Transurethral resection of prostate (TURP)

Patient and case

1. Name / Age / Sex
2. UHID / IP no. / Ward-Bed
3. Date of surgery / OT no.
4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

1. Operating surgeonname, designation
2. Assistant(s)
3. Supervising consultantpresent in OT / available / not applicable
4. Steps done by the residentwhole procedure / named steps, under whose supervision
5. Anaesthetist
6. Scrub nurse / circulating nurse

Diagnosis and procedure

1. Pre-operative diagnosis
2. Post-operative diagnosis
3. Procedure planned
4. Procedure performedif different from plan, state why
5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
2. Site / side markedYesNot applicable
3. WHO Surgical Safety ChecklistSign inTime outSign out
4. Antibiotic prophylaxisdrug, dose, route, time given before incision
5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

• retrograde ejaculation (most men)
• bleeding, clot retention and blood transfusion
• TUR syndrome (low sodium from fluid absorption) with glycine or water
• urinary infection and sepsis
• urethral stricture
• bladder neck contracture
• temporary urgency or urge leakage; permanent incontinence is rare
• capsular perforation, ureteric orifice injury, rarely rectal injury
• need for repeat surgery later

Pre-operative details for this operation

1. IndicationLUTS not controlled on medicinesUrinary retention (catheter since date)Recurrent UTI / haematuria / bladder stone from BPHUpper tract changes
2. Prostate sizevolume in ml on ultrasound / TRUS; median lobe present or not
3. Symptom score and flowIPSS, Qmax, post-void residual
4. PSA and any biopsyvalue and date
5. Urine culturesterile / organism treated with which antibiotic
6. Baseline serum sodium, creatinine, Hb
7. Anticoagulants / antiplateletsdrug and date stopped
8. 5-alpha reductase inhibitor before surgeryYes (drug, duration)No

Anaesthesia and position

1. AnaesthesiaSpinalGeneralspinal lets the team talk to the patient and notice early signs of TUR syndrome
2. PositionLithotomy
3. Energy sourceMonopolarBipolargenerator settings (cut / coag)
4. Irrigation fluid1.5% glycineSterile waterSorbitol0.9% normal saline (bipolar only)total volume used in litres; bag height
5. Resectoscopesheath size (Fr), continuous flow or not, loop type

Operative findings

1. Urethranormal / stricture (site); dilated to which size
2. Prostatelateral lobes, median lobe, length from bladder neck to verumontanum, bleeding tendency
3. Bladdertrabeculation, sacculation, diverticulum, stone, tumour; ureteric orifices seen
4. Capsular perforationNoneSmall (site)Large (site, action taken)

Procedure (steps)

1. Urethral dilatationsounds used, up to which Fr
2. Resectoscope passedUnder visionWith obturator
3. Cystourethroscopywhole bladder seen; ureteric orifices identified (marked with coagulation if needed)
4. Median lobe resectiondown to bladder neck fibres, level with trigone
5. Lateral lobe resectionstarting position (o'clock); from bladder neck to proximal verumontanum; down to capsule fibres
6. Anterior and apical tissueresected without going distal to the verumontanum
7. Chip evacuationEllik evacuator; bladder checked empty of chips
8. Haemostasisloop / roller ball; checked with inflow lowered
9. Resection timeminutes from start to end of cutting
10. Verumontanum and sphincter preservedYes
11. Suprapubic region at endSoftDistended (action taken)

Closure, drains and dressing

1. Cathetersize (Fr), two-way / three-way, balloon volume in ml
2. Catheter placementStandardOver guidewire / with catheter guide
3. TractionNoneGentle traction taped to thigh (time started, planned release)
4. Continuous bladder irrigationfluid (normal saline), rate
5. Colour of effluent at end

Specimens and implants

1. Prostatic chips for HPEweight in grams; container, formalin, requisition sent
2. Other specimensbladder biopsy / stone, if any

End of procedure

1. Estimated blood lossml
2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
3. Swab, needle and instrument countCorrectIncorrect: action taken
4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

1. Vitals and sensoriumwatch for confusion, headache, dizziness, nausea, vomiting or high BP: possible TUR syndrome
2. Serum sodiumstat in recovery if glycine or water used, or if absorption suspected
3. Continuous bladder irrigationnormal saline; adjust rate to keep effluent light pink; stop when clear
4. Catheter caretraction release time; do not remove balloon water
5. Intake-output chartsubtract irrigation volume from bag output to get true urine output
6. Antibioticsdrug, dose, duration
7. Oral fluids and dietfrom when
8. Catheter removal and voiding trialday planned, usually day 1 if urine clear
9. HPE follow-update to review report

Signature

1. Name and designation of person writing note
2. Medical Council registration no.
3. Signature / date / time of writingwrite before the patient leaves recovery