Surgical Treatment of BPH

When is surgical treatment suggested as a form of treatment?

When medical therapy fails, surgery is required to remove the obstructing tissue. Surgery is almost always recommended for men who are unable to urinate, have kidney damage, frequent urinary tract infections, significant bleeding or stones in the bladder.

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What are the different surgical treatments available?

Removal of the prostate can be accomplished in several different ways. The location of the enlargement within the prostate and the patient's general health will help the urologist determine which of the three following procedures to use.

Transurethral resection of the prostate (TURP): Transurethral resection is the most common surgery for BPH. In the United States, approximately 150,000 people have TURPs performed each year. This can be done using electric current or with laser light. After the patient receives anesthesia, the surgeon inserts an instrument called a resectoscope through the tip of the penis into the urethra. The resectoscope contains a light, valves for controlling irrigating fluid and an electrical loop that cuts tissue and seals blood vessels. The removed tissue pieces are carried by the irrigating fluid into the bladder and then flushed out and sent to a pathologist for examination under a microscope. At the end of the procedure, a catheter is placed in the bladder through the penis. The bladder is continuously irrigated with fluid through the catheter in order to monitor bleeding and prevent blood from clotting and obstructing the catheter. Since there are no surgical incisions with this procedure, patients normally stay in the hospital only one to two days. Depending on surgeon preference, the catheter may be removed while the patient is still in the hospital or the patient may be sent home with the catheter in place, attached to a leg bag for convenience and removed several days later as an outpatient procedure. 

Transurethral incision of the prostate (TUIP):
Transurethral incision is used for men with smaller prostate glands who suffer from significant obstructive symptoms. Instead of cutting and removing tissue to relieve the obstructed bladder, this procedure widens the urethra by making several small cuts in the bladder neck where the urethra joins the bladder and in the prostate itself. This reduces the pressure of the prostate on the urethra and makes urination easier. Patients normally stay in the hospital one to three days. A catheter is left in the bladder for one to three days after surgery.

Minimally Invasive Surgical Treatments

Newer surgical modalities for the treatment of BPH have been aimed at providing a one-time minimally invasive therapy that is associated with fewer complications than TURP.

Transurethral microwave thermotherapy (TUMT): Transurethral microwave thermotherapy is a minimally invasive surgical treatment which uses a device to apply heat to the prostatic tissue causing necrosis and relief of bladder outlet obstruction. While the improvements in some outcomes following TUMT have not quite reached those associated with TURP, significant improvements in urinary symptoms have been reported for long time periods. In addition, re-treatment rate for recurrent lower urinary tract symptoms occurring secondary to BPH during a 3 year follow up period has been reported to be close to 25%. Another study reported that by two years after treatment with TUMT, 46.9% of patients were using medical therapy with an alpha-adrenergic antagonist and 17.6% of patients elected for re-treatment with TURP. Overall, it is still unclear as to the long term effectiveness in the relief of lower urinary symptoms after treatment with TUMT. One of the major advantages of TUMT is that it can be performed in a single 1-hour session as an outpatient procedure without any general or spinal anesthesia. Reports of complications vary, and range from 0 to 38%, based on the study and the investigators? criteria for complications.

Transurethral needle ablation (TUNA): Another technique currently approved for treating patients with symptoms of BPH uses high-frequency radio waves to cause thermal injury to the prostate. Transurethral needle ablation is a relatively new procedure that uses needles to deliver interstitial low-level radio frequency energy to produce a temperature above 100oC and subsequently cause prostatic cell tissue necrosis. The procedure duration averages approximately 30-45 minutes. TUNA can be performed under local anesthesia, IV sedation or transperineal prostate block. Therefore, TUNA does not require an additional hospital stay and is generally performed as an outpatient procedure. The most common intra-operative complication reported is a burning sensation, which can be significant to cause the termination of the procedure in !1% of patients. However, this can be managed by a prostatic nerve block prior to beginning the procedure. Like many of the other minimally invasive procedures, TUNA avoids significant intra-operative bleeding by heat coagulation. The overall incidence of peri- and post-operative complications following TUNA is ~25%, a rate that is significantly lower than TURP.

Open prostatectomy: When a transurethral procedure cannot be done, open surgery may be required. Open prostatectomy for BPH is also performed for a prostate that is too large to remove through the penis. Other reasons for choosing an open prostatectomy include patients with large bladder diverticula, with large bladder stones and who cannot physically tolerate having their legs placed in stirrups for TURP/TUIP surgery.

An incision is made in the abdominal wall from below the belly button to the pubic bone. The prostate gland can then be removed in its entirety through either an incision in the fibrous capsule surrounding the prostate (retropubic prostatectomy) or through an incision made in the bladder (suprapubic prostatectomy). Postoperative pain is mild to moderate. Patients usually stay in the hospital for several days and go home with a urinary catheter. In some cases a second catheter draining the bladder through the lower abdominal wall is used.

Frequently asked questions:

Will surgery for BPH affect my ability to enjoy sex?

Most urologists say that even though it takes a while for sexual function to return fully, most men are able to enjoy sex again. Most experts agree that if you were able to maintain an erection shortly before surgery, you will probably be able to do so after surgery. Most men find little or no difference in the sensation of orgasm although they may find themselves suffering from retrograde ejaculation.

Is BPH a rare condition?

No, it is very common. It will affect approximately 50 percent of men between the ages of 51 and 60 and up to 90 percent of men over the age of 80.

Does BPH lead to prostate cancer?

No, BPH is not cancer and cannot lead to cancer, although both conditions can exist together. There are usually no symptoms during the early stages of prostate cancer, so yearly physical examinations and PSA testing are highly recommended.

Content provided courtesy & permission of the American
Urological Association Foundation, and is current as of 5/2010. 
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