of one leaf, when the other side leaves are cut, it can be found that the inverted V-shaped tissue appears on the resection side, and should be re-cut, and then check whether there is a similar situation in the clockwise or counterclockwise direction. The tissue should be removed. When the bottom is removed, the rectal examination should be given counterpressure, and the depth of the resection can be judged to avoid cutting through the rectum. For larger benign prostatic hyperplasia, the above situation may occur multiple times, and multiple rotations should be performed. However, it must be checked frequently whether it is below the level of fineness. Jingjing is a "border", it must be preserved, below the level of fine, that is, easy to hurt the external sphincter. The three leaves are hyperplasia, first cut in the middle leaves, otherwise interfere with the operation, but should not be cut too deep, mainly on the sides of the neck near the bladder, when the electric cut, stimulate the obturator nerve, the thighs violently. In this case, the electric cut should be stopped to avoid injury to the bladder or prostate surgical capsule perforation. During the electric cutting process, tell the patient not to take a deep breath. If you want to cough, say hello first, and stop cutting. Because these can be increased due to abdominal pressure, squeeze the bladder, electric injury and the posterior wall of the bladder. 5. Stop bleeding Identifying bleeding points and effective hemostasis is an important part of the TURP process. Bleeding is not only at the site of resection, especially at the beginning of resection, and the sharp angles of the electrosurgical circle move, which can injure the prostatic hyperplasia tissue that has not been resected in the inward compression. The bleeding in the field of view at the resection site is cloud-like, without bleeding. At this time, the bleeding point should be sought in the opposite direction of the resection site. Most of the bleeding from the resection is from the arteries and venous sinus, and there is very little venous bleeding, which needs to be treated separately. Arterial bleeding can be pulsatile (consistent with the patient's pulse rate), or it can be continuous ejection, bright red, and even after bladder filling and compression of the prostate fossa, bleeding continues. In general, arterial bleeding is easily controlled by electrocoagulation. In each adenoma tissue area, a single artery can repeatedly bleed during the electric cutting process, so it is not necessary to cut once and condense once, and electrocoagulation should be stopped at the end of the resection of the area. However, arterial bleeding of the surgical envelope must be stopped immediately. The main principle of hemostasis is that after removing a region, the bleeding point in this region must be firmly stopped, and then another region; otherwise, multiple bleeding, blurred vision, excessive blood loss, and affection of resection. Open sinus hemorrhage, dark red blood rushing out instead of ejecting, it is difficult to use electrocoagulation to stop bleeding, blood loss may be large, venous pressure is close to 10 ~ 12kPa, lower than prostate follicle lavage, therefore, perfusate easy to enter blood vessels Within, there is excessive blood volume, low sodium, and low hemoglobinemia. If hemolysis is used, hemoglobinemia can also occur. Bacteremia can occur if the surgical field has been infected. The sinus hemorrhage is bright, dark red, non-pulsating, and continuously flows out of irregular dark cavities or cracks like spring water. If an attempt is made to control by electrocoagulation, the result often ends with an enlarged opening and a failure to stop bleeding. In the process of washing electrocoagulation and hemostasis, if you want to check the bleeding site, the open venous sinus can not be seen because the prostatic fossa irrigation pressure is greater than the venous pressure. However, when the bladder contents are removed by resection of the sheath, the dark red blood will follow as the pressure in the prostatic fossa decreases, indicating that the sinus hemorrhage is re-examined and found. It must not continue to attempt to stop venous sinus bleeding by electrocoagulation, because the irrigating fluid can flow directly into the sinus through the resection mirror, and the resection can only be completed as soon as possible. The balloon catheter is then inserted and the appropriate water bladder is compressed to control sinus bleeding. 6. Flushing and discharge of bladder contents In the TURP process, in addition to continuous perfusion of the irrigation fluid, the operating mirror should be pulled out periodically, and the tissue pieces and blood clots in the bladder should be flushed out in time by the Ellik ejector filled with sterile saline. Whether it is Reuter reflux modified resectoscope or pubic puncturing retractable resectoscope, every 10 to 15 minutes of resection, need to be sucked once, otherwise the blood clot and the resected tissue fragments of the bladder will easily block the suction hole. Causes extravasation of the flushing fluid that is not noticed for a while. In the absence of such a retracting mirror of the continuous suction device, 400 ml of irrigation solution should be rinsed per perfusion or flushed every 5 minutes. If you use an electric negative pressure continuous suction device, you should pay attention to: 1 whether the suction tube is properly positioned in the suction pump; 2 whether the suction tube is fully filled with perfusate and the flow is smooth; 3Trocar punctures the small side tube of the suction sleeve ( Safety alarm) Is there any liquid flowing out? If the liquid in the suction tube is intermittent, there is gas, and the circulation is not smooth, the porous suction tube should be pulled out (the outer sleeve cannot be pulled), and the blocked blood clot or tissue should be removed. The operating mirror was removed and the contents of the bladder were drawn with an Ellik ejector (Fig. 7.11.2-15). Also check the tension of the lower abdomen, pay attention to the presence or absence of liquid seepage outside the bladder. Bladder content is immersed in a large container containing a large amount of lavage fluid. The glass container and the rubber ball are filled with liquid, and the ball is connected to the ejector to remove air. The ejector is inserted into the resected sheath sheath, first open the perfusion irrigation fluid switch, pre-fill the bladder with about 100ml, close the perfusion (flush) fluid into the switch, and pull out the sheath sheath 2~3cm to avoid suction during vacuum suction. In the bladder mucosa, repeatedly squeeze and release the rubber ball, sucking out the contents of the bladder, and the blood clots and tissue fragments sink into the bulb of the glass ejector. The ejector is pulled out and quickly poured into the sieve together with the water, the liquid flows through the debris of the tissue, and finally the tissue fragments are weighed with a balance. Since the tissue has been dehydrated during the electric cutting process, the weight added by 20% is equivalent to the normal weight of the excised tissue. 7. Judging whether to cut or not Because the prostatic hyperplasia resembles an irregular walnut or egg, it is impossible to accurately determine the distance between each part of the hyperplasia and the urethra to the surgical capsule. Therefore, it is necessary to cut the depth of each area to meet the standard, which is mainly based on observation and experience. The mark of the cut is that the bladder neck sees the ring fiber. According to the initial endoscopy, cut one side first, cut into a "cavity" or "wolf", and then cut the other side. But don't see the fiber bundle network structure, or even the adipose tissue (the tissue visible under the microscope has a shiny yellow surface with sparkling highlights). Because of this situation, it shows that the outer membrane is cut, the irrigation liquid can be extravasated. If the sinus is also cut, it is difficult to stop bleeding and affect the next operation. Finally cut the stone level at 12 o'clock (some people start from 12 o'clock, then cut 6 o'clock), 12 o'clock should not be cut too deep, because the front of the prostate is extremely rich in the posterior pubic venous plexus, the most easy to cut broken. After the three-leaf cut, the resection mirror is pulled to the upper edge of the external sphincter, and the clock is rotated clockwise to check again. The uncut prostate tissue is a cement sponge-like shape, and the inverted "V" or inverted "U" shape protrudes into the prostate fossa. It should be removed again. At this point, the prostate fossa is very spacious. Flush the bladder contents with an Ellik ejector. Carefully inspect the bladder cavity with a resection mirror, there may be some debris left unclean, you can use the electric cutting ring to gently pull out through the mirror sheath, leave the mirror sheath, fill the rinse solution 300 ~ 400ml, pull out the sheath, try "Urine", if the urine line is thick, it can be powerful. If it is not "line" or can not be discharged, there will be blockage of debris, re-inserted into the resection mirror, and thoroughly check the electrocoagulation bleeding point. So far the resection has ended. 8. Insert the catheter Most urological surgeons prefer to use a three-chamber balloon catheter with 20 to 50 ml of water in the capsule, which is pressed against the bladder neck and repeatedly rinsed until the back fluid is clear or only slightly bloody, avoiding the water bladder in the prostate fossa. Because it can cause bladder neck spasm, severe pain, hinder prostate gland contraction and hemostasis, resulting in postoperative urgency and urinary incontinence. However, if the sinus is cut, it is difficult to stop the blood, and the water bladder should be placed in the prostate gland to help stop bleeding. The method is to insert a three-cavity catheter with a water capsule capacity of 30 ml into the bladder, and inject 15 ml of water into the balloon, and then slowly pull it into the prostate capsule, and then inject 15 ml of water to maintain the water bladder in the prostate fossa; if the bladder is flushed, it is not satisfactory. , then add 5 ~ 10ml of water. The balloon catheter is circulated smoothly. After the rinsing liquid is clear, the Trocar suction cannula is inserted into the 12~14F catheter from the pubic bone, the Trocar suction tube is removed, the catheter is filled with water 10ml, and the puncture mouth is 2.5% iodine and 75%. Treat with ethanol and cover with sterile gauze. If the resection of the tissue is large, the urethral balloon catheter is not satisfied with the hemostasis of the prostate fossa, and the flushing solution is red. The catheter can be properly pulled outward, and the sterile gauze strip is tightly tied to prevent retraction. The water bladder squeezes the bladder neck to enhance compression and hemostasis. complication There are two important complications of TURP: first, bleeding, and perforation of the prostate capsule, which can cause extravasation and infiltration of perfusate (if venous sinus is open), and dilute hyponatremia (TURP syndrome).