Endoscopic Management of BPH

Endoscopic surgery is the mainstay of operative management for bladder outlet obstruction due to benign prostatic enlargement. The options range from resective and ablative techniques (TURP, photovaporization) to minimally invasive, ejaculation-preserving approaches (UroLift, TUIP), with the choice driven by gland size, anticoagulation status, and the patient's priorities around sexual function.

Transurethral Resection of Prostate (TURP)

Preoperative Considerations

• Anticoagulation: higher risk for postoperative transfusion, clot retention, and VTE, consider laser prostatectomy
• Counsel that retrograde ejaculation occurs in 62-78%
• Erections: 30% report improvement vs 20% report worsening, overall no change in sexual activity

Operative Technique

1. Dorsal lithotomy, genitals at edge of bed, optimize space between legs by spreading knees
2. Resectoscope: 30 degree lens, yellow sheath (26Fr), visual obturator
3. Confirm bi vs mono polar equipment and irrigation
4. Prep and drape patient
5. Set up light + camera cord and irrigation fluid with stopcock
6. Place sound in meatus to passively dilate urethra
7. Lubricate entire scope length (minimizes stricture formation)
8. Insert resectoscope, empty bladder, examine prostate, verumontanum, and ureteral orifices
9. Resect prostate starting with median lobe, then move anteriorly for lateral lobes
10. Reassess and repeat resection for adenoma as needed, shorter swipes near apex
11. Obtain hemostasis as needed
12. Remove chips with Ellik or Toomey syringe
13. Repeat obtaining hemostasis, reassess at lower pressure
14. Remove scope with bladder full (may see passive drainage), place 20Fr 3-way catheter and inflate with 30mL sterile water, irrigate to confirm placement and drainage

Operative Tips

• Bipolar vs monopolar: bipolar has no risk TUR syndrome but monopolar better at hemostasis, mainly surgeon preference
• Anesthesia: can consider spinal if high risk
• Bipolar settings: 200 resection, 120 vaporization
• Monopolar settings: 90 cut, 60 coag
• Chip length: avoid short chips, prolongs resection time and makes identifying bleeding more difficult
• Visualization: always keep 1/4 loop visible to maintain same resection depth
• Fulcrum: sweep hands in opposite direction of resection (think clock face), allows loop to resect entire depth of prostate (shaped like a bowl)
• Collecting chips: cut off top and bottom of suction bag to isolate chips then scoop directly into specimen cup
• TUR syndrome: more common in larger glands (> 45g) and longer surgeries (> 90min)
• Intraoperative erection: rare, may require phenylephrine injection
• Verumontanum = the key distal landmark: resect only to the proximal (bladder) edge of the veru — never resect distal to it, as this risks intrinsic-sphincter incontinence (higher risk after prior radiation, brachytherapy, or cryotherapy).
• Resection sequence: take the median lobe first, down to the circular bladder-neck fibers so it lies flush with the bladder floor (don't over-resect and undermine the neck); then open the fossa at 6 and 12 o'clock and take the lateral lobes, resecting the first loop length 360° before progressing more distally at the same plane.
• Venous sinuses: the tissue turns from foamy to stromal/fibrous as you near the surgical capsule; resecting deeper opens venous sinuses (irrigant absorption). Avoid short "scalloping" bites; long even loop lengths leave a smooth fossa. At the end, lower the irrigation height to reveal venous bleeders that pressure had tamponaded.
• Apical trimming last: withdraw distal to the veru to see the resection edge, then trim the apical lateral-lobe tissue by rotating the scope at the proximal veru without any in/out movement.

TUR Syndrome and Extravasation

• TUR syndrome (dilutional hyponatremia) occurs only with glycine or sterile water irrigant absorbed through open venous sinuses — bipolar/laser in saline eliminates the risk. With a sodium-free irrigant, consider spinal anaesthesia so an awake patient can report early signs (dizziness, nausea, headache), and send a stat serum sodium if you suspect absorption. Moderate (Na > 120 mEq/L): free-water diuresis with IV furosemide (10–40 mg). Profound (< 120): add IV 3% hypertonic saline — a small 50–200 mL volume has a marked effect.
• Extravasation of irrigant into the space of Retzius (from aggressive resection) causes suprapubic distension; decompress with a Penrose drain through a suprapubic stab (a Kelly clamp "popped" through the fascia above the pubis), removed the next day.
• Catheter: a large-bore 22–24 Fr with a 30-cc balloon, inflated up to 50 cc after a large resection so it is not pulled down into the fossa; continuous irrigation runs overnight and usually stops on POD1.

Expected Postoperative Course

• Void trial POD#1
• If patient passes, discharge POD#1 without catheter
• If patient fails, replace catheter, void trial in 3-5 days
• Stool softeners to prevent constipation (can cause hematuria from straining)
• Avoid physical activity causing perineal pressure for 4-6 weeks
• Intermittent hematuria and dysuria normal for 4-6 weeks
• 75-93% report improved voiding symptoms

Postoperative Complication Management

• Bleeding: fill balloon to 50-60mL, place catheter on traction, transfuse prn
• Bladder neck contracture: 2%, slowly decreasing flow rates, confirm with cystoscopy, open laterally until it accommodates cystoscope, can give methylene blue to identify obliterated opening
• Stricture: 4%, lubricate scope to prevent intraop, low rates with SP catheters over urethral catheters

Prostatic Urethral Lift (UroLift)

Preoperative Considerations

• Contraindicated if history urinary retention
• Perform cystoscopy to rule out presence of median lobe
• Perform sizing, less effective for glands > 80g
• Should have minimal effect on erectile and ejaculatory function (no tissue removed)

Operative Technique

1. Place patient in dorsal lithotomy position, prep/drape similar to TURP
2. Insert cystoscope, inspect bladder and prostate
3. Position device 1.5cm distal to bladder neck, visualizing verumontanum
4. Unlock safety
5. Compress against prostatic tissue at 2 or 10 oclock (anterolateral position)
6. Pull needle trigger (blue trigger)
7. Pull retraction trigger (gray trigger) to pull needle back
8. Move scope proximally towards bladder until silver line visible
9. Push urethral release button to cut suture
10. Usually place 4 implants, more if needed

Postoperative Management

• 1/3 failed immediate void trial and required catheter for ~1 day
• Up to 2% have inadequately placed implants and need removal due to encrustation
• Many patients will likely require a second treatment in the future due to tissue growth

Photovaporization (PVP, KTP)

Preoperative Considerations

• Useful for patients on active anticoagulation, but best if patients can be bridged
• Works best for prostates < 80-100g

Operative Technique

1. Position similar to TURP (see above), prep/drape
2. Set up separate laser irrigation cord, keep closed until ready to start surgery (will avoid running out of fluid)
3. Reverse trendelenberg to 6 degrees (forces bubbles into bladder to improve visualization)
4. Dilate meatus and lubricate entire scope length
5. Insert cystoscope into bladder, assess location of ureters and trigone relative to bladder neck
6. After inspecting, open laser and attach to irrigation fluid
7. Position laser so blue triangle is visible (can damage scope if laser too close)
8. Can rapidly zap entire prostate on 80 to superficially cauterize all tissue
9. Take down median lobe, either by creating lateral channels first or just working from one side to the other
10. Increase the energy level as needed (120+)
11. Maintain appropriate distance and timing, otherwise laser will coagulate and not vaporize
12. Obtain hemostasis as needed
13. Can consider giving 20mg IV furosemide to assist with diuresis
14. Place 18Fr 2-way or 22Fr 3-way (if concerned for bleeding)
15. Disposition: admit and perform void trial in AM, admit and discharge with catheter in AM for clinic void trial, or discharge from PACU with catheter for clinic void trial

Laser Settings and Technique (greenlight / MoXy)

• The greenlight (KTP/LBO, 532 nm, absorbed by haemoglobin, 0.8 mm penetration) is side-firing and aims 70° forward; power evolved 60 W → 80 W → 120-W HPS → 180-W XPS with the MoXy fiber. Start at 60–80 W vaporize / 20–35 W coagulate, then raise vaporization to 140–180 W for the adenoma (MoXy energy limit ~650 kJ).
• Keep the fiber ~2 mm from tissue (no less than 1, no more than 3 mm), sweep < 30° at ~2 s per sweep — too fast chars the tissue (dysuria), too slow coagulates it (sloughing, irritative LUTS); bubbles confirm vaporization. Keep the blue triangle in view (protects the lens); the red circle should not be seen while firing.
• Make lateral grooves at 5 and 7 o'clock down to the capsule, vaporize floor→anterior aiming for a "barrel" (not "funnel") fossa, and treat anterior tissue last (the sphincter sits more proximally). For a bleeder, compress it with the beak/fiber and aim the coagulation beam obliquely around the edges; a Bugbee or bipolar loop handles refractory bleeding.
• ~1/3 of PVP patients develop retrograde ejaculation (vs ~3/4 after HoLEP); the reintervention rate is ~6%.

Postoperative Management

• Maintain fluid intake to minimize hematuria
• Dysuria minimized by avoiding accidental tissue coagulation during surgery, can treat with NSAIDs and occasionally a steroid taper
• Transfusion need is rare

Holmium Laser Enucleation (HoLEP)

Preoperative Considerations

• HoLEP most closely approximates open simple prostatectomy endoscopically — the holmium laser develops the plane between the adenoma and the surgical capsule, and the enucleated lobes are then morcellated and sent for pathology.
• Size-independent and the preferred endoscopic option for very large glands (a minimally invasive alternative to open prostatectomy); randomized trials show outcomes equivalent to TURP and open prostatectomy, with shorter catheterization, less blood loss, and shorter stay.
• Its hemostasis makes it safe on antithrombotic therapy. Patients stay overnight; teach Kegels for early stress incontinence. Very large glands may need a cystotomy or perineal urethrostomy (with a catheter for 1–2 weeks). Incidental prostate cancer is found in 5.7–11.7% of morcellated specimens.

Laser Settings

• 100–120 W holmium (Ho:YAG, 2140 nm, 0.4 mm penetration) with a 550 µm end-firing fiber: 2 J / 40–50 Hz for enucleation and hemostasis, and a lower 2 J / 20 Hz near the sphincter (apical dissection and dividing the apical mucosal bridge).
• Three-lobe technique for a significant median lobe; two-lobe technique when the median lobe is small or only the lateral lobes are enlarged.

Operative Technique

1. Grooves — incise at the 5 and 7 o'clock positions lateral to the median lobe, from the bladder neck down to the veru, and deepen to the surgical capsule (keep the scope beak pointing into the groove).
2. Median lobe — connect the distal grooves just proximal to the veru, lift the adenoma with the scope beak, and divide the capsular attachments retrograde (sharp laser + blunt beak) until the lobe floats free in the bladder; re-check the ureteric orifices near the neck, and control capsular bleeders by defocusing the tip 2–3 mm away (2–2.5 J / 40–50 Hz).
3. Lateral lobes (one at a time) — incise the mucosa lateral to the veru (2 J / 20 Hz), find the capsule plane beneath the apex, and dissect circumferentially (rotate the scope up to 90°) toward 1 o'clock (left lobe) / 11 o'clock (right lobe), keeping the beak wedged between adenoma and capsule for countertraction.
4. Anterior commissure — cut a 12 o'clock groove from the bladder neck, extending it circumferentially to meet the inferior enucleation plane.
5. Apical mucosal bridge — rotate the scope to trap the distal mucosal strip and divide it with the fiber pointed away from the sphincter (2 J / 20 Hz).
6. Morcellate — with hemostasis achieved and the bladder well distended, pass a reciprocating-blade morcellator through an offset nephroscope, engage the free lobes, and morcellate up toward the centre of the bladder (never near the mucosa); collect the tissue in a trap for pathology.

Postoperative Management

• A 20–22 Fr three-way catheter (60-mL balloon), ± continuous irrigation, usually removed on POD1; overnight stay; a 1-week antibiotic course for a prior positive culture or retention.

Transurethral Incision of Prostate (TUIP)

Preoperative Considerations

• Useful for younger patients who want to avoid retrograde ejaculation
• Size: best candidates are small glands (< 30g)
• Median lobe is not a contraindication

Operative Technique

1. Position similar to above
2. Insert resectoscope and examine prostate and bladder neck
3. Incise at 5 o'clock or 7 o'clock positions, unilaterally or bilaterally
4. Can incise with laser or hot knife
5. Incise down to surgical capsule (some incise down to periprostatic fat)
6. Obtain hemostasis
7. Insert catheter to monitor immediate urine appearance

Choice and technique detail:

• Single- vs two-incision: a single incision (7 or 8 o'clock — placed slightly lateral, which springs the tissue apart better than a midline 6 o'clock cut) minimizes retrograde ejaculation; the two-incision technique (the classic, at 4 and 8 o'clock) has a slightly higher success rate. Single-incision carries a ~10% retrograde-ejaculation risk vs ~25–40% for two-incision (both far below TURP's 50–95%).
• Incision landmark: start just inside the bladder neck (~0.5–1 cm) and carry it to the proximal verumontanum at uniform depth, deepening until the circular bladder-neck fibers spring apart (some continue to periprostatic fat) — inadequate depth dooms the procedure to failure.
• Tools/settings: a Collings knife at 70 cut / 70 coag, or a holmium laser (1.4 J, 5–10 pulses/s) or KTP for better hemostasis; a mild median lobe can be desiccated, but a substantial median lobe is better treated by TURP.

Postoperative Management

• Can keep overnight or discharge immediately, with(out) catheter
• Retrograde ejaculation: 0-37%, less with unilateral incision

Reported Surgical Complications (from Campbell's)

	mTURP	bTURP	TUNA	TUMT	HoLEP	PVP	TUVP	TUIP
Temporary retention	4.3-6.8%	3.3-3.7%	23%	10-24%	2.7-5.9%	5.2-9.9%	2-9.8%	4.9-11.3%
UTI	4.1-6.2%	2.6-8.4%	4%	15-20%	0.9-2.7%	4.2-12%	0%	—
BNC	2-3.2%	0.5%	—	0%	1.2-1.5%	1.1-5%	0.5-1%	—
Stricture	3.4-4.1%	0.5-4.7%	0.5%	0-2%	1.9-4.4%	1-6.3%	1.9-3.3%	2.9-8.8%
Incontinence	0.6-1.5%	0-1%	—	—	0.9-1.1%	0-0.4%	0-2%	0.3-1.8%
Transfusion	2-4.4%	1.5-2.3%	rare	0%	0-1%	0%	0-0.5%	1.1%
Clot retention	4.9-7.2%	2.7-7.9%	—	1%	0%	0%	0-0.5%	—
Hematuria	3.5-15.7%	1%	6-28%	1-26%	0%	0.7%	0%	4.3%
Dysuria	0.8%	0%	8-14%	14%	1.2%	8.5-13.9%	2.9%	—
Urgency	2.2%	0.2%	10%	—	5.6%	0%	0%	—
Storage symptoms	—	—	—	18-31%	—	—	21%	—
Reoperation for BPE	0.5%	0.2%	19%	4%	0%	0.7-5.6%	2.4%	—
Reoperation other than for BPE	1.1%	0.2%	0%	—	1.9-2.8%	—	5.4%	9.6-18.4%
Capsular perforation	0.1%	0%	—	—	0.2%	0%	0%	—
Conversion to TURP	n/a	0%	n/a	n/a	0%	3.5%	0%	—
TUR syndrome	0.8-2.5%	0%	0%	0%	0%	0%	0%	—
Bladder mucosal injury	0%	0%	0%	—	3.3%	0%	0%	—