Transurethral Resection of Prostate (TURP or the 're-bore')
Our prostate gland grows and also becomes stiffer as we age. The urethra pipe draining our bladder passes through the prostate gland so changes in the prostate gland can lead to restriction of the flow of urine out of the bladder (symptomatic benign prostatic enlargement). The bladder, a hollow muscle, responds to this obstruction by becoming a thicker more powerful muscle which allows the generation of more pressure to overcome the obstruction. An unfortunate consequence of a thicker bladder is also a bladder which is less distensible and more irritable leading to more frequent and urgent urination both during the day and also at night. The urine flow may be difficult to initiate, quite slow and you may feel as though the bladder is not able to empty completely. In some cases urinary retention may develop requiring insertion of a catheter to drain the bladder. Incomplete bladder emptying increases the risk of urinary infection, incontinence and bladder stones. The likelihood of experiencing these symptoms relates to your age and whether other male family members have suffered from symptomatic benign prostatic enlargement. Prostate cancer seldom causes these symptoms and is no more likely in men with symptomatic benign prostatic enlargement.
For men who find the symptoms bothersome then the first line of therapy is usually to reduce intake of caffeinated beverages and alcohol. Next, we may advise trying a medication to either relax the muscle within the prostate or to slowly shrink the prostate gland over several months. These medications provide subjective mild relief of symptoms in most men. Surgery is significantly more effective than medication. It is performed using a long telescope inserted into the penis. The central, overgrown part of the prostate gland is trimmed, relieving the obstruction. Surgery is indicated for men who have suffered from repeat or severe urinary retention, recurrent urinary infection or the development of bladder stones and in men who have either failed medication therapy or who cannot tolerate the side effects of the medication.
A general or a spinal anaesthetic is administered. Intravenous antibiotics are given. A long instrument (resectoscope) in inserted into the penis, the bladder and prostate gland inspected then the inside of the prostate gland is trimmed away with an electrocautery device. I saline rather glycine irrigation fluid to reduce the risk of metabolic disturbance. The amount of prostate removed depends on the size of the gland. The average prostate resection is approximately 15gm and takes 45 minutes however in large prostates over 100gm of tissue may be removed. Following tissue removal the bleeding blood vessels are cauterised then a large catheter is inserted into the bladder. For very enlarged prostate glands it may not be feasible to remove the obstruction by telescope. In these cases I advise an open operation via the lower abdomen to allow complete and safe relief of obstruction.
Sometimes an additional supra-pubic catheter will be inserted during surgery. This is most likely if you have a very distended bladder termed 'chronic retention'. The supra-pubic catheter will stay in place for several weeks until the bladder has recovered satisfactory emptying.
Aspirin, clopidogrel, dabigatran, warfarin and any other blood thinning medications will need to be stopped prior to surgery. We will advise you on the timing of when to stop and re-start these medications.
A urine sample needs to be provided to the laboratory 1 week prior to surgery.
Following surgery saline is irrigated in and out of the catheter to flush away accumulated blood and prevent the formation of blood clots. You will be quite comfortable immediately after surgery. Some men experience a strong desire to pass urine when the catheter is present. This is due to spasm of the bladder muscle and settles with use of antispasmodic medication. Once the bleeding has settled then the catheter is removed, this is usually on the second post-operative day. After the catheter has been removed you will experience burning with voiding, urinary frequency and urgency and sometimes some incontinence. These symptoms have largely resolved by six weeks however urinary urgency will continue to improve over six months. We encourage a high fluid intake for several weeks to dilute the urine which helps relieve the discomfort of voiding and also flushes through any ongoing bleeding. Bleeding continues at a low level for several weeks. It is usually more noticeable in the mornings when you are relatively dehydrated and clears during the day. Two weeks following surgery there may be a one day period of more significant bleeding and this is due to the 'scab' falling off the prostate. Avoid heavy lifting and stirring for the first six weeks following surgery to reduce the risk of more significant bleeding.
Sexual function following surgery
All men will experience permanent reduction in or absence of ejaculate fluid. The fluid is still produced by the prostate gland at the time of orgasm however it flows back into the bladder rather than along the urethra. The next time you void the semen will pass out with urine. This may alter the sensation of orgasm.
Erections are usually unaffected following surgery. There is just a small chance that erections may be adversely affected.
Return to work
Most men are able to return to a sedentary job at 2 weeks. Heavy activity should be avoided for 6 weeks to prevent bleeding.
I will meet with you 3 months following surgery to review your recovery. Beyond this point further appointments are not usually needed however if you have any concerns then please contact me.
Risks recognised as common or serious are listed below but this does not include the rare and extraordinary.
- Temporary retention following catheter removal 20%. This is due to temporary incoordination between the bladder and sphincter muscle as a result of surgery. Catheter re-insertion followed by another attempt at voiding 1-2 days later usually resolves this.
- Bleeding requiring transfusion <5%
- Urethral stricture 5%
- Recurrent bleeding from the prostate remnant <5%
- Significant and persisting incontinence 1%
- Persisting urinary symptoms 10%