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Preface and Contents

Benign Prostatic Hyperplasia (BPH)

Surgical Therapies

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Surgical Therapies

Specific surgical procedures commonly used are transurethral resection of the prostate (TURP), transurethral incision of the prostate (TUIP) and open prostatectomy.

1. Transurethral Resection of the Prostate (TURP)

TURP remains the gold standard treatment of prostate surgery and is more successful than medication. It relieves urinary obstruction in at least 85% to 90% of cases, and the improvement is usually long-lasting. TURP is a minimally-invasive operation, performed by urologists to remove part of the prostate gland blocking urine flow. TURP does not require any skin incision or stitches, but requires hospitalization.

Before surgery

  • Before the procedure, fitness of the person is ensured.
  • The patient is asked to stop smoking as smoking increases the risk of getting a chest and wound infection, and can delay recovery.
  • The patient is asked to discontinue blood-thinning medications (warfarin, aspirin and clopidogrel).

During the procedure

  • TURP generally takes about 60 to 90 minutes.
  • TURP is usually done using spinal anesthesia. Antibiotics are given to prevent infection.
  • During TURP, an instrument (resectoscope) is inserted in the urethra through the tip of the penis to remove the prostate.
  • The resectoscope has a light and camera for vision, an electrical loop to cut tissue and seal blood vessels, and a channel which carries irrigating fluid into the bladder.
  • Prostate tissue removed during the procedure is sent to a laboratory for histopathological examination to exclude prostate cancer.

After surgery

  • The hospital stay is usually 2 to 3 days after TURP.
  • Following surgery, a large triple lumen catheter is inserted through the tip of the penis (through the urethra) into the bladder.
  • A bladder irrigation solution is attached to the catheter and the bladder is irrigated and drained continuously for about 12–24 hours.
  • Bladder irrigation removes blood or blood clots that may result from the procedure.
  • When the urine is free of significant bleeding or blood clots, the catheter is removed.

Advice after surgery

Following measures after TURP help in early recovery:

  • Drink more fluids to flush out urine from the bladder.
  • Avoid constipation and straining during defecation. Straining can result in increased bleeding. If constipation occurs, take a laxative for a few days.
  • Do not start blood-thinning medications without advice of the doctor.
  • Avoid heavy lifting or strenuous activity for 4-6 weeks.
  • Avoid sexual activity for 4-6 weeks after surgery.
  • Avoid alcohol, caffeine, and spicy foods.
The most effective and popular surgical treatment of BPH is TURP.
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Possible complications

  • Immediate common complications are bleeding and urinary tract infection; while less common complications are TURP syndrome and problems from surgery.
  • Subsequent complications of TURP are narrowing (stricture) of the urethra, retrograde ejaculation, incontinence and impotence.
  • Ejaculation of semen into the bladder (retrograde ejaculation) is a common sequel a of TURP, occurring in about 70% of cases. This does not affect sexual function or pleasure but causes infertility.
  • Factors which can increase the risk of complications are obesity, smoking, alcohol abuse, malnutrition and diabetes.
TURP is done under spinal anesthesia without making the patient unconscious, thus, requiring a shorter hospital stay.
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After discharge from the hospital, contact the doctor if the patient has:

  • Difficulty or inability to void.
  • Severe pain which persists even after medications.
  • Bleeding with large blood clots that block the catheter.
  • Signs of infection, including fever or chills.

2. Transurethral Incision of the Prostate (TUIP)

Transurethral incision of the prostate (TUIP) is an alternative to TURP for men with smaller prostates or very poor health and therefore, not suitable for TURP.

The set-up for TUIP is similar to TURP, but rather than removing tissue from the prostate, two or more deep lengthwise incisions (cuts) are made in the prostate. The cuts widen the urethral passage, relieve pressure on the urethra and improve the flow of urine.

Benefits of TUIP are less blood loss, less surgery-related complications, shorter hospital stay and recovery time; and less risk of retrograde ejaculation and urinary incontinence as compared to TURP.However, TUIP is less effective in providing symptom relief and/or symptoms return faster over a shorter period of time in some patients requiring a follow up treatment with TURP. TUIP is not the most effective method of treatment for a large-sized prostate.

Ejaculation of semen into bladder is a common complication of TURP leading to infertility (inability to father children).
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3. Open Prostatectomy

Open prostatectomy is a type of surgery where an incision is made in the abdomen to remove the prostate. With availability of many effective and less invasive options, open prostatectomy is rarely used in the treatment of BPH.

An open prostatectomy is reserved only for very few men with severely enlarged prostates and in patients suffering from other problems that need simultaneous correction during surgery.

Minimally Invasive Treatments (MITs)

Minimally invasive methods are those that hurt the least. With modern technology and research, minimally invasive treatments are aimed at treating BPH through simpler procedures with less complications. These treatment modalities generally use heat, laser, or electrovaporization to remove excess tissue from the prostate. All of these treatments use a transurethral approach (going up through the urethra in the penis).

Benefits of minimally invasive treatments are: shorter hospital stay, need for minimal anaesthesia, less risks and complications than standard prostate surgery, and shorter patient recovery times. Disadvantages of these methods are: less effectiveness than standard TURP, more likely to need surgery again after 5 or 10 years, non availability of prostate tissue for histopathological examination (to exclude hidden prostate cancer) and fewer long-term studies for their safety and efficacy. Important additional drawback is that minimally invasive treatments (MITs) are not available in majority of developing countries and are currently more expensive.

TUIP is an alternative to TURP for men with smaller prostates or high risk patients for whom TURP is not suitable.
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Different minimally invasive treatments used in BPH are transurethral microwave thermotherapy (TUMT), transurethral needle ablation (TUNA), water-induced thermotherapy (WIT), prostate stents and transurethral laser therapy.

  1. Transurethral Microwave Thermotherapy (TUMT): In this procedure,microwave heat is used to burn excess prostate tissue blocking urine flow.
  2. Transurethral Needle Ablation of the Prostate (TUNA): In this procedure, radiofrequency energy is used to coagulate and necrose excess prostate tissue blocking urine flow.
  3. Water-Induced Thermotherapy (WIT): In this technique, hot water causes heat-induced coagulation and necrosis of the excess prostate tissue.
  4. Prostatic Stents: In this technique, a stent is placed within the narrowed area of the prostatic urethra. The stent keeps the channel open and allows easy urination. Stents are flexible, self-expanding titanium wire devices shaped like small springs or coils.
  5. Transurethral Laser Therapy: In this technique, laser energy destroys the obstructing portions of the prostate by heating.
MIT benefits: less risks and shorter hospitalization; Concerns: cost effectiveness and long term safety.
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When should a patient with BPH consult a doctor?

Patients with BPH should consult a doctor in case of:

  • Complete inability to urinate.
  • Pain or burning during urination, foul-smelling urine, or fever with chills.
  • Blood in the urine.
  • Loss of control of urination causing wetting of underclothes.
Prostatic stent is a safe and effective treatment when medications are ineffective & surgery is contraindicated.