Prostatectomy; TURP; Suprapubic prostatectomy; Transurethral resection of the prostate; Prostate removal; Open prostatectomy
The prostate gland is an organ at the base of the bladder in men. The tissues in the gland may need to be surgically removed or destroyed as a way to treat prostate enlargement (benign prostatic hypertrophy) or Prostate cancer.
The symptoms of an enlarged prostate include:
- Frequent urination with small amounts of urine
- Need to urinate at night
- Difficulty starting a stream of urine
- Slow stream of urine
- Urine dripping out of urethra after urination (dribbling)
- Feeling that bladder is never empty
- Urinary tract infection
These symptoms can often be relieved by removing all or part of the prostate gland. This can be performed in a number of different ways, depending on the size of the prostate and the cause of the prostate enlargement.
The three most common procedures for surgically removing the prostate to treat non-cancerous enlargement are transurethral resection of the prostate (TURP), transurethral incision of the prostate (TUIP), and open prostatectomy.
The decision regarding the type of prostatectomy to perform depends on the size of your prostate gland. Generally, for prostates less than 30 grams, TUIP is recommended.
For glands bigger than 30 grams and less than 80 grams (this number depends on the experience of the surgeon), TURP is performed. If the prostate is bigger than 80 grams, open prostatectomy is recommended.
Transurethral resection of the prostate is the gold standard treatment and most common surgical procedure for benign prostatic hyperplasia (BPH). TURP is performed using spinal or general anesthesia. A special kind of cystoscope (tubelike instrument) is inserted into the penis through the urethra to reach the prostate gland.
A special cutting instrument is inserted through the cystoscope to remove the prostate gland piece by piece. Blood vessels are cauterized (electric current is applied to stop the bleeding) during the surgery.
A Foley catheter (artificial tube to remove urine from the body) is placed to help drain the bladder after surgery. The urine will initially appear very bloody, but will clear with time.
A bladder irrigation solution may be attached to the catheter to continuously flush the catheter, thus keeping it from becoming clogged with blood or tissue. The bleeding will gradually decrease, and the catheter will be removed within 1 to 3 days. You will remain in the hospital for 1 to 3 days.
Transurethral incision of the prostate (TUIP) is similar to TURP, but is usually performed in people who have a relatively small prostate. This procedure is usually performed on an outpatient basis and usually does not require a hospital stay.
A small incision is made in the prostatic tissue to enlarge the lumen (opening) of the urethra and bladder outlet, thus improving the urine flow rate and reducing the symptoms of BPH. A Foley catheter may be placed to help drain the bladder after surgery. The catheter will usually remain in place for a few days after surgery.
A key advantage to the TUIP is the preservation of normal ejaculation. One difference between TURP and TUIP is what happens to ejaculate after orgasm. The TURP causes the ejaculate fluid to be projected into the bladder instead of through the penis. The TUIP procedure usually continues to allow the ejaculate fluid to be expressed through the penis, the normal way. Unfortunately, many patients are not candidates for TUIP due to configuration of their prostates.
Although the transurethral approach is more commonly used, other surgical approaches to removal of the prostate gland (such as the transvesical, retropubic, and suprapubic approach) are sometimes used. The primary advantage of the transurethral approach is that it does not create an external incision. However, it is difficult to remove a large prostate using TURP.
To perform an open prostatectomy (sometimes called suprapubic or retropubic prostatectomy), an incision is made in the lower abdomen between the umbilicus (belly-button) and the penis through which the prostate gland is removed. This is a much more involved procedure and usually requires a longer hospitalization and recovery period.
Open prostatectomy is performed using general or spinal anesthesia. You will return from surgery with a Foley catheter in place. Occasionally, a suprapubic catheter will be inserted in the abdominal wall to help drain the bladder.
A bladder irrigation solution may be attached to the catheter to continuously flush the catheter, thus keeping it from becoming clogged with blood. A drainage tube may also be placed in the abdominal cavity to drain excess blood and fluids from the area.
Urine may initially appear very bloody, but this should resolve in a few days. The Foley catheter and suprapubic catheters will remain in place for 5 days to a few weeks until the bladder has sufficiently healed.
Various other procedures are available, such as those that destroy prostate tissue with heat generated by microwaves or lasers. These generally seek to remove prostate tissue with better control over bleeding and quicker healing.
For example, photoselective vaporization of the prostate (PVP), one of the newer laser technologies, is typically done as an outpatient procedure. The patient goes home on the same day. Other examples include transurethral laser incision of the prostate (TULIP), visual laser ablation (VLAP), and transurethral needle ablation (TUNA).
These procedures have demonstrated short-term effectiveness in select patients, but have not had adequate long-term testing.
Prostate removal may be recommended for:
- Inability to completely empty the bladder (urinary retention)
- Recurrent bleeding from the prostate
- Bladder stones with prostate enlargement
- Extremely slow urination
- Stage A and B Prostate cancer
- Increased pressure on the ureters and kidneys (hydronephrosis) from urinary retention
Prostate surgery is not recommended for men who have:
- Blood clotting disorders
- Bladder disease (neurogenic bladder)
Risks for any anesthesia are:
- Reactions to medications
- Problems breathing
Risks for any surgery are:
Additional risks include:
- Problems with urine control (incontinence)
- Difficulty achieving and maintaining an erection (impotence)
- Loss of sperm fertility (infertility)
- Passing the semen into the bladder instead of out through the urethra (retrograde ejaculation)
- Urethral stricture (tightening of the urinary outlet)
Expectations after surgery
TURP is typically successful at removing the symptoms of an enlarged prostate, although some sources report that within 10 years, about 20% of the people will require another surgery to remove additional prostate tissue.
TUIP has been shown to successfully relieve the symptoms of BPH in people with a relatively small prostate gland.
Open prostatectomy is successful in relieving the symptoms of BPH.
Hospital stay for open prostatectomy is about 4 to 7 days. Complete recovery from surgery can take 3 weeks. Drink plenty of fluids to help flush fluids through the bladder. Avoid coffee, cola drinks, and alcoholic beverages as these can cause irritation of the bladder and urethra.
by Dave R. Roger, M.D.