Surgery to Treat Benign Prostatic Hyperplasia
Known as simple prostatectomy, surgery for BPH typically involves removing only the prostate tissue that is surrounding and pressing on the urethra. The procedure can be performed in one of two ways: through the urethra (transurethrally) or by making an incision in the lower abdomen.
Simple prostatectomy for BPH differs from radical prostatectomy for prostate cancer. In the cancer surgery, the surgeon removes the entire prostate and the seminal vesicles (glands located on each side of the bladder that secrete seminal fluid).
Surgery is the fastest, most reliable way to improve BPH symptoms. Fewer than 10 percent of patients will require a repeat procedure five to 10 years later. However, surgery is associated with a greater risk of long-term complications, such as ED, incontinence, and retrograde ("dry") ejaculation, compared with other treatment options for BPH. (Retrograde ejaculationejaculation of semen into the bladder rather than through the penisis not dangerous but can provoke anxiety and may cause infertility.) The incidence of these complications varies with the type of surgical procedure.
Now that medications are available to treat BPH, fewer men are opting for surgery. If surgery is chosen, the operation will be postponed until any urinary tract infection or kidney damage from urinary retention has been successfully treated. Because blood loss is a common complication during and immediately following most types of BPH surgery, men taking aspirin should stop taking it seven to 10 days prior to surgery. Aspirin interferes with blood clotting.
Also called transurethral resection of the prostate (TURP), this procedure is considered the gold standard for BPH treatmentthe one against which other therapies are compared. More than 90 percent of simple prostatectomies for BPH are performed transurethrally.
The procedure is typically done in the hospital under general or spinal anesthesia. In men with smaller prostates and no other medical problems, TURP may be performed as an outpatient procedure.
In TURP, prostate tissue is removed with a long, thin instrument called a resectoscope, which is inserted into the penis and passed through the urethra to the prostate. The resectoscope has a wire loop at the end to cut away prostate tissue piece by piece and to seal blood vessels with an electric current or laser energy. As the pieces of tissue are being cut away, they are washed into the bladder and then flushed out of the body through the resectoscope. A sample of the tissue is examined in the pathology laboratory to rule out the presence of prostate cancer.
Once the surgery is completed, a catheter is inserted through the urethra into the bladder. Fluid is continuously circulated to prevent blood clot formation and to monitor for bleeding. The catheter typically remains in place for one to three days. (It may be removed in the hospital, or a man may go home with the catheter and then return a few days later to have it removed.) Most men experience a greater urgency to urinate for approximately 12 to 24 hours after the catheter is taken out.
A hospital stay of one or two days is common with TURP. Men typically experience little or no pain after the procedure, and a full recovery can be expected within three weeks. Improvement in symptoms is noticeable almost immediately after surgery and is greatest in men who had the worst symptoms beforehand. Marked improvement occurs in about 90 to 95 percent of men with severe symptoms and in about 80 percent of those with moderate symptoms. This rate of improvement is significantly better than that which can be achieved with medication or through the self-help measures employed during watchful waiting. In addition, more than 95 percent of men who undergo TURP require no further treatment over the next five years.
The most common complications immediately following TURP are bleeding, urinary tract infection, and urinary retention. Longer-term complications can include ED, retrograde ejaculation, and incontinence, all of which can be treated. However, increasing evidence suggests that TURP may cause no more problems with sexual function than other treatments for BPH and, in some instances, may even bring about improvements in sexual functioning. The risk of death from TURP is very low (0.1 percent).
An open prostatectomy is the surgery of choice when a man's prostate is so large that TURP can't be performed safely. Two types of open prostatectomy can be performed for BPH: suprapubic and retropubic. Both require an incision from below the navel to the pubic bone.
A suprapubic prostatectomy involves opening the bladder and removing the inner portion of the prostate through the bladder. In a retropubic procedure, the bladder is moved aside, and the inner prostate tissue is removed without entering the bladder. Both procedures are performed in a hospital under general or spinal anesthesia.
As in TURP, removed tissue is checked for prostate cancer. After a suprapubic prostatectomy, two catheters are placed in the bladder, one through the urethra and the other through an opening made in the lower abdominal wall. The catheters remain in place for three to seven days after surgery. Following a retropubic prostatectomy, a catheter is placed in the bladder through the urethra and remains in place for a week. The hospital stay (five to seven days) and the recovery period (four to six weeks) are longer for open prostatectomy than for TURP.
Like TURP, an open prostatectomy is an effective way to relieve symptoms of BPH. However, complications are more common with open prostatectomyand, in some cases, the complications can be life threatening. As a result, open prostatectomy is reserved for otherwise healthy men with the largest prostates.
The most common complications immediately after open prostatectomy are wound infection and excessive bleeding, which may require a transfusion. Because an open prostatectomy is elective surgery, men can bank their own blood in advance, in case a transfusion is needed.
More serious complications of an open prostatectomy, although rare, include heart attack, pneumonia, and pulmonary embolism (a blood clot that travels to the lungs). Performing breathing exercises, moving the legs in bed, and walking soon after surgery can reduce the risk of pneumonia and blood clots. Long-term complications, including ED, incontinence, and retrograde ejaculation, are slightly more common with open prostatectomy than with TURP.