BPH Surgery: Know Your Options
Known as simple prostatectomy, surgery for benign prostatic hyperplasia (BPH), also known as benign prostatic enlargement (BPE), typically involves removing only the prostate tissue that is surrounding and pressing on the urethra.
The procedure can be performed in one of two ways: through the urethra (transurethrally) or by accessing the prostate through the lower abdomen with an abdominal incision or laparoscopically.
Simple prostatectomy for BPH differs from radical prostatectomy for prostate cancer, however. In the cancer surgery, the surgeon removes the entire prostate and the seminal vesicles (glands located on each side of the bladder that secrete seminal fluid).
Surgery is the fastest, most reliable way to improve BPH symptoms. Fewer than 10 percent of patients will require a repeat procedure five to 10 years later. However, surgery is associated with a greater risk of long-term complications, such as erectile dysfunction (ED), incontinence, and retrograde (“dry”) ejaculation, compared with other treatment options for BPH. (Retrograde ejaculation—ejaculation of semen into the bladder rather than through the penis—is not dangerous but can provoke anxiety and may cause infertility.) The incidence of these complications varies with the type of surgical procedure. Now that medications are available to treat BPH, fewer men are opting for surgery.
If surgery is chosen, the operation will be postponed until any urinary tract infection or kidney damage from urinary retention has been successfully treated. Because blood loss can be a complication during and immediately following most types of BPH surgery, men taking aspirin should stop taking it seven to 10 days prior to surgery. Aspirin interferes with blood clotting.
Also called transurethral resection of the prostate (TURP) or transurethral vaporization of the prostate (TUVP), transurethral prostatectomy is considered the gold standard for BPH treatment—the one against which other therapies are compared.
More than 90 percent of simple prostatectomies for BPH are performed transurethrally. The procedure is typically done in the hospital under general or spinal anesthesia. In men with smaller prostates and no other medical problems, transurethral prostatectomy may be performed as an outpatient procedure.
In TURP, prostate tissue is removed (resected) with a resectoscope, a long, thin instrument that is inserted into the penis and passed through the urethra to the prostate. In TUVP, the tissue is vaporized with electrical energy.
The resectoscope has a wire loop at the end to cut away prostate tissue piece by piece and to seal blood vessels with an electric current or laser energy. As the pieces of tissue are being cut away, they are washed into the bladder and then flushed out of the body through the resectoscope. A sample of the tissue is examined in the pathology laboratory to rule out the presence of prostate cancer. If vaporization is performed, however, no prostate tissue is available for examination. Short- and long-term results with TURP and TUVP have been shown to be similar.
Recovering from TURP
Once the surgery is completed, a catheter is inserted through the urethra into the bladder. Fluid is continuously circulated to prevent blood clot formation and to monitor for bleeding. The catheter typically remains in place for one to three days. (It may be removed in the hospital, or a man may go home with the catheter and then return a few days later to have it removed.)
Most men experience a greater urgency to urinate for approximately 12 to 24 hours after the catheter is taken out. A hospital stay may be required, but that is usually not the case. Men typically experience little or no pain after the procedure, and a full recovery can be expected within three weeks.
Improvement in symptoms is noticeable almost immediately after surgery and is greatest in men who had the worst symptoms beforehand. Marked improvement occurs in about 90 to 95 percent of men with severe symptoms and in about 80 percent of those with moderate symptoms. This rate of improvement is significantly better than that which can be achieved with medication or through the self-help measures employed during watchful waiting. In addition, more than 95 percent of men who undergo transurethral prostatectomy require no further treatment over the next five years.
The most common complications immediately following transurethral prostatectomy are bleeding, urinary tract infection, and urinary retention. Longer-term complications can include ED, retrograde ejaculation, and incontinence, all of which can be treated. However, increasing evidence suggests that transurethral prostatectomy may cause no more problems with sexual function than other treatments for BPH and, in some instances, may even bring about improvements in sexual functioning. The risk of death from transurethral prostatectomy is very low (0.1 percent).
An open prostatectomy is the surgery most often performed when a man’s prostate is so large that a transurethral procedure can’t be performed safely. Two types of open prostatectomy can be performed for BPH: suprapubic and retropubic, with either performed through an incision between the navel and the pubic bone or laparoscopically with small instruments passed through multiple holes in the abdomen.
A suprapubic prostatectomy involves opening the bladder and removing the inner portion of the prostate through the bladder. In a retropubic procedure the bladder is moved aside and the inner prostate tissue is removed without entering the bladder. Both procedures are performed in a hospital under general or spinal anesthesia. Removed tissue is checked for prostate cancer.
Recovering from an open prostatectomy
After a suprapubic prostatectomy, two catheters are placed in the bladder, one through the urethra and the other through an opening made in the lower abdominal wall. The catheters remain in place for three to seven days after surgery. Following a retropubic prostatectomy, a catheter is placed in the bladder through the urethra and remains in place for a week. The hospital stay (one to three days) and the recovery period (four to six weeks) are longer for open prostatectomy than for transurethral procedures.
Like transurethral prostatectomy, an open prostatectomy is an effective way to relieve symptoms of BPH. However, complications are more common with open prostatectomy—and in some cases the complications can be life threatening. As a result, open prostatectomy is reserved for otherwise healthy men with the largest prostates. The most common complications immediately after open prostatectomy are wound infection and excessive bleeding, which may require a transfusion.
More serious complications of an open prostatectomy, although rare, include heart attack, pneumonia and pulmonary embolism (a blood clot that travels to the lungs). Performing breathing exercises, moving the legs in bed, and walking soon after surgery can reduce the risk of pneumonia and blood clots. Long-term complications, including ED, incontinence, and retrograde ejaculation, are slightly more common with open prostatectomy than with transurethral prostatectomy.
If your doctor determines that you are not a candidate for TURP or an open prostatectomy, or you want other options, there are alternative surgeries and therapies available:
• Transurethral incision of the prostate. Like transurethral prostatectomy, ransurethral incision of the prostate (TUIP) is performed with a resectoscope inserted through the urethra. However, instead of cutting or vaporizing prostate tissue, the surgeon makes one or two small incisions in the prostate with an electrical knife or laser. These incisions alleviate the symptoms of BPH by decreasing the pressure that excess prostate tissue exerts on the urethra.
TUIP takes less time to perform than transurethral prostatectomy and, in most cases, can be done on an outpatient basis under general or spinal anesthesia. However, the procedure is effective only in men with prostates smaller than 30 g (about 1 oz.). The degree of symptom improvement in these men is similar to that achieved with transurethral prostatectomy, but patients may be more likely to require a second procedure. Because the incidence of retrograde ejaculation is lower than with transurethral prostatectomy, TUIP is a good option for men concerned about their fertility.
• Holmium laser prostatectomy. The holmium laser can be used in a variety of ways to treat BPH. In holmium laser ablation of the prostate (HoLAP), the excess prostate tissue is destroyed by the laser. Results appear similar to those achieved with transurethral prostatectomy and open prostatectomy. The main advantages of HoLAP appear to be reduced blood loss and shorter catheterization times and hospital stays.
A variation of HoLAP is holmium laser resection of the prostate (HoLRP). In this procedure, a holmium laser is used to cut the excess tissue. Another option is holmium laser enucleation of the prostate (HoLEP). This approach is well suited for transurethral removal of a prostate weighing more than 100 g (about 3.5 oz.), but few urologists are trained in this procedure. As with transurethral prostatectomy, holmium laser prostatectomy has the potential to cause ED and retrograde ejaculation.
• Photoselective vaporization of the prostate. Also called Green Light laser vaporization, photoselective vaporization of the prostate (PVP) uses a wavelength that is highly absorbed by hemoglobin. This results in minimal blood loss during the procedure and provides a safe approach for men on anticoagulants. PVP allows tissue removal similar to the traditional transurethral prostatectomy procedure while maintaining the safety characteristics of lasers. PVP is not as effective as transurethral prostatectomy for men with larger prostates.
• Thermoablation (heat) treatments. The goal of minimally invasive treatment for BPH is to reduce lower urinary tract symptoms and thereby improve quality of life, while minimizing treatment side effects. A variety of minimally invasive transurethral procedures have been introduced as alternatives to transurethral prostatectomy. These therapies use heat to vaporize tissue in the prostate, a process known as thermoablation.
The most common thermoablative procedures are transurethral microwave thermotherapy (TUMT) and transurethral needle ablation (TUNA). Although these treatments are associated with fewer adverse events, such as bleeding, incontinence, and retrograde ejaculation, most urologists have abandoned thermotherapies because of their inferior long-term effectiveness when compared with transurethral resection and ablative treatments.
• Prostatic urethral lift. In 2013 the FDA approved the UroLift system, a permanent implant inserted during a minimally invasive procedure known as a prostatic urethral lift (PUL). During a PUL, the surgeon moves the overgrown prostate tissue in the urethra that is blocking the flow of urine. The implants are used to hold the widened channel in place. The system is approved for use in men with BPH who are age 50 and older.
It’s not yet clear how a PUL compares with transurethral prostatectomy, but additional research is underway. Research to date has shown that transurethral prostatectomy offers greater symptom relief than PUL.