Surgery for BPH

Advances in medical technology have made surgery for BPH less common, now that clinicians can blast, vaporize, and burn away extra prostate tissue using invasive nonsurgical treatment options for BPH. But surgery for BPH is still an option for some men who may have severe BPH symptoms that do not respond to other approaches or who have complications that make surgery a wiser choice.

BPH surgery, of course, requires that you stay in the hospital for at least a day or two, followed by a recuperation period of up to several weeks, and then there’s always the possibility of side effects and complications.

TUIP: Transurethral Incision of the Prostate

This surgical procedure is called a transurethral incision of the prostate, in which a clinician inserts an instrument through the urethra and threads it to where the prostate meets the bladder. The instrument delivers an electrical current or laser beam that cuts a few small “slits” in the prostate muscle tissue. The cuts force the muscles that control the opening and closing of the bladder neck to relax, which makes it easier for urine to flow out of the bladder and into the urethra. TUIP is considered to be useful for men whose prostate is only slightly enlarged so they don’t need TURP, a procedure that requires more cutting. TUIP is performed in a hospital, under general or spinal anesthesia, and you will need to stay for one full day after the procedure is done. A catheter is typically placed for up to three days, so you may go home with it still intact. TUIP relieves symptoms in about 80 percent of men who undergo the procedure. (Fitzpatrick 2007) Possible side effects of TUIP include problems with erections (4-25% of men), urinary incontinence (<1%), and retrograde ejaculation (6-55%) About 10 percent of men need another operation in about 15 years. (Fitzpatrick 2007)

TURP: Transurethral Resection of the Prostate

Transurethral resection of the prostate (TURP) is typically reserved for severe cases of BPH in which very bothersome symptoms have not been relieved by other methods. The surgery is performed under general or spinal anesthesia. In TURP, a surgeon threads a thin wire loop through the urethra. Once it reaches the prostate, an electrical current is passed through the wire loop, and the now electrified loop is used to slice away tissue that is blocking the urethra. An average of 22 grams of prostatic tissue is removed. A catheter is placed after the procedure, and you will need to stay in the hospital for about two days or until your urine is free of significant blood or clots. The good news is that about 70 percent of men who undergo TURP enjoy improvement of their symptoms. Now the bad news: retrograde ejaculation occurs in 25 to 99 percent of men who undergo TURP, although retrograde ejaculation does not affect sexual function. From 3 to 35 percent of men experience erection problems after having a TURP.  A small number of men (2-3%) need to have the surgery repeated in three years. (Fitzpatrick 2007) Other possible complications include rectal perforation, incontinence, sepsis, remote stricture, ruptured bladder, sphincter damage, or TUR syndrome, in which the sterile irrigation fluid used during surgery gets into the bloodstream and lowers a man’s sodium level, resulting in disorientation, nausea, vomiting, and possibly seizures and brain edema.

A variation of TURP is bipolar TURP, which is very similar to the traditional method except the surgeon uses a bipolar loop. The bipolar loop allows the surgeon to cut at a slower pace, which improves control of bleeding, produces a cleaner prostate tissue extraction, and reduces the risk of TUR syndrome.

Incontinence after TURP

TVP: Transurethral Vaporization of the Prostate

TVP stands for transurethral vaporization of the prostate, a variation of TURP. Rather than using an electrified coil to cut tissue away, a tiny cylindrical roller is electrified and literally rolled over the offending tissue. Thus the surgeon vaporizes the tissue away instead of cutting it. A drawback to TVP is that as each layer is vaporized away, the layer beneath it is filled with coagulated blood, which makes it hard to vaporize. Therefore TVP is not usually used on men who have larger prostates that would require a lot of “rolling.”

Holmium Laser Enucleation of the Prostate

Holmium laser enucleation of the prostate (HoLEP) is an outpatient procedure that is similar to open prostatectomy, but is associated with fewer risks. HoLEP uses laser to remove all the prostate tissue that is blocking urinary flow and prevents the regrowth of tissue. Like holmium ablation of the prostate (HoLAP), the laser energy for HoLEP is delivered through a thin flexible fiber that is passed through the penis to the prostate. The clinician uses the laser to cut away the affected tissue. The removed tissue can then be examined for prostate cancer and other conditions. A catheter is needed after the procedure but usually is removed the day after treatment.

Holmium laser enucleation of the prostate is not generally associated with erectile dysfunction, and complications such as urinary incontinence and bleeding are uncommon. About 10 to 15 percent of men who have prostates larger than 100 grams may experience stress incontinence after undergoing HoLEP, although incontinence usually resolves within six weeks. Blood in the urine is typical for several weeks and possibly up to six weeks, and burning with urination can also be expected for several weeks. Urethral stricture occurs in about 5 percent of cases. Use of HoLEP can improve urination for five to seven years without a need for follow-up treatments.

Prostatectomy

Prostatectomy, or complete removal of the prostate, is the most radical of all the treatments for BPH. Open prostatectomy, using either the retropubic or suprapubic approach, is the treatment of choice for men who have extremely large prostates (100 grams or larger). The suprapubic prostatectomy is rarely used. Read a full account of prostatectomy surgery here

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