SPECIFIC T-L

CONTENT T.A EVALUATION

OBJECTIVES STRATEGIES

II. TURP (Transurethral Resection of Prostate)

A. Describe A. Anatomic and Physiologic Overview 5 min - Visual Aide

structures and - Powerpoint
function of the In the male, several organs serve as parts of both the urinary tract and the Presentation
male reproductive reproductive system. Disorders in the male reproductive organs may interfere with
system. the functions of one or both of these systems. As a result, diseases of the male
reproductive system are usually treated by a urologist. The structures in the male
reproductive system include the testes, the vas deferens (ductus deferens) and
seminal vesicles, the penis, and certain accessory glands, such as the prostate
glands and Cowper’s gland (bulbourethral gland).

A. Identify the B. Definition “Q-A” activity

indications and
contraindications TURP is a surgical procedure involving the removal of prostate tissue using a Mechanics: In this
of TURP. resectoscope inserted through the urethra. activity, the
reporters shall ask
C. Purpose/Indication of TURP 5 min - Powerpoint the student
Presentation learners randomly
TURP has been long considered the “gold standard” surgical treatment for - Video with questions
obstructing BPH specifically when the major glandular enlargement exists in the - Lecture relevant to their
medial lobe that directly surrounds the urethra. A relatively small amount of tissue Discussion discussed topics.
must require resection so that excess bleeding will not occur and the time required to
complete the surgery will not be prolonged. TURP may be performed with the patient
under general or spinal anesthesia.
A resectoscope is passed through the urethra. Tiny pieces of tissue are cut
away, and the bleeding points are sealed by cauterization. The bladder and urethra
are continuously irrigated during the procedure, allowing visualization of the
resection. Repeated irrigation and drainage of these fluids ensure that resected
tissue and debris are removed from the bladder. Sterile, isotonic solution is selected
however, normal saline is avoided because of its suboptimal conductivity properties.
Also, hypotonic solution such as water must never be used.

D. Contraindication 10 min

Some relative contraindications include unstable cardiopulmonary status and

 a history of uncorrectable bleeding disorders. Patients with a recent myocardial
infarction or coronary artery stent placement should not have elective TURP surgery
for a least 1 month because of the increased risk of cardiovascular events and other
complications. A reasonable minimum delay of 3 months is suggested, but waiting at
least 6 months after any significant myocardial event is optimal before performing an
elective TURP.
Patients who cannot be safely taken off blood thinners such as Plavix would
also not be candidates for elective TURP surgery. If surgery is needed, they may be
treated with a Greenlight or vaporization laser surgery instead.
Patients with myasthenia gravis, multiple sclerosis, or Parkinson disease in
whom the external sphincter is dysfunctional and/or the bladder is severely
hypertonic should not have a TURP because intractable incontinence invariably
would result. Patients who have had major pelvic fractures that involved damage to
the external urinary sphincter also should not undergo a TURP for similar reasons.
Patients who have recently completed definitive radiation therapy for prostate
cancer are not candidates for TURP because of the unacceptably high rate of urinary
incontinence reported. If a TURP is absolutely necessary, it should be delayed at
least 6 months after definitive radiation therapy. Alternatives to TURP in such a
situation include drainage with a Foley or suprapubic catheter, intermittent self-
catheterization, and various other less-invasive prostatic surgical procedures.
Patients with prostate cancer who are considering brachytherapy (radioactive
seed implantation) or cryotherapy as part of their definitive treatment should not
undergo a TURP because the resected tissue would be necessary for optimal
needle, probe, and seed placement. The patient would also have an increased risk
for incontinence.
An active urinary tract infection is another contraindication for TURP surgery.
Usually, the surgery can be rescheduled following a course of appropriate antibiotics.

E. Complication

1. TURP Syndrome – Patient can develop water intoxication, known as

transurethral resection (TUR) syndrome, as a result of excessive irrigating
solution being absorbed during surgery. It is characterized by
hyponatremia, hypervolemia, hemolysis and acute renal failure. Cerebral
edema may result, which creates a medical emergency. Clinical
B. Discuss the manifestations include agitation, acute delirium, bradycardia, tachypnea, 15 min - Socialized
different and vomiting. Discussion
complications - Visual Aide
affecting TURP 2. Incontinence – Persistent incontinence after TURP affects 1% to 2%. - Powerpoint
postoperative Clients with overactive detrusor contractions (overactive bladder), voiding Presentation
patients. frequency, and sensory urgency initially may note an increase in the
frequency of urinary leakage or de novo incontinence. Pharmacotherapy
combined with pelvic muscle rehabilitation and fluid and dietary control
may be required to control overactive bladder that has been “unmasked”
by removal of obstructive prostatic tissue.

3. Retrograde ejaculation – Because the verumontanum is destroyed during

most prostate surgery, antegrade (forward) ejaculation cannot occur.
Instead, semen goes into the bladder during ejaculation and is voided with
the next urination, creating cloudy urine. This effect is harmless, but sexual
function may be impaired unless the client is advised of this anticipated
effect and reassured that it is expected to alter fertility potential but not
libido or erectile function.

4. Thrombophlebitis - Because patients undergoing prostatectomy have a

high incidence of deep vein thrombosis (DVT) and pulmonary embolism,
the physician may prescribe prophylactic (preventive) low-dose heparin
therapy. The nurse assesses the patient frequently after surgery for
manifestations of DVT and applies elastic compression stockings to reduce
the risk for DVT and pulmonary embolism.

5. Excessive bleeding - The immediate dangers after a prostatectomy are

bleeding and hemorrhagic shock. This risk is increased with BPH because
a hyperplastic prostate gland is very vascular. Bleeding may occur from
the prostatic bed. Bleeding may also result in the formation of clots, which
then obstruct urine flow. The drainage normally begins as reddish-pink and
then clears to a light pink within 24 hours after surgery. Bright-red bleeding
with increased viscosity and numerous clots usually indicates arterial
bleeding. Venous blood appears darker and less viscous. Arterial
hemorrhage usually requires surgical intervention (e.g., suturing of
bleeders or transurethral coagulation of bleeding vessels), whereas
venous bleeding may be controlled by applying prescribed traction to the
catheter so that the balloon holding the catheter in place applies pressure
to the prostatic fossa. The surgeon applies traction by securely taping the
catheter to the patient’s thigh.

6. Infection – Urinary tract infections and epididymis are possible

complications after prostatectomy. It is mostly due to poor irrigation or
 introduction of bacteria by poor aseptic technique during installation of
irrigating system and urinary catheters. Intravenous or oral antibiotics are
administered in the first few days after surgery. The patient is encouraged
to increase fluid intake to promote flushing of the system, help prevent
urinary stasis and decrease the chance of infection. The nurse reviews the
symptoms of UTI (fever higher than 37.6oC, chills, painful urination, back
or flank pain and general malaise) which the patient should report to the
physician.

F. Nursing Management

Preoperative Care
• Reducing anxiety. Establish communication with the patient to assess his
understanding of the diagnosis and of the planned procedure. Preoperative
teaching - Include attention to expectations about the procedure, such as
anticipated changes in voiding and sexual function
C. Describe the • Preparing the patient. Properly assess the patient’s health history, 20 min Oral Evaluation
nursing contraindications and other preoperative assessment. Client taking any drug or
management of supplement with anticoagulant effects should be discontinued before the surgery. - Socialized
patients who will Obtained informed consent Discussion
be submitted or • Providing Instruction. - Visual Aide
have undergone - Powerpoint
TURP. Postoperative Care Presentation
• Maintaining fluid balance. The urine output and the amount of fluid used for
irrigation must be closely monitored. Monitored electrolyte imbalance as well.
Frequently assess the client’s output (must include records of intake and output,
amount of instilled with the irritation. Monitor for retention
• Relieving pain. Ensure catheter patency and prevent catheter dislodgement.
Administer medication as prescribe. Offer warm compresses to the pubis or sitz
bath to relieve spasm. Encourage to ambulate.
• Monitor for bleeding. Monitor vital signs and laboratory results. Implement
strategies to stop bleeding and to prevent or reverse hemorrhagic shock. If blood
loss is extensive, fluids and blood component therapy may be given.
• Prevent infection. Careful aseptic technique should be used when irrigating the
bladder. Proper care of the catheter is important. Monitor for signs of local and
systemic infection. Maintain closed drainage system unless manual irrigation is
required. Encourage fluid intake, ambulation and deep breathing. Rectal
procedures should be avoided.
• Manage temporary incontinence. Keep in his mind that these problems are just
 temporary and have time to be resolve. Be understanding to the patient and assist
him in cleansing the perineal area. Counsel about the use of containment devices,
urethral clamps and absorbency products. Encourage muscle exercises.

Self Care
• Provide teaching. Includes catheter and wound management, activities that are
limited based on surgeon’s orders (heavy lifting, strenuous activity for 4-6 weeks,
prolonged sitting except during meals, sexual activity, and driving or riding in an
automobile at least 2 weeks.
• Prevent injury Advise not to strain during defecation for at least 6 weeks.
Docusate sodium, prune juice, and milk of magnesia. Increase amount of fluid
intake. Avoid or limit alcohol and other bladder stimulant such as caffeine.
Smoking should be discouraged because coughing puts strain on the surgical
area.
• Teach pelvic muscle rehabilitation Men with postprostatectomy incontinence
who practiced repeated pelvic muscle contractions with or without behavioural
biofeedback or electrical stimulation several times a day reported decreased
incontinence following treatment
• Arrange Follow Up Patient should report any elevated temp., unusual bleeding,
manifestation of wound infection or UTI and obstructed urinary flow.

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