Open Adenomectomy / Trans Urethral Resection of Prostate (TURP)
Surgical Treatment of Benign Prostatic Hyperplasia
Most doctors might recommend removal of the enlarged part of the prostate as the best long-term solution for patients with BPH.
Usually this is the best choice when you have already tried medical treatment and failed or when you have some clinical parameters that make us predict through algorithms that you will not avoid an intervention sooner or later.
With surgery for BPH, only the enlarged tissue that is pressing against the urethra is removed, the rest of the inside tissue and the outside capsule are left intact. Surgery usually relieves the obstruction and incomplete emptying caused by BPH. The following section describes the types of surgery that are used. If you consider prostate as a tangerine, we remove the inner part (edible) leaving the capsule (skin) intact.
Surgical Methods / Options
In the few cases when a transurethral procedure cannot be used, open surgery, which requires an external incision, may be used. Open surgery is often done when the gland is greatly enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired. General or spinal anesthesia is given and an incision is made. Once the surgeon reaches the prostate capsule, he scoops out the enlarged tissue from inside the gland.
With advancing of novel technologies and improved surgical techniques usually do not favor this treatment any more.
On the other hand, in order to avoid not being fair we have to admit that all studies of other minimally invasive techniques of removal of the adenoma, compare their results with the results of open surgery as still are considered as the “golden standard” regarding the results as it can guarantee the complete extirpation of the adenoma.
Patients usually stay hospitalized for 3-6 days.
Transurethral resection of the prostate (TURP) involves coring out the central part of the prostate (rather like one might core out the centre of an apple) to physically enlarge the channel one passes urine through. It was the first `keyhole` operation and remains the standard to which other operations for BPH are compared. It is performed under general or spinal anaesthetic, usually lasts 45-60 minutes and involves no incisions on the outside. It is performed using an electrical loop inserted into the urethra via a telescope. It cuts tissue and seals blood vessels as it removes the prostate in slivers. These are washed out at the end of the operation and a catheter is inserted for 1-2 days, through which irrigation fluid flows into the bladder to rinse any blood in it.
TURP is the classic treatment for urinary symptoms due to the prostate (prostatism) or BPH. It is the gold standard treatment for BPH with over 35 year of history to support its efficacy. Prostatic tissue is removed and so the physical bulk of the prostate is reduced. Obstruction is reduced and urinary symptoms considerably improved. The operation is performed through the penis and usually there are no cuts or surgical incisions. The procedure is tolerated reasonably well with over 90% patient satisfaction according to the British national prostatectomy audit.
Indications for TURP
There are several potential reasons for having a TURP:
- The inability to pass urine without a catheter (`urinary retention`)
- recurrent urine infections due to obstruction caused by the prostate
- urinary symptoms due to an enlarged prostate (BPH) that are bothersome and are not adequately improved by medicines, serious side effects of medical treatment or changing one`s lifestyle
- urinary symptoms due to BPH that are bothersome and cannot be treated by drugs or other minimally invasive techniques
- urinary symptoms due to BPH proven to be due to bladder outlet obstruction on urodynamics with a desire to remove obstruction in order to avoid long term problems of bladder outlet obstruction
- kidneys that are not functioning properly because the prostate is blocking the bladder
- bleeding from the prostate due to its enlargement (BPH), which may not have improved with a 5-alpha reductase inhibitor like finasteride or dutasteride
- prostate cancer (`channel TURP`): this is to allow urine to flow and is not intended to be curative
What are the advantages of a TURP?
TURP has several advantages. These include:
- rapid removal of prostatic tissue at the time of surgery
- it can be combined with some other procedures such as removing small bladder stones
- many years of data to support its use with a thorough understanding of its advantages, risks and outcomes
What are the risks of a TURP?
The most common is the inability to pass urine after the procedure (`urinary retention`). This may occur in about 6%) cases and usually resolves after another period of catheterisation.
Approximately 70% of men find that they have either a very reduced volume of semen or no semen when they have an orgasm and ejaculate. This is called `retrograde ejaculation`. The semen is passed in the urine. This is not dangerous, but obviously some men may find that unacceptable.
The quality of a man`s erections may get worse or sometimes get better. As it is not possible to guarantee that erections will not be affected, one needs to think about this possibility before undergoing a TURP.
Blood in the urine may occur for up to 3 weeks after leaving hospital. About 1 to 2 weeks after the operation, blood clots may appear in the urine and the urine may become pink. Drinking fluid and going to the toilet frequently clears the clots.
Blood loss may occur and in 4% of cases, a blood transfusion might be required. Occasionally, bleeding results in blood clots in the urine. If these are very large, they may block the catheter. A urinary infection may occur.
The Glycine fluid used during the procedure can be absorbed resulting in a drop in the sodium level of the blood. This is known as `TUR syndrome`. This can occur in 2% of men. In some cases, this is serious, but it can be avoided by following safe procedures. This syndrome does not occur with ΑvantGarde Urology patients as we use saline bipolar technology not glycine.
After the procedure, a strong sense of urgency may develop i.e. an urgent desire to pass urine sometimes associated with urinary leakage (`urge incontinence`). This occurs because the bladder muscle is intrinsically overactive in about 1 in 3 men who have the procedure, and the prostate prevented leakage by its sheer bulk before surgery. Drugs such as tolterodine, oxybutynin or solifenacin can improve these symptoms. This usually resolves by 6 months.
Rarely (less than 1 in 30 men), the muscle mechanism that controls the flow is damaged by TURP leading to incontinence on activity (`stress incontinence`). Pelvic floor (`Kegel`) exercises can help this and again this usually resolves within 6 months of surgery. In the most severe cases, another operation may be needed to reduce leakage.
A narrow area may develop in either the urethra, which is known as a urethral stricture, or at the bladder neck, which is known as a bladder neck contracture. This affects about 1 in 30 men after TURP and can explain why urinary symptoms deteriorate after an initial improvement. These may need further surgical procedures before improvement.
What are the alternatives to a TURP?
There are several procedures of which the most common are listed below.
- Holmium enucleation of the adenoma: Its advantages over TURP are less bleeding and a much shorter catheterisation time and hospital stay. The procedure is performed via a telescope inserted into the urethra under spinal or general anaesthetic and usually lasts 30-60 minutes.
- Green Light PVP laser prostatectomy: Its advantages over TURP are less bleeding and a much shorter catheterisation time and hospital stay. The procedure is performed via a telescope inserted into the urethra under spinal or general anaesthetic and usually lasts 30-60 minutes.
- Open prostatectomy. In the few cases when a transurethral procedure cannot be used, open surgery, which requires an external incision, may be used. Open surgery is often done when the gland is greatly enlarged, when there are complicating factors, or when the bladder has been damaged and needs to be repaired. General anaesthesia is given and an incision is made. Once the surgeon reaches the prostate capsule, he or she scoops out the enlarged tissue from inside the gland.
- TUIP (transurethral incision of the prostate) also known as a bladder neck incision (BNI). For men with smaller prostates, an alternative operation may be chosen: In this case, the surgeon uses an instrument that makes a few small cuts in the prostate and bladder neck rather than removing tissue. These cuts reduce the obstruction in the urethra and improve urine flow.
Are any special tests required before TURP?
To ascertain whether you require prostate surgery and to be able to advice you on the best treatment options, you will need to have a prostate assessment.
What do I need to do before a TURP?
You should take your normal medication as before the procedure. If you are on aspirin or clopidogrel (Plavix), these drugs will need to be stopped 10days before the operation. In addition, if you are on warfarin, this will need to be stopped and the appropriate alternative will be suggested. So ensure this is discussed with your urologist.
It is important to exclude a urinary tract infection before your procedure. The urine should be checked by a health professional.
No food should be eaten 6 hours before but clear water only can be consumed 3 hours before the planned time of laser prostatectomy.
What happens during a TURP?
Under general anaesthesia (i.e. asleep) or spinal anaesthesia (i.e. numb from the waist down), a telescope examination is made of the prostate and bladder using a camera mounted on the end of a tube passed through the water pipe (urethra). TURP involves coring out the central part of the prostate (rather like one might core out the centre of an apple) using an electrical loop inserted into the urethra via a telescope. It cuts tissue and seals blood vessels as it removes the prostate in slivers. These are washed out at the end of the operation to physically enlarge the channel one passes urine through. The procedure usually lasts between 30-60minutes and involves no incisions on the outside. A catheter is inserted for 1-2 days, through which irrigation fluid flows into the bladder to rinse any blood in it.
Patients are discharged from hospital 48hours following TURP and should avoid heavy physical exercise for 2 weeks. Urinary flow is usually markedly improved immediately but frequency may take 6-12 weeks to completely settle. Most of the patients experience retrograde ejaculation after TURP i.e. sperm going back into the bladder at the time of climax, rather than coming out of the penis, and being washed out of the bladder the next time it is emptied. There is also a 5% risk of impotence after TURP, usually in men aged over 70 years.
What happens immediately after a TURP?
At the end of a TURP, a catheter will be inserted through the urethra into the bladder to drain away the urine and blood. It is normal for the fluid draining from the bladder to be bright red after the operation. There is some discomfort but usually no pain post-operatively. The catheter will be left in place for a few days and removed when the urine is pink. Drinking plenty of fluids (8 cups a day or 3 litres/day) will ensure a good flow of urine and decrease the possibility of blood clots, which can block the catheter The catheter may cause you to have bladder spasms or to feel the need to urinate. These symptoms can be improved by drugs.
You may be given antibiotics while you are in the hospital to prevent infection. The day after surgery, you should be able to get out of bed and walk around.
The catheter is held in place by a balloon inflated with water. When the balloon is deflated, the catheter slips out. You may feel pain the first few times you urinate because the prostatic urethra will still be healing. After removal of the catheter, the desire to pass water may be very urgent and it may sting a little. This improves gradually over the next few weeks. If you have difficulties, it may be helpful for you to try to hold on for 10 minutes each time you wish to pass water. Medication can also help. Another exercise is to stop passing urine in midstream and count to three. This helps improve your control. Do not worry if you experience some dribbling of urine at this stage. Providing your bladder is emptying completely, you will be able to go home. Sometimes, an ultrasound scan of the bladder will be performed to check the bladder is empty.
What is life like after TURP?
Recovery can take anywhere from two to eight weeks. During the first few weeks after the operation, there may be a deterioration of some of the symptoms present before surgery. You may have some temporary problems controlling urination, but long-term incontinence rarely occurs. These symptoms can be helped by pelvic floor exercises and medication sometimes, especially to reduce the urge to pass urine.
During the first month after TURP, the scab inside the prostatic urethra may loosen and cause bleeding. The bleeding usually will subside if you increase your fluid intake and decrease your physical activity or by resting in bed and drinking fluids.
In general, you should:
- Continue drinking a lot of water to flush the bladder.
- Avoid straining when moving your bowel.
- Eat a balanced diet to prevent constipation. If constipation occurs, ask your doctor if you can take a laxative.
- Avoid caffeine and alcohol
- Don`t do any heavy lifting for 2 weeks
- Don`t drive or operate machinery until you feel ready and for at least 1 to 2 weeks
Contact your doctor if
- your urine is so red that it is difficult to see through it,
- if it contains clots or bits of tissue (slough)
- if you feel significant or increasing discomfort
By six to eight weeks after the operation, urination should be easier and less frequent, although you may have to get up at night to urinate. Months may go by before you feel completely normal. Generally, the longer you had the problem before you were treated, the longer your recovery time will be.
How soon can I return to normal activities?
Most patients can resume normal activities within the week. This would include a desk job and driving a car, which you should be able to resume within a couple of weeks. You will have to avoid more strenuous activities, as well as lifting more than 30 pounds or riding a lawnmower for example, for about 6 weeks following TURP.
Will I still be able to have sex following TURP?
There is a small chance that TURP will affect your ability to have an erection. However, if you were in good health and were capable of having an erection before the operation, your chances of resuming normal sexual activity are very good. You should be able to resume sexual activity usually about 4 weeks following your procedure, however, you should discuss with your urologist before proceeding. Many men are afraid that prostate surgery will make their sex life a thing of the past. Today, that is generally not the case. In fact, if you have been suffering with an enlarged prostate for a long period, your sex life may actually improve after surgery.
Although most men are able to continue having erections after TURP, a prostate procedure frequently makes them sterile (unable to father children) by causing a condition called retrograde ejaculation or dry climax.
Many people have found that concerns about sexual function can interfere with sex as much as the operation itself. Understanding the surgical procedure and talking over any worries with the doctor before surgery often help men regain sexual function earlier. Many men also find it helpful to talk with a counsellor during the
Is further treatment needed later for BPH?
Since surgery for BPH leaves behind part of the gland, it is still possible for prostate problems, including BPH, to develop again. However, surgery usually offers relief from BPH for at least 15 years. Only 10 percent of the men who have surgery for BPH eventually need a second operation for enlargement. Usually these are men who had the first surgery at an early age.
Sometimes, scar tissue resulting from surgery requires treatment in the year after surgery. Rarely, the opening of the bladder becomes scarred and shrinks, causing obstruction. This is known as `a bladder neck contracture` and may need a surgical procedure similar to transurethral incision. More often, scar tissue may form in the urethra and cause narrowing (`urethral stricture`). This problem can usually be solved during an outpatient visit when the doctor stretches the urethra.
Can I get prostate cancer even though I have had a TURP? BPH and Prostate Cancer: No Apparent Relation
Prostate cancer is still a possibility, since surgical procedures such as TURP do not remove the entire prostate. Prostate cancer can appear in the remaining tissue of the prostate. Therefore, it is important to maintain contact with your doctor, so that he or she can determine if any further investigation or treatment is required.
Although some of the signs of BPH and prostate cancer are the same, having BPH does not seem to increase the chances of getting prostate cancer. Nevertheless, a man who has BPH may have undetected prostate cancer at the same time or may develop prostate cancer in the future. For this reason, the National Cancer Institute (http://www.cancer.gov/cancertopics/screening/prostate) and the American Cancer Society (http://www.cancer.org/docroot/home/index.asp) recommend that all men over 40 have a rectal examination once a year to screen for prostate cancer.
After BPH surgery, the tissue removed is routinely checked for hidden cancer cells. In about one out of 10 cases, some cancer tissue is found, but often it is limited to a few cells of a non aggressive type of cancer, and no treatment is needed.