Trans-Urethral Resection of the Prostate (TURP)
A Trans-urethral Resection of the Prostate (TURP) is an minimally-invasive operation, performed by your urologist, to remove the parts of your prostate gland that are pressing on your urethra in order to allow urine to flow more freely. The urologist passes a special tube through your urethra and uses a heated wire loop to shave off the overgrown areas of your prostate gland. In this way TURP is not an open surgery, and there will be no incisions or scars.
Not everybody with an enlarged prostate gland will require a TURP; however your urologist may recommend this procedure to you on the basis of your symptoms and the results of special investigations they have carried out. By allowing urine to flow more freely, a TURP can often relieve or reduce your symptoms.
Know about your prostate gland- Your prostate (see diagram) is a walnut-sized gland that lies at the base of your bladder (where urine is stored) surrounding the urethra (the tube that passes urine from your bladder, along your penis and out of your body).
The prostate gland is found only in males, and is part of the reproductive system. It produces nutrients for the sperms and produces components that make up the milky fluid (semen) that you produce when you ejaculate.
The most common cause of prostate gland enlargement is "Benign Prostatic Hyperplasia", often shortened to "BPH", which means extra-growth of normal (non-cancerous) cells. This process often begins at the age of 40, causing your prostate to gradually increase in size as you get older. BPH is very common and often exists with few or no symptoms. However as the prostate surrounds the urethra, the enlargement can squeeze the urethra making it difficult for you to pass urine. This may lead to symptoms that can include:
• Weak flow of urine
• Needing to strain to pass urine
• Not being able to empty the bladder completely, so needing to use the toilet more often both day and night.
To relieve the above symptoms of an enlarged prostate - TURP is carried out. Without TURP, your prostate gland may continue to enlarge, leading to worsening of your symptoms. It may also increase the risk of damage to your bladder and/or kidneys due to the increased pressure and stress that is required to pass urine through the squeezed urethra. Although there are other ways of treating the enlarged gland, TURP is the commonest type of surgery to treat an enlarged prostate gland.
Alternatives to Surgery
As mentioned, not all men with BPH require a TURP and there are three main alternative treatment options, as outlined below. However not all the options may be appropriate for you, and your urologist can assess and advise you on the best treatment option suitable to you.
1. Observation of symptoms and lifestyle modifications: If your symptoms are mild and not too troublesome, you may choose not to have any active medical or surgical treatment. If you are waking often at night to pass urine, you may be advised to limit your fluid intake in the evenings, and reduce your consumption of tea or coffee. BPH does not always get worse and it can sometimes improve over time.
2. Taking medications: Drug treatments for BPH either cause shrinking of the enlarged prostate gland, or relaxing of the muscles of your bladder and prostate gland. In this way they can help urine to flow more freely and may alleviate your symptoms. However medication must be taken continuously to maintain relief, and some patients find them to have little effect on their symptoms.
The two most popular medications are broadly called- alpha blockers – that help to decrease the tone and relax the muscles, and 5 alpha reductase inhibitors – that reduce the size of the enlarged prostate by acting on the male hormone, testosterone.
Besides the regular tablets, in some countries herbal preparation such as derivatives from the plant ‘Saw Palmetto’ is a very popular form of medication. Limited scientific data does suggest that it may relieve the symptoms in some patients. Likewise there are many other natural products that practitioners claim can help to improve enlarged prostate symptoms; however there is not sufficient scientific evidence to support these claims.
Laser & Other Methods
1. Laser Prostatectomy - This is again undertaken, like TURP, through an endoscope but causes less bleeding. It uses laser to cut and evaporate the prostate tissue. The advantage is that the patient may be discharged with a catheter the same day or the next day. The most popular is the Holmium laser to treat the enlarged prostate. This works by carving out the prostate tissue like an apple and later the tissue is removed from the bladder by using special equipment called a morcrelator.
KTP or Green light laser is another popular method – in this the prostate tissue gets evaporated with the heat it produces.
2. Open surgery to remove the prostate gland or ‘open prostatectomy’: This may be considered if your prostate is too large to be treated by TURP. There are various approaches undertaken to remove the enlarged gland. One can approach it either through the lower side of the abdomen or through the perineum. It must be remembered that once the enlarged gland tissue is removed it can again recur. The term ‘open prostatectomy’ in this context is a misnomer, because one never removes the whole gland but only the enlarged tissue the ‘adenoma’ of the prostate .
3. Ultrasound (High intensity Focused Ultrasound), Microwave, TUNA (Trans-Urethral Needle Ablation) – are other methods of treating the prostate gland enlargement- however they are not widely popular.
The laser, ultrasound and microwave are different modalities and have been developed to ensure that there is minimum morbidity, like bleeding, when treating the gland. Of these, only the laser, and to some extent the TUNA, are popular but are more expensive. However they are done as a day case and hence there is some reduction in the hospitalizations costs.
Patients with high risk for surgery have also been treated as a day case using injection of Botox to relax the prostate smooth muscles. Some urologists have also injected alcohol in the gland.
Temporary internal stents, that keep the prostatic area open, were used in the past instead of a long term indwelling catheter especially in high risk patient who were not fit for surgery.They are not popular due to much discomfort to the patient.
Anesthesia: TURP can be performed under either spinal or general anesthesia. Having spinal anesthesia means your body will be made numb from the waist down - you will be awake, but you will feel no pain. In contrast, when under general anesthesia you will be unconscious throughout the surgery, and also feel no pain. To prepare for the surgery, no food or drink is allowed for 6 hours before the anesthetic. However to keep you hydrated, you may have a ‘drip’, where a small tube is placed into one of your veins and attached to a bag of fluid.
Operation: In the operating theatre, the surgeon will insert a thin tube-like telescope (a ‘resectoscope’) into your urethra, and an attachment that carries a heated wire loop will be used to ‘chip away’ at the prostate gland and stop any bleeding. During the operation, your bladder will be flushed with sterile solution in order to remove the chippings of prostate tissue. These chippings will also be examined under a microscope (biopsy) to check for abnormal cells. The TURP is usually complete within 1 hour.
When the TURP is complete, a thin flexible tube called a ‘catheter’ will be placed through your urethra, up into the bladder, and salt water instilled through the catheter into the bladder to flush out any remaining blood clots from the surgery. The catheter will then drain urine and the salt-water from your bladder.
It is normal for your urine to contain some blood (hematuria) after a TURP so do not be alarmed. The catheter is usually left in place to continue to both flush and drain your bladder, until your urine is suitably clear of the blood and this usually takes two to three days. With the catheter in place, some men experience bladder spasms (contractions) with a sudden urge to pass urine. These usually pass within a few minutes, and your doctor or nurse can help you relieve them in a number of ways.
You may have a little discomfort in your urethra after the operation and your doctor can give you pain-killers to alleviate these symptoms. You will usually remain on the fluid ‘drip’ until you are drinking enough fluids yourself, and the blood in your urine has reduced. It is important to keep yourself well hydrated to help flush out your bladder. Drinking 2 ˝ liters of water per day is recommended.
Once the catheter has been removed, you may experience a mild burning discomfort when you pass urine. This is because your urethra will be slightly swollen and sore from the surgery and having the catheter in place. This symptom is normal, and will not last for long. It is also common to have less control while passing urine for a short time after your TURP, with occasional leaking or dribbling, urgency to urinate or difficulty in controlling flow. These symptoms are transient and your nurse can teach you certain exercises to help improve your control.
After laser prostatectomy you may be able to return home the same day with the catheter in place.
After TURP you will be able to return home in 3 to 5 days. This is usually a day after the removal of the catheter. The urologist ensures that you are able to pass urine comfortably before going home.
Keeping well hydrated is very important. By drinking 2 liters of water per day you can help regain control of your bladder sooner and reduce your risk of infection.
Please contact your urologist if you notice any of the following symptoms after your surgery:
• Heavy bleeding
• A high temperature
• Increasing pain
• Inability to urinate.
It is sometimes not unusual to continue to have occasional redness of the urine for a few weeks after your TURP. Rarely bleeding may continue for 10-14 days after your operation, when the scab that forms on your healing prostate gland surface, after surgery, falls off. The bleeding, if significant, may be frightening and in this situation it is best to contact the urologist or visit the hospital. If the urine is light red, drinking extra glasses of water can help clear your urine.
On an average, it takes around 4-6 weeks to recover fully from a TURP and resume all your normal activities, including sex. It is a good idea to avoid any strenuous activity until you have recovered fully.
Your urologist will see you again for follow-up appointments in order to assess your improvement and deal with any concerns that may arise.
Risks - TURP
TURP in general, is a safe and effective operation. However all surgery is associated with risks, and you should be aware of the risks involved in TURP before you agree to go through with the surgery. Your urologist can provide you will useful advice and discuss your concerns.
The main risks of TURP are as follows:
1. Retrograde ejaculation (dry orgasm): Around 75% of men find that little or no semen is ejaculated during orgasm after TURP. This happens because the surgery makes it possible for semen to travel up into the bladder rather than out through the penis. This is a long -term side effect. This shouldn’t interfere with sex and orgasm and most men return to the same level of sexual activity as before the treatment. However, retrograde ejaculation may affect your fertility. Research has shown that TURP does not increase risk of impotence or erectile dysfunction.
2. Prostate gland re-enlargement: The prostate gland may continue to enlarge after surgery, and in the future, a repeat procedure may be required when symptoms return. This happens to around 10% of patients within 10 years of their TURP.
3. Urinary infection: This affects around 3% of patients and can cause symptoms such as pain or burning when passing urine. Urine infections can be treated with antibiotics.
4. Excessive bleeding: This happens to around 3% of patients, and you may need a blood transfusion or a second operation to stop the bleeding.
5. Injury to the Urethra: This affects around 2% of patients and the resultant scar tissue can lead to ‘urethral stricture’ formation, where a section of the urethra narrows, reducing the flow of urine.
6. TURP Syndrome: This is when too much of the fluids used to flush your bladder are absorbed into your blood stream, leading to a salt imbalance in your blood. This can make you confused, nauseous or unsteady on your feet and may be particularly dangerous in those with existing heart or kidney problems. This is a very rare complication of TURP which usually develops early, whilst still in the operating theatre or the recovery room. It is very important to inform a member of staff if you experience any of the above symptoms after your operation.
7. Deep Vein Thrombosis (DVT): This is when a blood clot develops in the veins of the leg, which can break off and travel to the lungs to cause a blockage. DVT is rare potential risk of any operation, and people having surgery are routinely given medicines or compression stockings to wear during the operation to help prevent it.
Written by: – Shilpa Jha
Edited By: – Dr.Shroff
Uploaded by: – Lingaraj