Transurethral resection of the prostate (TURP) is the gold standard to which other surgeries for BPH are compared. This procedure is performed under general or regional anesthesia and takes less than 90 minutes.
The surgeon inserts an instrument called a resectoscope into the penis through the urethra. The resectoscope is about 12 inches long and one-half an inch in diameter. It contains a light, valves for controlling irrigating fluid, and an electrical loop to remove the obstructing tissue and seal blood vessels. The surgeon removes the obstructing tissue and the irrigating fluids carry the tissue to the bladder. This debris is removed by irrigation and any remaining debris is eliminated in the urine over time.
Patients usually stay in the hospital for about 3 days, during which time a catheter is used to drain urine. Most men are able to return to work within a month. During the recovery period, patients are advised to
- avoid heavy lifting, driving, or operating machinery;
- drink plenty of water to flush the bladder;
- eat a balanced diet;
- use a laxative if necessary to prevent constipation and straining during bowel movements.
Blood in the urine (hematuria) is common after TURP surgery and usually resolves by the time the patient is discharged. Bleeding also may result from straining or activity. Postsurgical bleeding should be reported to the urologist immediately.
Some patients have initial discomfort, a sense of urgency to urinate, or short-term difficulty controlling urination. These conditions slowly improve as recovery progresses, but it is important to remember that the longer the urinary problems existed before surgery, the longer it takes to regain full and normal bladder function after surgery.
Up to 30 percent of men who undergo TURP experience problems with sexual function. Complete recovery of sexual function may take up to 1 year. The most common, long-term side effect of prostate surgery is retrograde ejaculation (dry climax), which results when the muscle that closes the bladder neck during ejaculation is removed along with the obstructing prostate tissue. Semen enters the wider opening to the bladder instead of being expelled through the penis, causing sterility but not affecting the man's ability to experience sexual pleasure. This complication is not an issue for most men requiring prostate surgery.
If the prostate is greatly enlarged, if the bladder has been damaged, or if the patient has complications prohibiting transurethral surgery, prostatectomy (removal of the obstructing prostate) may be necessary. This procedure is sometimes the best and safest approach.
Prostatectomy is performed under general or regional anesthesia. The surgeon makes an external incision in the lower abdomen or in the perineum (area between the rectum and the scrotum). If the surgeon accesses the prostate from the abdomen, the procedure is called suprapubic or retropubic prostatectomy; surgery through the perineum is called perineal prostatectomy. Once access is gained, the prostate is removed.
After prostate surgery, a urinary catheter is inserted to ensure bladder emptying. Urine output and color and continuous bladder irrigation (CBI), if present, are monitored. Blood in the urine is an expected side effect of prostate surgery. CBI is used to maintain the effectiveness of the urinary catheter, remove blood clots, and cleanse the surgical area. If bladder spasms occur, the surgeon should be notified.
Once they have been discharged from the hospital, patients should abstain from sexual intercourse for 6 weeks after surgery. Strenuous activity and lifting is to be avoided throughout the recovery period, which can take up to 8 weeks.
Potential complications include incontinence and impotence. Depending on the procedure, stress urinary incontinence may result when pressure is put on abdominal muscles. Urge incontinence and involuntary passing of urine while asleep also may occur. Patients are encouraged to use Kegel exercies to strengthen pelvic floor muscles and to increase their water intake. Erectile and ejaculatory dysfunction may occur, depending on the procedure.
Transurethral incision of the prostate (TUIP) may be recommended to treat a prostate that is not greatly enlarged. The surgeon makes one or more cuts in the bladder neck where the urethra joins the bladder, extending into the prostate. This reduces the prostate's pressure on the urethra and makes urination easier. TUIP may provide relief with a lower incidence of retrograde ejaculation than TURP. However, its long-term benefits and risks compared to TURP have not been established.
Transurethral ultrasound-guided laser incision of the prostate (TULIP) is a new procedure that is similar to TUIP, except that the cuts are made with a laser.
Holmium laser enucleation of the prostate (HoLEP) produces results that are similar to TURP with fewer complications. In this procedure, a holmium laser is used to remove obstructive prostatic tissue and seal blood vessels. Approximately 1015% of patients with large prostates (>100 gm) experience stress incontinence after undergoing HoLEP. In most cases, incontinence resolves within 6 weeks.