Several surgical approaches are used to treat BPH. Reasons for performing prostate surgery include:
- Persistent or recurrent episodes of urinary retention (inability to urinate)
- Persistent blood in the urine
- Bladder stones
- Moderate or severe lower urinary tract symptoms that do not improve with medication
- Kidney failure from inability to empty the bladder
Surgical options include invasive and minimally invasive procedures. The choice of which surgical procedure to use depends on various factors, including a man’s age and general health.
The most effective surgical procedure, transurethral resection of the prostate (TURP), is also the most invasive and has the highest risk for serious complications. However, because it is more effective than less invasive procedures, TURP remains the procedure of choice for many doctors.
Minimally invasive procedures use laser or some other form of heat to destroy excess prostate tissue. Although minimally invasive procedures may be an appropriate choice for some patients, including younger men, none to date have proven superior to TURP.
Transurethral Resection of the Prostate (TURP)
Transurethral resection of the prostate (TURP) involves surgical removal of the inner portion of the prostate, where BPH develops. It is the most common surgical procedure for BPH, although the number of procedures has dropped significantly over the past decades because of the increased use of effective medications and the increasing use of laser procedures.
Procedure. The surgeon inserts a thin fiber-optic tube called a resectoscope into the urethra. No incision or stitches are needed. The resectoscope is a type of endoscope. It has a telescope lens to help the surgeon see the prostate gland. The surgeon uses a wire cutting loop inserted into the resectoscope to cut away excess prostatic tissue, and water solutions are used to flush away the excised matter. TURP usually requires a 1 to 2 day hospital stay.
A Foley catheter generally remains in place for 1 to 3 days after surgery to allow urination. This device is a tube inserted through the opening of the penis to drain the urine into a bag. The catheter can cause temporary bladder spasms that can be painful. The catheter may be removed while the patient is in the hospital or after he is sent home.
Recuperation. Urine flow is stronger almost immediately after most TURP procedures. After the catheter is removed, patients often feel some pain or sense of urgency as the urine passes over the surgical wound. These sensations generally last for about a week and then gradually subside. Complete healing takes about 2 months. The following are some tips for speeding recovery and avoiding complications:
- During recuperation avoid driving, operating heavy equipment, lifting, sudden movements, and straining the muscles in the lower tracts, such as during a bowel movement.
- Drinking 3 to 4 glasses of water a day after surgery is important to flush the bladder and help healing.
- Foods that help prevent constipation, such as fruits and vegetables, are important. A laxative may be needed if constipation occurs.
- Pelvic floor (Kegel) exercises can help reduce incontinence. Performing three to four sets of 30 contractions daily is recommended.
- Don’t resume sexual activity until your doctor says it is safe to do so.
- Check with your doctor about any drugs or herbal supplements that you take to make sure that they will not thin blood and increase bleeding.
Complications. The TURP procedure is generally safe but there are some risks for short- and long-term complications.
Immediate short-term complications after surgery may include:
- Bleeding. Some blood in the urine is normal after TURP surgery but persistent heavy bleeding or clotting is a sign of a more serious complication. In rare cases, if the bleeding is very heavy, patients require blood transfusions.
- Infection. Urinary tract infections are more likely to occur the longer the catheter is in place
- Urination problems. Temporary urinary leaking or dribbling (urinary incontinence) is common after surgery and usually resolves within a month. Temporary inability to urinate (urinary retention) may occur for a few days following surgery, which is why a catheter is used to help remove urine.
- TURP syndrome. If the fluids used during TURP build up, water intoxication can develop, which can be serious. TURP syndrome occurs in a very small percentage of patients and can be treated with diuretics to remove excess fluid.
Long-term complications after surgery may include:
- Loss of Ejaculation. Retrograde ejaculation, also called dry orgasm is very common. With this condition, the semen is ejaculated into the bladder rather than out through the urethra. Retrograde ejaculation does not affect sexual pleasure, but it does impair fertility.
- Erectile Dysfunction. Erectile dysfunction, the inability to maintain an erection, is not common but can occur.
- Urinary Incontinence. Temporary urinary incontinence is common after TURP but in rare cases some men become completely unable to hold back their urine.
- Repeat Surgery. Up to 10% of patients who undergo TURP need a repeat operation within 5 years. Sometimes, scarring in the bladder severe enough to cause obstruction occurs within a year of the procedure and may require transurethral incision (TUIP). More often, the urethra is scarred and narrows, but usually this condition can be corrected by a simple stretching procedure performed in the doctor's office.
Other Invasive Surgical Procedures
Transurethral Incision of the Prostate (TUIP). In TUIP, the surgeon makes only one or two incisions in the prostate, causing the bladder neck and the prostate to spring open and reduce pressure on the urethra. TUIP is generally reserved for men with minimally enlarged prostates who have obstruction of the neck of the bladder.
TUIP is less invasive than TURP, has a lower rate of the same complications (particularly retrograde ejaculation), and usually does not require a hospital stay. More studies are still needed, however, to determine whether they are comparative in long-term effectiveness.
Simple Prostatectomy. In simple prostatectomy, the enlarged prostate is removed through an open incision in the abdomen using standard surgical techniques. This is major surgery and requires a hospital stay of several days. Simple prostatectomy is used only for severe cases of BPH, when the prostate is severely enlarged, the bladder is damaged, or other serious problems exist. Some patients need a second operation because of scarring. Side effects of simple prostatectomy can include erectile dysfunction and urinary incontinence. This surgery can be performed through an incision in the lower abdomen or key hole incisions for robot-assisted laparoscopy.
Procedures. Laser technology is used for removal of prostate tissue. Laser procedures can usually be done on an outpatient basis, and there is little risk for bleeding. The procedure involves passing a small tube with a tiny camera and the laser fiber through the urethra of the penis. The procedure is performed under spinal, epidural, or general anesthesia.
Laser procedures have a faster recovery time and less risk of incontinence than invasive surgical procedures, but their long-term effectiveness is less clear. Laser surgery may not be appropriate for men with larger prostates. The procedures use various forms of heat to destroy cells with mechanisms that range from coagulation to complete vaporization:
- Transurethral holmium laser ablation of the prostate (HoLAP) uses laser energy to target and vaporize obstructing prostate tissue. The removal of the tissue helps to restore urine flow.
- Transurethral holmium laser enucleation of the prostate (HoLEP) is similar to HoLAP except a portion of the prostate is cut into smaller pieces and then flushed out from the bladder.
- Holmium laser resection of the prostate (HoLRP) is similar to HoLEP except the prostate fragments are removed through a resectoscope instrument.
- Photoselective vaporization of the prostate (PVP) uses a potassium-titanyl-phosphate (KTP) laser ("green-light" laser) to vaporize prostate tissue. The procedure is virtually bloodless and may be a better option for men taking anticoagulant ("blood thinner") medication. Improvement lasts for up to 1 year after the procedure. More studies are needed to confirm long-term efficacy.
Other Less Invasive Procedures
These minimally invasive procedures carry fewer risks for incontinence or problems with sexual function than invasive procedures, but it is unclear how effective they are in the long term.
Transurethral Microwave Thermotherapy (TUMT). Transurethral microwave thermotherapy delivers heat using microwave pulses to destroy prostate tissue. A microwave antenna is inserted through the urethra with ultrasound used to position it accurately. The antenna is enclosed in a cooling tube to protect the lining of the urethra. Computer-generated microwaves pulse through the antenna to heat and destroy prostate tissue. When the temperature becomes too high, the computer shuts down the heat and resumes treatment when a safe level has been reached. The procedure takes 30 minutes to 2 hours, and the patient can go home immediately afterward.
Transurethral Needle Ablation (TUNA). Transurethral needle ablation is a relatively simple and safe procedure, using needles to deliver high-frequency radio waves to heat and destroy prostate tissue.
Transurethral Electrovaporization (TUVP). Transurethral electrovaporization uses high voltage electrical current delivered through a resectoscope to combine vaporization of prostate tissue and coagulation that seals the blood and lymph vessels around the area. Deprived of blood, the excess tissue dies and is sloughed off over time.
Prostatic Stents and Implants
Prostatic stents used for BPH are flexible mesh tubes that are inserted into the urethra. Typically, the insertion procedure takes only 15 minutes. Patients need only regional anesthetic and mild sedation. There is minimal recuperation and no overnight hospital stay. Unfortunately, stents often need to be removed later because of poor placement or complications, including irritation when urinating, urinary tract infections, stone formation, and treatment failure. At this point, stents seem best suited for high-risk surgical patients or those with a limited life expectancy.
In 2013, the FDA approved the UroLift system, the first permanent implant to treat men ages 50 and older with BPH. The implants are placed during a minimally invasive procedure and help to keep the lobes of the enlarged prostate gland open to improve urine flow. The device has not been compared directly in studies with other established treatments. It appears to have less impact on sexual health than other surgical procedures.