What happens during surgery?

The aim of surgery is to make the prostate gland smaller so that it no longer pushes against the bladder and urethra. In most of the approaches, tiny instruments are guided through the urethra (transurethral) until they reach the prostate, where they are used to remove tissue or widen the urethra. This kind of procedure is known as “keyhole surgery.” If the prostate gland is very large, it may be operated on from the outside, through a cut in the abdominal wall ("open surgery"). This is rarely necessary, though.

Many different surgical techniques and many different instruments and devices can be used to remove prostate tissue in different ways.

What is the most common approach?

A technique called transurethral resection of the prostate (TURP) is considered to be the standard surgical approach. This procedure involves inserting a thin tube called a resectoscope into the urethra (the tube that pee comes out of) and guiding it through to the prostate. The resectoscope is equipped with a tiny camera and an electrical loop that is used to mechanically remove prostate tissue. The loop produces heat at the same time, which quickly seals off the blood vessels. The resectoscope also has valves that regulate the release of fluid to flush the removed tissue out. TURP takes about 90 minutes and is done under local or general anesthetic. Men who have had this procedure usually need to have a urinary catheter (a tube that drains the bladder) for a few days after, and generally stay in the hospital for two to seven days. They then have to rest and take it easy for a few weeks.

Some variations of TURP are also considered to be standard treatments and have similar outcomes and consequences to conventional TURP. These include transurethral electrovaporization (TUEVP), transurethral vaporesection (TUVRP) and plasmakinetic enucleation of the prostate (PkEP).

There is another well-established surgical procedure called transurethral incision of the prostate (TUIP). In this approach, the pressure on the urethra is relieved without removing any prostate tissue. To do this, the surgeon makes one or two small incisions (cuts) where the bladder meets the prostate. This frees up a little space for the narrow urethra, relieving the pressure. The advantage of this technique is that certain side effects, such as bleeding, are less common. But TUIP is only suitable for men whose prostate is not very enlarged. And the procedure might have to be repeated after a while.

How effective is TURP and what consequences can it have?

Studies have shown that TURP can permanently reduce prostate-related problems. Nine months after having TURP, about 75 out of 100 men only have mild symptoms. For example, at night they only need to get up to go to the bathroom once, or not at all. The other men usually still benefit from TURP, but the effect is smaller. Side effects are common, though.

The most common side effect of TURP is “dry orgasm" or "dry climax" (retrograde ejaculation). This is where no semen, or much less than usual, leaves the penis during ejaculation. Instead, the semen flows into the bladder. This can happen if the muscles that normally close the entrance of the bladder during ejaculation are damaged during surgery. About 65 out of 100 men have this side effect after TURP. Although dry orgasms aren’t harmful and usually don’t affect men’s sexual pleasure during orgasm, they do reduce fertility.

Some men are afraid that they will have erection problems after surgery. Although there is no guarantee that this won’t happen, research has shown that permanent erection problems are rare. Some men even feel more comfortable with their sexuality after surgery because they no longer have bothersome symptoms such as having to go to the bathroom a lot.

Other possible consequences of TURP include urinary tract infections (UTIs) and temporary loss of bladder control (incontinence). And – like with most operations – there is a risk of bleeding that needs to be treated. In rare cases, surgery can cause narrowing of the urethra. Long-term consequences such as permanent incontinence are rare.

TURP can also lead to "TUR syndrome" – a condition associated with temporary nausea, vomiting or confusion. Although this complication is rare, it can be life-threatening. It can develop if some of the fluid that is used during surgery (to flush away the removed prostate tissue) gets into the bloodstream. In rare cases, TUR syndrome can cause cardiovascular problems. The studies in this area found that 2 to 3 out of 100 men developed TUR syndrome, but it did not have any serious health consequences.

Do laser treatments have any advantages over TURP?

As well as the standard approaches such as TURP, there are a number of other surgical techniques. They mainly differ in terms of the instruments and sources of energy used to remove or destroy the prostate tissue. Most of the other techniques are carried out using laser beams. Like in TURP, the instruments are inserted into the urethra and guided to the prostate.

The laser treatments include:

• holmium laser enucleation of the prostate (HoLEP)
• holmium laser resection of the prostate (HoLRP)
• thulium laser resection of the prostate (TmLRP)
• thulium laser enucleation of the prostate (TmLEP)
• photoselective vaporization of the prostate (PVP), also known as green light laser therapy

The two holmium techniques are about as invasive as TURP is. Research suggests that they are probably about as effective as TURP too. An advantage of the holmium techniques is that people can leave hospital and have their catheter removed sooner.

Research on thulium laser resection (TmLRP) has shown that the treatment outcome is similar to that of TURP. Severe bleeding after surgery was less common after thulium laser resection. Men who had this treatment were able to leave the hospital and have their catheter removed sooner.

Another advantage of laser treatment is that there is no risk of TUR syndrome occurring. But like TURP, they can still lead to dry orgasms.

Other surgical approaches such as TmLEP and PVP haven’t been scientifically proven to be at least as effective as TURP.

Which approach is most suitable?

When deciding which approach is the best option for you, it is important to discuss the pros and cons of the various surgical techniques with a doctor. The decision will depend on the size of your prostate, but also on personal factors such as your age and how healthy you are otherwise.

Not every hospital will use every single technique, though, so the choice of surgical approach will also depend on what is available. As with any surgical intervention, the surgeon's level of experience with a certain approach and the hospital's area of specialization will play an important role.

What happens after surgery?

Most kinds of prostate surgery are carried out in hospital. The amount of time you will have to stay in hospital will depend on the type of treatment you have and how quickly you recover. To prevent the healing wound from coming into contact with urine, a urinary catheter is needed for a few days after surgery. A catheter is a thin plastic tube that drains the bladder through the urethra. The tube is held in place by a small water-filled balloon in the bladder. This can lead to painful bladder spasms, mainly in the first few hours and days. Antibiotics are sometimes used to prevent infections.

In the first two days after surgery your urine might have blood or clumps of blood in it – particularly following TURP. It is important to drink a lot of water in the first few days in order to rinse the bladder and speed up the healing process. Mild bleeding may occur later too, for example when scabs break away and are flushed out.

Even if you no longer have any pain, it will take some time for the wound to heal completely. That is why it is important to take care in the first few weeks: strenuous physical activities, sudden movements and lifting heavy objects increase the risk of the wound bleeding. You can talk to your doctor about what you can do in everyday life to recover more quickly.

It can take a few months for everything to return to normal. During this time you may have urinary problems, such as an urge to urinate or temporary loss of bladder control. Your organs need some time to adjust to the changes in the operated area and to start working normally again, so it's important to be patient.

Sources

• Alexander CE, Scullion MM, Omar MI et al. Bipolar versus monopolar transurethral resection of the prostate for lower urinary tract symptoms secondary to benign prostatic obstruction. Cochrane Database Syst Rev 2019; (12): CD009629. [PMC free article: PMC6953316] [PubMed: 31792928]
• Brookes ST, Donovan JL, Peters TJ et al. Sexual dysfunction in men after treatment for lower urinary tract symptoms: evidence from randomised controlled trial. BMJ 2002; 324(7345): 1059-1061. [PMC free article: PMC104331] [PubMed: 11991908]
• Castellani D, Wroclawski ML, Pirola GM et al. Bladder neck stenosis after transurethral prostate surgery: a systematic review and meta-analysis. World J Urol 2021; 39(11): 4073-4083. [PubMed: 33974100]
• Franco JV, Garegnani L, Escobar Liquitay CM et al. Transurethral microwave thermotherapy for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia. Cochrane Database Syst Rev 2021; (6): CD004135. [PMC free article: PMC8236484] [PubMed: 34180047]
• Institute for Quality and Efficiency in Health Care (IQWiG). Non-drug local procedures in the treatment of benign prostatic hyperplasia: final report; commission N04-01. 2008.
• Institute for Quality and Efficiency in Health Care (IQWIG). Non-drug interventions for the treatment of benign prostatic syndrome (BPS): update; rapid report; commission N15-07. 2016.
• Institute for Quality and Efficiency in Health Care (IQWiG). Non-drug local procedures for treatment of benign prostatic syndrome: update; rapid report; commission N09-01. 2009.
• Wasson JH, Reda DJ, Bruskewitz RC et al. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. The Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. N Engl J Med 1995; 332(2): 75-79. [PubMed: 7527493]

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