MODIFIED TURP LOOP FOR BLADDER NECK INCISION UNYIME O. NSEYO, M.D. DANIEL C. MERRILL, M.D. From the Department of Urology, University of California-Davis, and Urology Section, Martinez Department of Veterans Affairs Medical Center, Martinez, California
Transurethral incision of bladder neck (TUIBN) has been employed primarily to relieve bladder neck obstruction in patients with small prostate glands. These patients are at significant risk for bladder neck contracture following traditional transurethra][ prostateetomy; previous investigators have found that the incidence of this complication can be reduced if the obstructing bladder neck is incised rather than excised.14 Orandi 1 reported that in 646 matched eases followed over fifteen years, transurethral incision of prostate (TUIP) provided better results and fewer eomplications than the standard transurethral resection. TUIBN has the added advantages of (1) a low incidence of long-term secondary bladder neck fibrosis, (2) a low incidence of retrograde ejaculation, and (3) a shorter operative time. TUIBN also may be more cost effective than transurethral resection of prostate (TURP), since it requires a shorter hospital stay. Since the incidence of retrograde ejaculation is less than 28 percent following TUIBN, 2~3it should be the treatment of choice for patients with obstructing small prostates who wish to avoid retrograde ejaculation. Turner-Warwick4 used a hot knife to create a unilateral or bilateral (5 and/or 7 o'clock positions) full thickness endoscopic incision from the bladder neck to the level of the verumontanum. The appearance of fat in the incision insured the completeness of the incision. Presently the urethrotomy knife is the standard instrument for incision of the bladder neck. Bleeding following the cold knife incision is controlled with eleetrocautery using a Bugbee electrode. The primary disadvantage of present TUIBN techniques is that they do not yield prostatic tissue for histologic analysis.
168
FIGURE 1. Modified 26F ACMI that is passed through 28F resec bladder neck incision.
For the past five years on (D.C.M.) has performed TUII fled 26F ACMI resectoscop~ passed through a 28F reseetosq 1). Incisions with the modified sue specimens for histologie a those obtained by needle biop: (Fig. 2). The modified loop al, coagulate bleeding points. Th, performed at 5 and 7 o'clock l~ bladder neck to the verumonta prostatic capsule. The excised sent for histologic analysis. This technique has been err in patients with primary blad~ tion and in several patients w contracture following TURP tectomy. The procedure is parl
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t r a n s u r e t h r a l incision of o b s t r u c t i n g n e c k of bladder diverticulum. I n s u m m a r y w e d e s c r i b e a n e w t e c h n i q u e for p e r f o r m i n g T U I B N w h i c h p r o v i d e s tissue for histologie analysis a n d thus a m e t h o d for d e t e c t ing u n s u s p e c t e d p r o s t a t e eaneer. D e p a r t m e n t of Veterans Affairs Medical Center 150 Muir Road Martinez, California 94553 (DR. NSEYO)
i;UttE 9,. Section of prostatic tissue obtained with ~d(]]:~dTURP loop. Benign specimen shows fibro,,s,C;~iar tissue with prostatic glands oJ varying size ~ b~ double layer 094cuboidal-columnar epithe~i ~ome 094the glands are dilated with protein~,,o~secretzons. }tie'is w h o h a v e h a d r a d i c a l p r o s t a t e e t o m y ~]t provides a method for determining ~ e r the bladder n e c k o b s t r u c t i o n is seeond~/!It~ b e n i g n or m a l i g n a n t disease. We also *'~ ci?: [~!!i~mployed t h e m o d l•h .e d l o o p to p e r f o r m
References 1. Orandi A: Transurethral incision of prostate (TUIP): 646 cases in I5 years, chronological appraisal, Br J Urol 57:703 (1985). 2. Dorflinger T, et al: Transurethral prostateetomy or incision of the prostate in the treatment of prostatism caused by small benign prostates, Scand J Urol Nephrol (Suppl) 104:77 (1987). 3. Larsen CJ, et ah Transurethral incision versus transurethral resection of the prostate for the treatment of benign prostatic hypertrophy, a preliminary report, 8eand J Urol Nephrol (Suppl) 104:83 (1987). 4. Turner-WarwickR: A urodynamie review of bladder outlet obstruction in the male and its clinieai implications, in TurnerWarwick R, and Whitside G (Eds): Symposiumon Clinical Urodynamics, Urol Clin North Am 6:171 (1979).
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Transurethral incision of bladder neck (TUIBN) has been employed primarily to relieve bladder neck obstruction in patients with small prostate glands. These patients are at significant risk for bladder neck contracture following traditional transurethra][ prostateetomy; previous investigators have found that the incidence of this complication can be reduced if the obstructing bladder neck is incised rather than excised.14 Orandi 1 reported that in 646 matched eases followed over fifteen years, transurethral incision of prostate (TUIP) provided better results and fewer eomplications than the standard transurethral resection. TUIBN has the added advantages of (1) a low incidence of long-term secondary bladder neck fibrosis, (2) a low incidence of retrograde ejaculation, and (3) a shorter operative time. TUIBN also may be more cost effective than transurethral resection of prostate (TURP), since it requires a shorter hospital stay. Since the incidence of retrograde ejaculation is less than 28 percent following TUIBN, 2~3it should be the treatment of choice for patients with obstructing small prostates who wish to avoid retrograde ejaculation. Turner-Warwick4 used a hot knife to create a unilateral or bilateral (5 and/or 7 o'clock positions) full thickness endoscopic incision from the bladder neck to the level of the verumontanum. The appearance of fat in the incision insured the completeness of the incision. Presently the urethrotomy knife is the standard instrument for incision of the bladder neck. Bleeding following the cold knife incision is controlled with eleetrocautery using a Bugbee electrode. The primary disadvantage of present TUIBN techniques is that they do not yield prostatic tissue for histologic analysis.
168
FIGURE 1. Modified 26F ACMI that is passed through 28F resec bladder neck incision.
For the past five years on (D.C.M.) has performed TUII fled 26F ACMI resectoscop~ passed through a 28F reseetosq 1). Incisions with the modified sue specimens for histologie a those obtained by needle biop: (Fig. 2). The modified loop al, coagulate bleeding points. Th, performed at 5 and 7 o'clock l~ bladder neck to the verumonta prostatic capsule. The excised sent for histologic analysis. This technique has been err in patients with primary blad~ tion and in several patients w contracture following TURP tectomy. The procedure is parl
UROLOGY
/
F E B R U A R Y 1991
/
VOLUMt
t r a n s u r e t h r a l incision of o b s t r u c t i n g n e c k of bladder diverticulum. I n s u m m a r y w e d e s c r i b e a n e w t e c h n i q u e for p e r f o r m i n g T U I B N w h i c h p r o v i d e s tissue for histologie analysis a n d thus a m e t h o d for d e t e c t ing u n s u s p e c t e d p r o s t a t e eaneer. D e p a r t m e n t of Veterans Affairs Medical Center 150 Muir Road Martinez, California 94553 (DR. NSEYO)
i;UttE 9,. Section of prostatic tissue obtained with ~d(]]:~dTURP loop. Benign specimen shows fibro,,s,C;~iar tissue with prostatic glands oJ varying size ~ b~ double layer 094cuboidal-columnar epithe~i ~ome 094the glands are dilated with protein~,,o~secretzons. }tie'is w h o h a v e h a d r a d i c a l p r o s t a t e e t o m y ~]t provides a method for determining ~ e r the bladder n e c k o b s t r u c t i o n is seeond~/!It~ b e n i g n or m a l i g n a n t disease. We also *'~ ci?: [~!!i~mployed t h e m o d l•h .e d l o o p to p e r f o r m
References 1. Orandi A: Transurethral incision of prostate (TUIP): 646 cases in I5 years, chronological appraisal, Br J Urol 57:703 (1985). 2. Dorflinger T, et al: Transurethral prostateetomy or incision of the prostate in the treatment of prostatism caused by small benign prostates, Scand J Urol Nephrol (Suppl) 104:77 (1987). 3. Larsen CJ, et ah Transurethral incision versus transurethral resection of the prostate for the treatment of benign prostatic hypertrophy, a preliminary report, 8eand J Urol Nephrol (Suppl) 104:83 (1987). 4. Turner-WarwickR: A urodynamie review of bladder outlet obstruction in the male and its clinieai implications, in TurnerWarwick R, and Whitside G (Eds): Symposiumon Clinical Urodynamics, Urol Clin North Am 6:171 (1979).
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