Transurethral Resection of the Prostate
- Overview on transurethral resection of the prostate (TURP)
- Why have a TURP?
- What are the advantages of a TURP?
- How well does TURP work?
- What are the risks or disadvantages of a TURP?
- What are the alternatives to a TURP?
- Are any special tests needed before a TURP?
- What do I need to do before a TURP?
- What is a Transurethral Resection of the Prostate (TURP)
- What happens immediately after a TURP?
- What is life like after TURP?
- What will happen to my sex life?
- Will I be able to get erections?
- What happens when I ejaculate?
- Will I still have an orgasm if I can’t ejaculate?
- Is further treatment needed later for BPH?
- Can I get prostate cancer even though I have had a TURP?
- Who does the TURP and does experience matter?
- Who is suitable for treatment by TURP?
- Who is unsuitable for treatment by TURP?
TURP is the classic treatment for urinary symptoms due to the
prostate (prostatism) or BPH. 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, although associated with
retrograde ejaculation. It is the gold standard treatment for BPH with
many years of history to support its use.
There are several potential reasons for having a TURP:
- urinary symptoms due to an enlarged prostate (BPH) that are
bothersome and are not adequately improved by medicines 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
- The inability to pass urine without a catheter ('urinary
retention')
- kidneys that are not functioning properly because the prostate
is blocking the bladder
- recurrent urine infections due to obstruction caused by the
prostate
- bleeding from the prostate due 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
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
- widespread use throughout hospitals in most countries by
urologists
Almost 9 out 10 men who have a TURP for BPH find that their symptoms
are significantly better after TURP providing
- bladder outlet obstruction is proven (e.g. on urodynamic
studies)
- bladder that contracts with normal strength and has not become
weak.
Men experience a much stronger flow of urine,
shorter time in the toilet when passing urine and longer intervals
between visits to the toilet. If the bladder did not empty before
surgery, then getting up a night may also improve. After a year, the
urgent desire to pass urine that some men suffer also gets better.
Men who have had to use a catheter to empty their bladder before find
that they can pass urine without a catheter in many cases. However, this
is not always true..
Most men have little trouble with the procedure and only about 1 in 6
have some form of problem. The most common is the inability to pass
urine after the procedure ('urinary retention'). This may occur in about 1 in 14 men (about
6%) and usually resolves after another period of
catheterisation.
Blood loss may occur and so anaemia may be a problem in
1 in 25 patients (4%) requiring a transfusion. Occasionally, bleeding
results in blood clots in the urine. If these are very large, they may
block the catheter. A urinary infection may occur and rarely this
can be severe and lead to loss of life. This is very rare affecting less
than 1% of men.
The 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 (i.e.
1 in 50 men). In some cases, this is serious, but it can be avoided by
following safe procedures.
Bleeding can occur in the urine for up to 3 weeks after leaving
hospital. About 1 to 2 weeks after the operation, blood clots may appear
in the urine, which also becomes pink. Drinking fluid and going to the
toilet frequently clears the clots.
After the procedure, a strong sense of urgency may develop i.e. an
urgent desire to pass urine sometimes associate 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.
Most men (over 70%) 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 in which case they should either not have
surgery or choose TUNA, which does not have this side-effect.
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.
There are several procedures of which the most common are listed
below.
- Transurethral
Needle Ablation (TUNA) of the prostate: this is a less invasive
procedure than TURP, can be performed in day surgery or as an outpatient,
with fewer problems and maintains normal ejaculation. Symptoms are improved
after TUNA, but not as much as after TURP.
-
Green Light PVP laser prostatectomy: Compared to TURP, There is much
less blood loss, a shorter hospital stay and reduced chance of needing a
blood transfusion. For up to 2 months after PVP, there may be much more
frequency, urgency and discomfort felt in the bladder and penis when passing
urine.
-
Open prostatectomy:
For this, an incision is made in the lower abdomen under general anaesthetic
or when the skin is made numb from the waist down, and the prostate removed.
Urinary symptoms are improved possibly slightly better than TURP. A
prolonged hospital stay is required and bleeding can occur sometimes
requiring a blood transfusion. This option is reserved for very large
prostates that are usually too large to be treated by one of the other
options.
-
Prostate stent:
This is usually reserved for patients who are unsuitable for any other form
of therapy. It is performed in day surgery, involves local anaesthesia, but
is probably less effective than the other options. Problems are more common
later than after other procedures.
- Transurethral Microwave Thermotherapy (TUMT): this is another minimally
invasive option that works well in selected patients but still results in
retrograde ejaculation.
In general, the tests performed before to evaluate urinary symptoms
are all that required. If there is concern that the prostate is not the
only cause for problems, then a
flexible cystoscopy to examine the prostate, bladder and urethra
(water pipe) may be necessary. If there is concern that prostate cancer
may be present, then it may be necessary to take
prostate biopsies.
You should take your normal medication as before the procedure. Ask your
doctor if you should stop aspirin or clopidogrel (Plavix) 7 days before the operation. In addition, you
may need to stop warfarin, so be sure to check what needs to be done. You may
need a blood test before surgery to determine if clotting has become normal
enough. In some cases, you
may be allowed to continue with warfarin.
If you have symptoms that might indicate a urine infection, antibiotics may
need to be given to make it safe to have the procedure. Symptoms such as pain
passing urine, increased visits to the toilet, bladder discomfort, offensive
smelling urine or feeling unwell may indicate a urine infection. The urine
should be checked by a health professional.
No food should be eaten 6 hours and no fluid drunk 4 hours before the planned
time of laser prostatectomy. Special stockings to reduce the chance of a
blood clot in the legs are worn on the day of surgery.
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). As the instrument used for the procedure is
quite large, the urethra may be enlarged slightly by performing what is known as
an optical urethrotomy. A resectoscope
is passed to the prostate. This has a tiny looped wire that is used to shave away layer after layer of prostatic tissue.
The shaved tissue is then flushed into the bladder and washed out through the
tubing at the end of the operation.
For men with smaller prostates, an alternative operation may be
chosen: a TUIP (transurethral
incision of the prostate) also known as a bladder neck incision (BNI). 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.
A catheter is placed in the urethra. This is used to wash the bladder
gently following the procedure.
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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 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.
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 or BNI, 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.
Contact your doctor if
- your
urine is so red that it is difficult to see through it,
- if it contains clots
- if you feel significant or increasing discomfort
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.
- Don't do any heavy lifting.
- Don't drive or operate machinery.
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.
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You should not resume sexual activity until your surgeon says you are ready,
which is usually about 4 weeks. 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.
There is a small chance that TURP or open prostatectomy 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, and if the nerves
involved were not affected by the procedure, your chances of resuming normal
sexual activity are very good. However, surgery cannot usually restore potency
that was lost before the operation. Complete recovery of the sexual function you
had may take up to 1 year, lagging behind a person's general recovery. The exact
length of time depends on how long after symptoms appeared that BPH surgery was
done and on the type of surgery.
Although most men are able to continue having erections after a TURP, a
prostatectomy frequently makes them sterile (unable to father children) by
causing a condition called "retrograde ejaculation" or "dry climax." During
sexual activity, sperm from the testes enters the urethra near the opening of
the bladder. Normally, a muscle blocks off the entrance to the bladder, and the
semen is expelled through the penis. However, the coring action of prostate
surgery cuts this muscle as it widens the neck of the bladder. Following
surgery, the semen takes the path of least resistance and enters the wider
opening to the bladder rather than being expelled through the penis. Later it is
harmlessly flushed out with urine.
Most men find little or no difference in the sensation of orgasm, or sexual
climax, before and after surgery. Although it may take some time to get used to
retrograde ejaculation, you should eventually find sex as pleasurable after
surgery as before.
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.
If you have any problems after treatment for a prostate condition, talk to your
doctor. Erection problems and loss of bladder control can be treated, and
chances are good that you can be helped.
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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.
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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.
Who does the TURP and does experience matter?
Almost all urological surgeons are taught how to perform a TURP and so NHS or
Private Consultant Urological Surgeons should be able to perform the procedure
as part of their basic training.
Men who fulfil one of the reasons for surgery are
suitable for TURP. There should be a good reason to undergo the procedure. The
advantages, alternatives and risks need to be carefully considered before having
the procedure.
If there is uncertainty about having a TURP, it may be wiser to try drugs for
a period of time, as these can alleviate symptoms well in some people. TUNA can
also alleviate symptoms and is less invasive than a TURP and preserve normal
ejaculation.
Men with urinary symptoms and have no obstruction at all on
urodynamics are unlikely to do well after a TURP.
Certain conditions or drugs make bleeding significantly more likely
during or after TURP. Such drugs include aspirin, warfarin, clopidogrel
and other drug thinners. Other
surgical
options less likely to cause bleeding such as
laser prostatectomy may cause fewer problems.
Men who have an unstable heart (e.g. recent heart attack or coronary
stent) or lung problem may be better waiting for a few months before
having a TURP. If necessary a
prostatic stent can be inserted if men are unable to pass urine and
this can avoid a catheter.
Certain neurological conditions (e.g. myasthenia gravis, multiple
sclerosis, or Parkinson disease) give rise to urinary symptoms in their
own right. In such cases, extra special care should be taken to ensure
that the prostate is in fact the primary cause for the symptoms.
Video-urodynamic studies are necessary before surgery otherwise
incontinence may results. If there is uncertainty about the benefit of a
TURP, a
prostatic stent can be inserted as this can be removed simply.
Similarly, severe pelvic fractures can also give rise to incontinence
after TURP.
Some men develop urinary symptoms after radiotherapy for prostate
cancer. In general, it is better to delay or avoid a TURP as much as
possible because incontinence may develop.
Treatment for prostate cancer by cryotherapy or brachytherapy can
also cause problems if a TURP is performed. Alternatives should be
sought if possible.
If an active urinary infection is present, a TURP should be deferred until
the infection has been cleared or antibiotics have been administered.
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