Common Urologic Problems: Benign Prostatic Hyperplasia Sujata K Patwardhan, Altaf Shaikh
Page numbers followed by f refer to figure and t refer to table
Abdominal distension 196
Ablation 285
capacity 20
Abnormal ejaculation 204
Acontractile detrusor 54
coronary syndrome 152
cystitis, epididymitis 64
renal failure 189
urinary retention 72, 72t, 148, 149, 224
Adenosine diphosphate pathway 151
exercise 216
hemostasis 28
Alfuzosin 202, 204
Alpha blocker 207
monotherapy 257
Amblyopia 204
College of Cardiology 153
Heart Association 153
Urological Association 117, 145
Aminoglycoside 117
Aminopenicillins 117
Amount of blood loss 226
Amoxicillin 117
Ampicillin 117
Anesthesia 84, 177, 183
Ankylosis of hip 64
Anti-androgens and
blood loss 103
intraoperative blood loss 103
Antidiuretics for nocturnal polyuria 217
Antimuscarinics for overactive bladder syndrome 217
Antiplatelets 181
and transurethral resection of prostate 151
Apical lobe enucleation 32
Applications of current urological lasers 131t
Argus sling 100, 100f
Arrhythmogenic right ventricular dysplasia 157
Arterial bleeding 177, 178, 178f
Artificial urinary sphincter 86, 87f
Aspirin 151, 152
antiplatelet agents 151
Asthenia 204
Asymptomatic prostatic enlargement 81
Atrioventricular node diseases 157
Autoclave 109
Automated prostate volume 169f
Backache 202
Balloon angioplasty without stenting 152
Barnes technique 3
Basic metal stent 152
Bell-shaped curve 44
enlargement of prostate 134, 231, 235
enlargement 274
obstruction 274
hyperplasia 1, 72, 84, 106, 106f, 108, 108f, 219, 235, 251, 256, 274, 290
Bilateral inguinal hernia 81
Biochemical recurrence after radical prostatectomy 219
circuit 10f
technology 10
TURP 16, 17, 126, 192, 270, 275
diverticulum 59
and benign enlargement of prostate 237
incision 59f
contracture 120, 292, 293, 293t
incision 26
reconstruction 226
outlet obstruction 40, 42, 274
stone 148
disorders and anticoagulants 277
in transurethral resection of prostate 174
loss 224
replacement 224
Blurred vision 202
Body mass index 213
Bone anchored sling systems 95
Botulinum toxin injection 202
Bounce bleeding 179f
Bowel herniation into bladder 196f
Bradycardia 189
Breast enlargement 200
British Pacing and Electrophysiology Group 157
Brugada syndrome 157
Bulbar stricture 299, 299f
Bulbospongiosus 95f
muscle 97f
Bulge of lateral lobes 164t
Canadian Urological Association Guideline 271
perforation 136
plication 62, 62f
and capsular dissection 63f
closure and supravesical cystostomy 64f
Cardiac failure 208
disease 216
system 213
Catheter 73, 116
expulsion 224
Causes of retrograde ejaculation 136
Cautery-free technique 73
Central nervous system 189
Cephalosporin 117
Cerebral venous sinus thrombosis 149
Cheaper irrigation solution 18
and progressive disease 207
prostatitis 148
retention 50, 51
urinary retention 50, 78, 148
Classification of UTI/urosepsis 115
Clopidogrel 151, 152
Coagulation cascade 182f
Coaptation of sphincteric urethra 98f
Cold knife incision 294
Colling's knife 294
Coma 189
Combination therapy 117, 141, 205, 258, 267
Complications of
laser prostatectomy 130
transurethral resection of prostate 175
Compression stocking 216
Computed tomography 239
for prostate volume 172f
Cone excision 5
Confusion 189
Content of inguinal hernia 239
and pulsed laser 21f
bladder irrigation 64
wave 279
Coronary artery disease 139, 142
Corpus cavernosum 135
Creation and role of plasma 13
Current lasers for BPH surgery 131
Cutting trench and tissue ablation 5, 5f
Cystitis 115, 116
assessment and urethral calibration 31
grade 164t
Cystoscopy 64, 163, 164, 293
Cystourethroscopy 92, 120
libido 200
semen volume 200
Deep vein thrombosis 65, 85
Definition of bipolar electrode 10
Delivery of radiofrequency energy 254
Desmopressin 217
Diarrhea 204
Diathermy variants comparison 10f
Digital rectal examination 163
Dihydrotestosterone 200
Dilated cardiomyopathy 157
Dilutional hyponatremia 66
Diode laser 123
Dissection 224
and finger enucleation 60f
Distal perforation 34, 34f
Distribution of alpha receptors 137f
Dizziness 203, 204
Doxazosin 202, 203
Drug eluting stents 152
Duloxetine 93
Dutasteride 103, 200, 258
Dyslipidemia 107
Dyspnea 203
Dyssynergic sphincter 51
Dysuria 41
Edema 203
Efficient energy application 28
Ejaculatory dysfunction 200
Electrocoagulation 135
Electromyelogram 49
Ellipsoid formula 166
End stage renal disease 220
Endocrine disorders 216
Endorectal coil 172
Enucleation 69f, 285, 303
technique 284
Erectile dysfunction 65, 108, 134, 142, 206
test 134f
Erection complex phenomenon 135
Ethylene oxide 109, 112
European Association of Urology 145, 271
Evolution of laser prostatectomy 25, 25f
Extracorporeal shock wave lithotripsy 153
Extraperitoneal bladder perforation 195, 195f
Faradic stimulation 119
Father of electrosurgery 8
Fatigue 203, 204
Fibrous gland 41
Finasteride 103, 200
absorption 186
height 191
Fluoroquinolone 117
Folly balloon catheter 180f
Fosfomycin trometamol 117
Frank pulmonary edema 189
Freyer's prostatectomy 59
Gland delivery 60f
Glutaraldehyde 109, 110
Good technique of dissection 28
Grade of severity of infection 115, 116
Green light laser vaporization 289
Gyrus system 11, 11f
H2O2 gas plasma sterilization system 111f
Headache 189, 202, 204
Health and lifestyle issues affecting sleep quality 215
Heart Rhythm Society 157
Hematuria 41, 67, 121, 212, 239
Hemorrhage in transurethral resection of prostate 113
Hemostasis 61
Heparin 151
High-grade prostate cancer 200
Holmium 27
and thulium enucleation 286
laser 25
ablation of prostate 274
enucleation of prostate 30, 124, 126, 192, 274, 276, 280, 286, 287, 303
incision 294
machine 29
resection of prostate 274
Holmium: yttrium-aluminum-garnet 39
Hybrid technique 71
Hyperammonemia 188, 190
Hyperglycinemia 189
Hyperinsulinemia 107
Hyperkalemia 159
Hypertension 107, 189
cardiomyopathy 157
obstructive cardiomyopathy 157
Hypnotics in insomnia 217
Hypoelectrolitemia 186
Hypokalemia 159
Hyponatremia 189, 217
Hypotension 189, 203
Impaired glucose metabolism 107
Implantable cardioverter defibrillator 157
Incidence of bladder neck contracture 293f
Indigenous design of laser bridge 29f
Inguinoscoral surgery 154
Inhibition of tachytherapy 159
International prostate symptom score (IPSS) 64, 126
Intestinal obstruction 196
Intracardiac thrombus 183
Intraperitoneal bladder perforation 195, 195f
Intraprostatic botulinum injections 198
Intravascular hemolysis 189
Intravesical BCG 234
Iodophores 109
Irrigating fluids 187t
Irrigation 16
fluid 186
Ischemic heart disease and hypertension 200
Karl Storz system 12, 12f
Laparoscopic management of benign prostatic hyperplasia 68
bladder calculi 59, 62
inguinal hernia with large adenoma 64
volume fast flow 48
Laser 275
absorption and tissue penetration 27f
in prostate surgery 155
in urology 39
prostatectomy 132, 148, 192, 292
wavelength 26
Lateral lobe enucleation 33
conductive trauma 18
intraoperative blood loss 184
Long QT syndrome 157
ejection traction 282
high-density lipoprotein cholesterol 108
molecular weight heparin 151
pressure chronic retention 80
retreatment rate 66
urinary tract symptoms 18, 72, 274
Lymphorrhea 224
Magnetic resonance imaging 172
Male sling 94
Management of
benign prostatic hyperplasia 144, 271
BNC 294
hyperglycinemia 191
malignancy in diverticulum 244f
post-prostatectomy urinary incontinence 89
post-TURP of prostate cancer 223
prostatic urethral strictures 299
urethral strictures 297
lobe enucleation 32
therapy of prostatic symptoms 205, 208, 261
Menopausal symptoms 213
Metabolic syndrome 107
and benign prostatic hyperplasia 106, 108
and urology 108
definition 107
Metastatic prostate cancer 228
Microwave thermotherapy 250
Midline perineal incision 95f
Mild TUR syndrome 190
Millin's prostatectomy 62
Minimally invasive
methods for prostate enucleation 284
treatment of benign prostatic hyperplasia 248
Minor wound infection 224
Missed bowel injury 196
circuit 9f
TURP technology 9
Morbidity of TURP 275
Morcellator 22, 22f
tip 22, 22f
with tubings 28
Morcelloscope 22, 22f
Multiple tumors 232
Muscle invasive TCC 233
burns 159
infarction 65, 152
and scarring 159
Naftopidil 216
congestion 203, 204
rhinitis 203
Nasopharyngitis 204
Nausea 189, 195, 202
Nerve injury 135
Nesbit technique 4
Nipple pain 200
N-methyl-D-aspartic acid receptors 191
Nocturia 210, 212, 215f
dyspnea 213
enuresis 210
polyuria 212
Noninsulin-dependent diabetes mellitus 108
Normal volume
flat curve 45
slow flow 44
Obesity 107
and benign prostatic hyperplasia 108
Obstructive sleep apnea 216
Olympus system 12, 12f
Open prostatectomy 58, 62, 65, 65t, 148
Opuntia flower 198
Orange plasma 15f
dysfunction 116
failure 116
Ortho-phthalaldehyde 109, 110
Orthostatic hypotension 204
Overactive bladder 108, 216
Overload of non-electrolyte fluid 186
Pacemaker pulse generator 156f
Paraureteral diverticulum 246, 246f
Parkinson's disease 235
mass 213
surgery 64
Penetration depth of lasers 26
Penile stricture 298, 298f
Penobulbar stricture 298, 298f
Per urethral catheter 73, 79
Peracetic acid 109, 111
coronary intervention 152
nephrolithotomy forceps 28
Perforation of mid fossa 34, 34f
hematuria 113
small volume flow 47
Phosphodiesterase inhibitors 139, 140
Photoselective vaporization 192
of prostate 40, 303
Phytotherapy 198
Pinus flower 198
definition 13
formation 14, 14f
Plasmakinetic button electrode 12, 13f
Platelet precursor 151
Port placement 68f
bladder neck contracture 292
incontinence 86, 90
Postural hypotension 203
Potassium-titanyl-phosphate 39, 126
chronic retention 79
flow study 49
Prevalence of nocturia 211
bowel neck obstruction 49
hemorrhage 113, 184
Proact system 102, 102f
Progenitor of resectoscope 8
Progression of prostate 83f
awareness program 145
cancer 148, 222
enucleation 284
gland size 191
malignancy 64
size 177
specific antigen 81, 280
stents 251
volume 173
Prostatectomy 69f
artery embolization 198
calculi 41
fossa stricture 299, 299f
lobar excision 63f
angle 105, 105f
length 164t
stricture 301
Prosthetic valves 183
embolism 183
embolus 65
Pulsed laser 28
PVP laser vaporization of prostate 126
Pyelonephritis 115
Pygeneum africanum 199
Quasi-bipolar 10
Radical prostatectomy in post-TURP 225
Reactionary hemorrhage 113, 114
Readjustable sling systems 100
Recatheterization 41
hematuria 147, 232
stricture urethra or hypospadias 64
tumors 232
urinary tract infection 116, 147, 212, 232
Reducing TUR syndrome 18
Refractory urinary retention 147
failure 216
insufficiency 147
after radical prostatectomy 219
in prostate cancer 219
Resection of prostate 1, 8
ejaculation 134, 136
urethrography 293
Retrourethral transobturator sling 96
Right bundle branch block 157
Robot-assisted laparoscopic prostatectomy 223
Role of
anticholinergics 119
duloxetine hydrochloride 119
dutasteride 184
endoscopy after balloon tamponade 180
intraprostatic adrenaline 184
nonsurgical management 80
pelvic floor muscle training 119
tranexamic acid in TURP bleeding 184
UDS 122
Schafer's nomogram 49
hemorrhage 113, 114
stone 239
Selective arterial prostatic embolization 184
Sepsis 115
Serum creatinine 145
Severe TUR syndrome 190
Sexual function 137
Shorter duration of
catheterization 18
operation 184
bladder diverticula 62
prostatic calculi 41
Single port transvesical enucleation of prostate 70
Sinus node disease 157
Size of prostatic adenoma 136
disturbance 213
hygiene 215
impairment 212
diverticulum 241f
fibrous gland 64
Spaulding classification of devices 109t
Sperm retrieval 138
Sphincter incompetence 120
Staging of post-TURP carcinoma prostate 222
Sterilization 109
of endoscopic equipment 109
Stinging nettle root 198
Stones 245, 245f
incontinence 64
urinary incontinence 226
Stricture urethra 290
Stroke 183
Succinylcholine-induced fasciculations 159
Suprapubic catheter 73, 79
Surgery for benign prostatic hyperplasia 232, 302
Tachycardia 189
Tachypnea 189
Tanagho's procedure 301, 301f
Three-dimensional ultrasonography 169
Thromboelastogram 153
Thrombosis of arteries 135
Thulium laser 20, 303
enucleation of prostate 20
incision 295
prostatectomy versus holmium 279
vapoenucleation 20
vaporization of prostate 20, 280
Torrential hemorrhage 181f
Tranexamic acid 184
sonography 145
ultrasonography 165
for prostate size 165f
Transient ischemic attack 183
Transitional cell carcinoma 231, 245
Transperineal ultrasonography 165
for prostate volume 165f
Transrectal ultrasonography 166
for prostate volume 166f
Frayers prostatectomy 284f
incision of prostate 148
management of BPH 151
microwave therapy 148, 252
needle ablation of prostate 148, 253
prostatectomy 184
resection of
bladder tumor 231
prostate 1, 84, 119, 134, 137, 148, 156, 177, 186, 274, 302
vaporization resection of prostate 148
Treatment of
penile and bulbar strictures 299
prostate cancer 229
Trimethoprim-sulfamethoxazole 117
TURP 274
syndrome 196, 216, 256, 257, 264, 269
Types of
electrosurgery 8
lasers 39
perforation 194
Ultrasonography 239
of large diverticulum 241f
Uncontrolled bleeding after surgery 113
Upgradation of grade 226
Ureteral deviation 246, 246f
Urethral stricture 120, 297, 297f
Urge urinary incontinence 235
bladder stones 147
extravasation 64
retention 67, 122, 224, 232
tract infection 115
urgency 64
Urolume urethral stent 300
Vaporization 125, 126, 282, 303
Vascular anatomy of prostate 175f
anatomy of prostate 176f
bleeding 180
leak 135
fibrillation 157, 159
tachycardia 157
Volume of ellipsoids 167f
Vomiting 189, 195
Warm saline solution 16
Water intoxication syndrome 186
Waterhouse procedure 300, 300f
Zephyr 88, 88f, 375
artificial sphincter 87, 87f
Chapter Notes

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Monopolar Transurethral Resection of the Prostate1

Ganesh Gopalakrishnan
Harshad Punjani
Benign prostatic hyperplasia (BPH) is a common urological disorder. One population-based study, published in 2001, suggests that it might affect up to 8.4% of men aged 40–49 years and 33.5% of those aged 60–70 years. In the 20th century, open surgical management of BPH became popular. A relatively high-morbidity and expensive procedure, open prostatectomy was gradually replaced by transurethral resection of the prostate (TURP) as the standard surgical treatment of small to medium sized BPH. High success rates, lower costs and shorter recovery times after TURP were among the factors contributing to the gradual replacement of open prostatectomy.
The surgical management of BPH is evolving at a rapid rate, with several new procedures available that challenge transurethral resection of the prostate as the standard treatment in the surgical management of small to medium sized glands.
For most of the 20th century surgeons were investigating newer, less invasive methods of relieving prostatic obstruction. While the obvious minimally invasive route was transurethral, several technical targets were needed to be met. These included adequate visibility, good, reliable light source and a controllable diathermy generator. With the introduction of the Hopkins rod-lens system, Xenon cold light source and solid state electrosurgical generators midway through the 20th century, modern day TURP came of age. This development was aided by the detailed description of the arterial supply of the prostate by Flocks in 1937.
Transurethral resection of the prostate (TURP) is still considered as the gold standard treatment of obstructive BPH. Although TURP is a safe option in the vast majority, it is not without morbidity. The overall mortality is around 0.2% but in the elderly and high risk patients it is considerably higher.
For effective and safe monopolar TURP, the following are necessary—a very good quality and safe, electrosurgical unit (ESU), compatible irrigant fluid, a good camera and light source and sturdy instrumentation. Needless to say that currently all these are freely available to make TURP really the gold standard operation for obstructive BPH.
Monopolar TURP requires the use of a reliable electrosurgical generator. Electrosurgery utilizes a radiofrequency current to cut and fulgurate tissues. The chosen frequency is important in achieving the desired effects without complications. Current ESU operate at 400,000 to 1 million Hz. Such high frequencies avoid undesirable neuromuscular 2contractions. The characteristics of the electric current will depend on what effect it has in tissues. A continuously alternating radiofrequency current, sine wave, delivers high current and high power. Such a current generates enough heat to cut tissues. Since the heat is so quickly dissipated, the surrounding tissue is not coagulated and hemostasis is poor. In order to fulgurate the tissue, short bursts of high voltage radiofrequency sine waves with a pause between is necessary.
The generator chosen is very important in deciding on the current delivered during the procedure. The power generated is dependent on the current delivered by the unit and the tissue resistance. Modern generators have the ability to adjust the current based on the tissue characteristics to keep the power constant. Older generators did not have this capability. More modern generators use microprocessors to monitor resistance in specific surgical conditions. Dessication occurs by a slow process of driving water out of the cells. Steam, bubbles and change in tissue color to a light brown hue are features of dessication. Changes in tissue characteristics during a TURP affect the performance of the instruments. Tissue charring has an insulating effect and lowers the efficiency of vaporization. Persistent application of power to one area, results in large scale dessication. This results in an increased resistance in the tissue and this necessitates a further increase in power levels. Fulguration is a superficial charring of tissue and requires a coagulation waveform to be generated by the ESU. This waveform is sparked to the tissue surface and heat is widely dispersed by long sparks and intermittent current application. Thus, energy does not penetrate deeply and only a superficial effect is obtained. The cells dry out quickly but do not vaporize, a char effect is obtained and this results in hemostasis.
Historically water was used as the irrigant fluid for TURP. Water is hypotonic and absorption could result in hemolysis, which can be potentially life threatening. Nevertheless, it is the cheapest fluid and has the clearest vision during resection. Majority of urologists now use 1.5% Glycine. While these fluids can be absorbed to produce electrolyte changes, the problem of hemolysis does not arise as these fluids are isotonic with plasma.
Camera systems have really revolutionized resection today. They have high resolution and the magnification that results make identification of tissue landmarks easy. The fiber optic light cables and Xenon light source in addition makes resection effective.
The discovery of the Hopkins rod-lens system provides unparallel clarity of vision. Resectoscope design has improved significantly and become sturdy. The main limiting factor in TURP is the size of the gland. Large glands in excess of 100 gram could take more than 90 minutes, which many consider to be the safe upper limit of resection time. The use of the continuous flow resectoscope has helped speed up resection times. It has also added a safety net to the operation by keeping the intraprostatic pressure low thus reducing the risk of absorption. Another important choice is whether one uses a thin loop or a thick loop for resections. The thin loop allows for more efficient vaporization and cutting. Since the current is not dissipated over a large area, one can achieve more precise tissue ablation. A thick loop by virtue of its larger surface area disperses current over a broad area. This causes current density to be less and produces more effective hemostasis. The choice of loop is the surgeons preference and is dictated by the level of his experience and his comfort levels with technology. 3Many surgeons employ suprapubic drainage using an standard Reuters canula or a suprapubic catheter while resecting large glands. This helps maintain low intraprostatic pressures during the resection and also reduces resection times as the bladder does not fill.
There are three main techniques that urologists use for TURP—the Barnes, the Nesbit and the Flocks. Whichever technique one uses it is important to remember that resection must be systematic and in an organized fashion. Each lobe of the prostate is dealt with individually. Hemostasis is achieved and only then does one resect the other lobe. If the prostate is large and there is a time constraint, there is no harm in doing a planned hemiresection of the prostate or coming back a few days later to complete the rest of the resection.
The Barnes technique starts with resecting the middle lobe at 6 o'clock all the way to the verumontanum. This creates a nice trough in the floor of the prostatic urethra, Once this has been done the right and left lobes are then dealt with separately but one at a time. Resection of the right lateral lobe starts at 6 o'clock and goes around clockwise to 11 o'clock. Similarly the left lobe starts at 6 o'clock but goes round anticlockwise to the 1 o'clock position. If there is a large anterior lobe this is resected separately from the bladder neck to the level of the verumontanum. In case the anterior lobe is not large this strip of tissue can be left intact.
Operative Technique
zoom view
Figures 1.1A to F: Stages in resection method of Barnes
Stages in resection method of Barnes
Coronal section through lower urinary tract bladder-prostate
  1. Arrangement prior to operation
  2. Excision of median lobe and basal portions of lateral lobes
  3. Further ablation of endovesical part of median and of the left lateral lobe together cut endourethral part of both
  4. Complete excision of left lateral lobe except for an apical remnant
  5. Same procedure on right hand side, only apical tissue now remains on either side
  6. Final arrangement after completion of resection.
The NESBIT technique is probably most commonly used by urologists for TURP. This technique of resection is based on the arterial supply to the prostate and aims to disconnect major bleeders during the early phase of resection, thus providing a relatively bloodless field for speedy resection of the prostate.
Resection starts at 11 o'clock by creating a trough at the bladder neck; resection then continues in this trough systematically towards the apex. This effectively detaches the lateral lobe, which is displaced medially and devoid of its blood supply. This detached lobe as well as the middle lobe is then resected together. One of the potential drawbacks of this technique is that in large glands a beginner could lose his way due to the large volume of prostatic tissue in the floor of the fossa.
Operative Technique
zoom view
Figure 1.2: Cross section through bladder above ureteric orifices
Left lobe has been divided from a 9 o'clock position at its equator and at right angles to capsule by trench cut. Tissue is subsequently removed down to the floor of prostatic cavity in series of horizontal slices. The procedure then continues with an identical approach to the opposite side.
Step 1: Formation of ventral pattern
  1. Endoscopic appearance
  2. View from bladder
  3. Lateral lobe domes seen from above.5
zoom view
Figures 1.3A to C: Step 1: Formation of ventral pattern
zoom view
Figures 1.4A to C: Step 2: Cutting trench and tissue ablation
Step 2: Cutting trench and tissue ablation
  1. Endoscopic appearance
  2. View from bladder
  3. View from ventral towards lateral lobes domes.
Step 3: Resection down to the floor of cavity
  1. Endoscopic appearance: Lateral lobes and median lobe have been ablated down to the floor of the cavity
  2. View from bladder: Circular funnel of remaining tissue seen
  3. View from ventral towards lateral lobe domes: Conical space easily seen together with the distal untouched portion.
Step 4: Cone excision
Clear the prostatic capsule of adenoma tissue by excavation and apical resection.6
zoom view
Figures 1.5A to C: Step 3: Resection down to the floor of cavity
zoom view
Figure 1.6: Step 4: Cone excision
The Flocks technique is a bit complicated. In this technique, the prostate is divided into four quadrants and each quadrant is resected separately.
Operative Technique
In some large glands, the prostate lobes extend beyond the verumontanum and resection must include these areas.
It is also acceptable that in very large glands a two-stage TURP be done. On one day, one lobe is resected and a few days later during the same hospitalization, the other lobe(s) are resected. There is literature evidence that hemiresection of the prostate as a planned procedure also results in normal voiding.7
Meticulous attention to hemostasis is necessary to prevent catheter blockage post-operatively. A 22 Fr or 24 Fr size 3-way catheter is used by most urologists for bladder drainage. The catheter balloon is inflated as per the surgeons choice. It is important to remember that larger balloon volumes can produce significant bladder spasms. The choice of instituting postoperative irrigation is surgeons’ preference and is usually carried out for a minimum of 24 hours after surgery.
Transurethral prostatectomy is an operation that distinguishes the “men from the boys”. It is an operation that is both difficult to teach and also learn. However, the advances in camera systems have overcome both these drawbacks. The advent of other minimally invasive treatments for the prostate especially laser prostatectomy has challenged the gold standard procedure. Only time will decide if it will continue to remain so.