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Prostate, transurethral resection of

 

Transurethral resection of the prostate (TURP) is a surgical procedure that involves cutting away a section of the prostate gland. TURP is often used to treat prostate enlargement.

Prostate enlargement

The prostate is a small gland in the pelvis that is only found in men. It is located between the penis and the bladder, and surrounds the urethra (the tube that carries urine from the bladder to the penis).

The main function of the prostate is to help with the production of semen. The prostate produces a thick, white fluid that is liquefied by a special protein known as prostate-specific antigen (PSA). The fluid is then mixed with sperm, produced by the testicles, to create semen.

If the prostate becomes enlarged, it can place pressure on the bladder and urethra. This can cause symptoms that affect urination (passing urine when going to the toilet). These symptoms include:

  • difficulties starting urination,
  • a frequent need to urinate, and
  • difficulty emptying the bladder fully.

The symptoms can range from mild to severe.

Prostate enlargement is a common condition that is associated with ageing. It is estimated that 60 per cent of men who are 60 years of age, or over, have some degree of prostate enlargement.

The cause of prostate enlargement is unknown, but most experts agree that it is linked to changes in hormone levels in a man's body due to ageing.

How common is TURP?

TURP is one of the most common types of prostate surgery, with an estimated 450 TURPs performed each year in Ireland.

Due to the nature of prostate enlargement, most TURPs are carried in men who are 60 years of age, or over, with the average age being 69 years.

A TURP is usually a straightforward procedure, and most men will be able to leave hospital within three days of having the operation.

A transurethral resection of the prostate (TURP) is usually recommended for moderate to severe prostate enlargement that fails to respond to treatment with medication.

The severity of prostate enlargement is assessed on how often your enlarged prostate is causing problems with your normal pattern of urination.

Moderate to severe prostate enlargement would usually mean that you experience some or all of the following problems at least half the time that you try to urinate:

  • problems with starting to urinate,
  • a weak, or intermittent, urine flow,
  • having to push, or strain, in order to pass urine,
  • a frequent need to urinate,
  • waking up frequently during the night to urinate (nocturia),
  • a sudden urge to urinate, which can result in incontinence if you are unable to find a toilet quickly enough (urge incontinence), and
  • being unable to empty your bladder fully.

The first treatment option for moderate to severe prostate enlargement is medication such as:

  • finasteride - which helps to reduce the size of the prostate, and
  • alpha blockers - which help relax the muscles of your bladder, making it easier for you to use to pass urine.

These medications do not work for everyone because the degree of prostate enlargement is often too large to be controlled using medication. If this is the case, a TURP is usually recommended.

Is a TURP suitable for everyone?

Most men can have a TURP even if they are not in particularly good health. However, there are a number of reasons why a TURP would not be considered a safe procedure, or where the risks of complications would be too high. These circumstances are explained below.

  • If you have recently had a heart attack and/or heart surgery. It would usually be recommended that you wait between 3-6 months before having a TURP.
  • If you have a neurological condition, such as Parkinson’s disease, or multiple sclerosis, you may have problem controlling your bladder. A TURP would make this problem much worse resulting in incurable urinary incontinence.
  • If you have recently had radiotherapy to treat prostate cancer. Again, having a TURP soon after radiotherapy would result in urinary incontinence. After having radiotherapy, a wait of at least six months is usually recommended before having a TURP.
  • If you are due to have cryotherapy treatment for prostate cancer (where intense cold is used to kill cancer cells) or brachytherapy (where radioactive ‘plugs’ are used to kill cancer cells). Removing a section of prostate before either treatment is completed carries the risk of making either treatment less effective.
  • If you have an active infection of your bladder, urethra, or kidneys. If this is these case, the TURP would need to be delayed until after the infection has been treated with antibiotics.

Preparing for surgery

If you need to have a transurethral resection of the prostate (TURP), before the procedure you should try to ensure that you are as fit possible.

If you do not usually exercise regularly, you should aim to exercise for at least half an hour every day. Walking, swimming, or even activities such as gardening are all good forms of exercise.

If you smoke, cutting down, or giving up completely, will help to reduce your risk of developing any heart and chest complications following the operation.

You may be sent an appointment for a pre-assessment of your health a few days before the operation date. This may involve having some blood tests and a general health check up in order to make sure that you are fit for surgery. If you have a pre-assessment appointment, you can use it as an opportunity to discuss any concerns that you have with your surgeon.

If you are currently taking medication to prevent blood clots, you may be asked to stop taking it at a certain time before having a TURP. This is because this type of medication thins the blood which could lead to excessive bleeding during surgery.

If you are taking warfarin, you will usually be asked to stop taking it 3-4 days before having surgery. If you are taking clopidogrel and/or aspirin, you will usually be asked to stop taking them 10-14 days before surgery

Surgery

A transurethral resection of the prostate (TURP) is performed using an epidural or general anaesthetic.

An epidural is an injection of anaesthetic into your spinal column.Once you have been given an epidural, you will temporarily lose all feelings from below your waist which means that you will not feel any pain during the procedure.

If you would prefer that the TURP be performed under a general anaesthetic (where you will be unconscious throughout the procedure) you should let your surgical team know.

A TURP is usually carried out using a device called a resectoscope. A resectoscope is a thin metal tubes that contains:

  • a light,
  • a camera, and
  • a loop of wire.

The surgeon will insert the resectoscope into your urethra (the tube that carries urine from your bladder to your penis) before guiding it to the site of your prostate with the help of the light and the camera.

An electric current is used to heat the loop of wire, and the heated wire is used to cut away the section of your prostate that is causing your symptoms. During the procedure, water is pumped through the resectoscope to flush away the pieces of prostate that have been removed.

A TURP usually takes between 30-60 minutes to perform, depending on how much of your prostate needs to be removed.

Once the TURP has been completed, you will be moved back to your hospital ward so that you can recover from the procedure.

How long will I have to wait for the operation?

This is variable and depends on the local hospital. It's not an operation that needs to be done within weeks and there is sometimes a waiting time of a few months. Ask your surgeon or GP about estimated waiting times when the operation is discussed with you.

 

Urination

Following a transurethral resection of the prostate (TURP) you will be unable to urinate normally for the first few days.

This is because your urethra (the tube that carries urine from your bladder to your penis) will be swollen and painful. Instead, a thin tube called a catheter will be inserted into your urethra and up into your bladder so that the urine can drain away.

Immediately after the operation, water may be pumped through the catheter in order to clean your bladder and to get rid of any blood clots and other debris. This is not usually painful, but it may make your bladder feel uncomfortably full.

After your urethra has healed and you are able to pass urine normally, the catheter will be removed and you will be able to go home.

Rest

After having a TURP, most men are up and about around a week after the surgery. However, you will be advised to take things easy for about a month to six weeks afterwards.

For the first four weeks, you should not lift, or move, any heavy objects (including shopping), or do any housework, or digging. If possible, ask friends or family members if they can help you around the house.

Once you feel able, some gentle exercise, such as walking, will help to keep your blood circulating, and it will lower your risk of getting a blood clot in your legs.

Any symptoms of pain can usually be treated by taking over-the-counter (OTC) painkillers, such as paracetamol or ibuprofen.

Fluids

After having a TURP, you may occasionally notice some blood in your urine for a few weeks. Drinking plenty of fluids, such as water, fruit juice, and tea, will help to flush any blood, or small blood clots, out of your bladder. You should aim to drink at least 1.2 litres (6-8 glasses) of fluid every day.

If you have constant bleeding, or if you have difficulty passing urine, you should contact your surgeon. It is normal to frequently feel the need to urinate for the first few weeks after the operation. This is because your urethra and bladder will have been irritated during the operation.

Sometimes, the irritation might feel like a stinging sensation when you urinate. Despite the stinging and a need to urinate more frequently, you should still drink plenty of fluid because it will also help to prevent an infection from developing.

Returning to work

Most men take between 6-8 weeks to fully recover from having a TURP. However, your GP or surgeon will be able to advise you about when it is safe for you to return to work. This will depend on your occupation. For example, if you work in an office, you may be able to return to work sooner than someone who does manual work, such as building.

Driving

You will be advised not to drive for six weeks after having a TURP. You will usually be able to drive again when you can comfortably carry out an emergency stop. Your GP will be able to advise you about this.

Having sex

It will probably be several weeks after your operation before you feel comfortable enough to have sex. Most men need to wait for between 6-8 weeks before having sex, after which time any bruising and tenderness should have healed.

Check-up

Before you leave the hospital after having a TURP, you should be given an appointment for a check-up at the outpatient clinic. This appointment will normally be around six weeks after your operation.

 

How will I feel once I have recovered?

You should notice that the symptoms that bothered you before are no longer there, or are present to a much lesser extent. For example:

  • You should no longer need to strain to urinate.  
  • You should be able to go about your normal activities without having to worry as much about being near a toilet. 
  • You should be more in control of holding your urine in.
  • You may not need to get up in the night to urinate as you used to. 
  • You should also notice that you have a stronger stream of urine. 
  • You may no longer need to wear incontinence pads if you do so already.

Advantages

The majority of men who have a transurethral resection of the prostate (TURP) find that it is effective in the long-term in improving both their symptoms and their general quality of life.

For example, in a study that interviewed 280 men 12 years after they had a TURP, only 13 per cent said that they were unsatisfied with the results of the surgery.

Disadvantages

The main disadvantage of a TURP is that the procedure carries a risk of accidentally damaging:

  • the bladder,
  • the urethra (the tube that carries urine from the bladder to the penis ), and/or
  • the nerves.

This can lead to the following complications:

  • retrograde ejaculation - an inability to ejaculate semen out of the penis,
  • urinary incontinence - some, or total, loss of bladder control,
  • urethra strictures - narrowing of the urethra, and
  • impotence - erectile dysfunction.

Retrograde ejaculation

Retrograde ejaculation is the most common complication of a TURP and it occurs in an estimated 70% of cases.

Retrograde ejaculation occurs when the semen that you ejaculate during sexual intercourse, or masturbation, does not come out of your penis, but flows into your bladder instead.

You will still experience the physical pleasure that is associated with ejaculation (the climax) in the normal way. However, you may not be able to father children if you have retrograde ejaculation.

Retrograde ejaculation is caused by damage to the nerves, or muscles, surrounding the neck of the bladder, which is the point where the urethra connects to the bladder.

Normally, upon ejaculation, semen is pushed out of your testicles and up through your urethra. It is prevented from moving into your bladder by the muscles around the neck of the bladder which close tightly at the moment of orgasm.

However, if the muscles or nerves surrounding the neck of your bladder are damaged, preventing them from closing, semen will flow into the bladder rather than up and out of the urethra.

Urinary incontinence

Around three per cent of men will develop urinary incontinence after having a TURP which usually takes one of three forms:

  • urge incontinence - where you have a sudden urge to pass urine and, if you do not find a toilet quickly enough, you will lose control of your bladder,
  • stress incontinence - where small amounts of urine leak out during physical activities, such as coughing, sneezing, laughing, and heavy lifting, and
  • total incontinence - where you lose all control of your bladder and urine can leak out at any time during the day or night.

Stress and urine incontinence are usually the result of short-term damage to the bladder and should resolve within 3-6 months.

An estimated one per cent of men will develop total incontinence which usually requires surgery to correct. One option is to insert an artificial valve (sphincter) between your bladder and urethra that can be used to control the flow of urine.

Urethra strictures

After having a TURP, urethra strictures develop in an estimated four per cent of men. It is thought that some of the electric current that is used during the TURP procedure may move back into the urethra causing scarring and narrowing the urethra.

Symptoms of a urethra stricture include:

  • straining to pass urine,
  • spraying of urine or a 'split-stream' of urine,
  • dribbling drops of urine once you have finished going to toilet, and
  • mild pain when passing urine.

If the narrowing of the urethra is mild, it can usually be treated by inserting a rod to widen the urethra. More extensive narrowing may require surgery to correct.

Impotence

Around one in five men may find it difficult to get and/or to maintain an erection after having a TURP. This is known as impotence or erectile dysfunction. However, it is usually a short-term problem and should resolve once the body recovers from the effects of the procedure.

Exactly how many men will experience permanent impotence is difficult to estimate because the results of various studies have been contradictory. For example, some studies have estimated that around one in 10 men will experience sustained problems in getting an erection, while others studies suggest that the quality of a man's erection actually improves after having a TURP.

Also, as impotence is often associated with ageing, it is not easy to estimate exactly how many cases of impotence are directly related to the TURP procedure. Further research is needed in order to shed more light on this issue.

Transurethral resection of the prostate (TURP) is generally a very safe procedure. However, as with all surgery, TURP is associated with a number of potential risks. These are explained below.

TURP syndrome

TURP syndrome (a syndrome is a collection of related symptoms) develops in an estimated two per cent of cases.

During a TURP, it is necessary to pump water through the urethra in order to clear away blood and debris. In cases of TURP syndrome, the water becomes absorbed into the bloodstream, leading to a potentially dangerous build-up of fluid inside the blood.

Initial symptoms of TURP syndrome include:

  • nausea,
  • vomiting,
  • disorientation,
  • dizziness,
  • headache
  • swelling of your abdomen, and
  • slow heart beat (bradycardia).

Left untreated, additional and more serious symptoms can develop such as:

  • twitching,
  • seizures (fits),
  • shortness of breath,
  • blue skin (cyanosis),
  • heart pain, and
  • coma.

If you start to experience the symptoms of TURP syndrome during your TURP procedure, the surgeon will stop the surgery, remove the resectoscope, and inject you with a type of medication to remove fluid from the body (diuretics).

Bleeding

Around three per cent of men experience excessive bleeding during a TURP and will need to be given a blood transfusion to replace lost blood.

Infection

An estimated three per cent of men will develop an infection of the urethra, or bladder, after having a TURP. This type of infection is known as a urinary tract infection(UTI).

Symptoms of a UTI include:

  • pain, or a burning sensation, during urination (dysuria),
  • needing to urinate frequently, or urgently,
  • feeling that you are unable to urinate fully,
  • cloudy, bloody, or bad-smelling urine,
    pain in your lower abdomen, and
  • mild fever (a temperature of between 37-38°C or 98.6-101.0°F).

Antibiotics can usually be used to successfully treat a UTI.

Death

A TURP carries a very small risk of causing death - the risk of dying during a TURP procedure is estimated at one in 400. The risk usually arises due to complications involving the heart, or a serious post-operative infection. Most deaths that occur following a TURP occur in older men who are 80 years of age or over.

Watchful waiting

If you have an enlarged prostate, but you are not finding your symptoms particularly troublesome, you may decide on a policy of watchful waiting. This means that you will not receive any immediate treatment, but you will have the option of having a transurethral resection of the prostate (TRUP) in the future if your symptoms get worse.

If you do not have a TURP, lifestyle changes, such as limiting your consumption of alcohol and taking regular exercise, may be recommended in order to improve your symptoms. See the prostate enlargement article for more information and recommendations.

Transurethral incision of the prostate (TUIP)

Transurethral incision of the prostate (TUIP) is an alternative to TURP for men who:

  • only have a moderately enlarged prostate, and/or
  • are in very poor health and are not suitable for TURP (TUIP generally involves less blood loss than TURP so it is a safer treatment option).

After having a TUIP, there is also a lower risk of experiencing retrograde ejaculation than there is with a TURP, which may be an important consideration for you, particularly if you wish to have children.

In some cases of retrograde ejaculation, it is possible to take a sample of sperm from your urine for use in fertility treatments such as artificial insemination, or IVF.

TUIP is carried out in a similar way to TURP, but rather than removing tissue from the prostate, two small incisions (cuts) are made in the prostate. The cuts allow your urethra to be widened, making it easier for you to pass urine.

Open prostatectomy

An open prostatectomy is a type of surgery where an incision is made in your abdomen, and the outer portion of your prostate is removed.

While an open prostatectomy may be effective in treating your symptoms, it carries a high risk of complications. Therefore, it is usually only recommended for men with severely enlarged prostates.

Complications of an open prostatectomy include:

  • impotence, and
  • urinary incontinence.

If these complications develop following an open prostatectomy, there is a greater chance that they will become permanent compared to if they occur following TURP.

However, it may be possible to treat the symptoms of impotence with medication, such as sildenafil (Viagra).

New techniques

There are a number of new surgical techniques that are broadly based on the same principle as a TURP, but they use new ways of removing the prostate tissue. Most of the newer types of surgery have fewer side effects, cause less bleeding, and the recovery time is usually quicker than a TURP.

However, as these treatments are still fairly new, their long-term effectiveness is unknown. They are also usually only suitable for men who have a moderately enlarged prostate. Men with a severely enlarged prostate will usually require a TURP.

The new techniques are explained below.

KTP laser vaporisation

KTP (potassium-titanyl-phosphate) laser vaporisation involves inserting a small tube known as a cystoscope into your urethra. The cystoscope fires pulses of laser energy in order to remove the affected section of your prostate.

Complications of KTP laser vaporisation include:

  • pain while passing urine,
  • urge incontinence, and
  • blood in your urine - this complication usually passes within a few weeks.

Transurethral radiofrequency needle ablation of the prostate

Transurethral radiofrequency needle ablation of the prostate (TUNA) involves inserting two electrodes into your urethra and attaching them to your prostate.

Radiofrequency energy is sent to heat the electrodes in order to burn away the excess prostate tissue. Complications of TUNA include:

  • retrograde ejaculation.
  • bleeding, and
  • urethra strictures.

Transurethral electrovaporisation of the prostate

Transurethral electrovaporisation of the prostate is a similar to a TURP, but the resectoscope is attached to a roller ball (like a mouse ball) rather than a coil of wire. High voltage electricity is passed into the ball which vaporises the excess tissue of the prostate before sealing any bleeding.

Transurethral electrovaporisation of the prostate has a similar complication rate to TURP but it is associated with less post-operative bleeding.


Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.