Transurethral Resection of prostate

What is TURP?

TURP is short for transurethral resection of prostate.

Why am I having this done?

Your urologist would have had a detailed discussion about why you are having the procedure done (See PROSTATE-LUTS-BPH – pt guide) Your doctor has determined that you need surgery on your prostate to treat your symptoms. Or, you may have had a catheter (tube) inserted into your bladder when you presented with an inability to pass urine – this procedure allows you to get rid of the catheter.

How will I be prepared for this procedure? You will have some blood and urine tests, an electrocardiogram, a chest x-ray and in some, an echocardiogram (this is to look at your heart function in some detail). You will then be seen by an anaesthetist who will determine the best type of anaesthetic for you – either general anaesthesia (GA) or regional / spinal anaesthesia. You will be told about fasting – generally, this should be for a minimum of 6 hours. You may be allowed to take water (and only water!) for upto 2 hours before the procedure – but it is best to check with your anaesthetist, so that your procedure is not delayed! Your anesthetist may prescribe a mild sedative either the night before or on the morning of the procedure to reduce your anxiety. With regards to taking other medications on the day of surgery, please check with the anesthetist at your pre-operative visit.

It is likely that you have signed the consent form (your permission for the surgeon to operate on you) in the clinic but if not this will be done before you go to the operating theatre. The form would have been countersigned either by the operating urologist or the registrar / resident doctor.

Is there any medication that I should stop before this procedure?

If you are taking aspirin or other blood thinners like clopidogrelor coumadin (warfarin), your urologist may ask you to stop these for a week or so prior to the operation. If you are on coumadin or warfarin because you have an artificial heart valve then you will be given specific advice regarding this.

What actually happens during the procedure? Will I have any cuts?

The entire procedure is done with the use of an instrument called a resectoscope inserted through your penis. This allows the urologist to see the prostate and into your bladder.

Electric current is used to cut away pieces of the prostate. These are then washed out and sent away for further examination under the microscope. Only the obstructing part of the prostate is removed, not the whole gland.

This operation takes approximately 45 – 60 minutes. Because the operation takes place through the penis, there is no visible scar or wound. However, you have been cut inside and this needs time to heal afterwards, which may take up to six weeks.

Cartoon showing TUR cavity at the end of the procedure

Electrified loop cutting the prostate and appearance of bladder neck at the end of the procedure.

Will I have any tubes after the procedure?

Yes, you will have the following:

1. Intravenous ‘drip’ into your vein to give fluids. This is likely to run for a few hours, so that you are well hydrated. This is likely to be stopped soon after you start eating and drinking normally. In rare instances, you may require a blood transfusion.

2. A catheter left in through your penis to drain the bladder. There will be irrigation fluid (saline) running into the bladder and draining out; this is to keep the bladder free of blood / clots. The irrigation is usually stopped early in the morning the following day. You will be expected to drink enough fluids to get your urine very light coloured (the average tends to be around 3 – 3.5 litres /day). The catheter is left in place for 2-3 days in total.

Will I have any pain after the procedure?

Most patients do not have pain, but experience some discomfort in the bladder area for a few hours after the operation. This can be treated with painkillers. Some patients are likely to experience spasms in the bladder – this not only causes pain in the bladder area, but can also lead to leakage of urine around the catheter. If this is troublesome, it can be treated with appropriate medication.

What happens after the catheter is removed?

Your catheter may be removed (the urologist or nurse may refer to this as TWOC – trial without catheter or TOV – trial of voiding) either on the 2nd or 3rd day after the operation. This depends on the clinical context and the urologist makes an individualized plan. You would have been prescribed some laxatives to help you open your bowels, before the catheter is removed.

A small proportion of men do not pass urine after the catheter is removed. If this happens, a catheter will be reinserted and you will be sent home. The catheter will be left in for a few days before it is removed again – this will usually happen in the outpatient clinic.

What should I expect when I go home and how do I take care of myself?

Most men will find that the urinary flow / stream improves almost straight away. The frequency and urgency will take a few weeks to settle down. The internal wound takes 4 – 6 weeks to heal, so you are likely to see some blood in the urine on an intermittent basis. It is best during this period, therefore, to avoid any strenuous activity (eg. lifting weights, cleaning the house, etc). Of course, you can undertake light activity like walking. It also helps if you keep drinking plenty of fluids when you see blood in the urine, to flush it away.

When the internal wound heals and the scab falls off – this can happen anytime between 2 – 4 weeks – you may see quite a bit of blood in the urine and this may be associated with burning when passing urine. You may need to see your doctor / urologist to check your urine and treat any infection if present. If you are unable to pass urine due to blockage by clots you may need to go back into hospital – this is unusual, but may happen.

It is quite common for men to feel tired after this operation. This can in fact last for a few weeks but will improve.

What effect will the operation have on my sexual life?

Erections: although it is commonly quoted as causing problems with erection, TURP probably does not actually cause erectile dysfunction.

Ejaculation: Your bladder neck closes during ejaculation allowing the semen to go forwards and come out of your penis. Since the bladder neck is resected during TURP, this will not happen, allowing the ejaculate to go back into the bladder. So, you may not notice any semen coming out when you ejaculate (dry ejaculation). This is not harmful in any way.

Orgasm: This is not affected by the procedure, although the sensation may be altered in the first few weeks after the procedure.

Fertility: Since the ejaculation is likely to be ‘dry’, you may not be able to father any children, but it has to be understood that this is not a reliable form of contraception.

When can I resume sexual activity?

There are no hard and fast rules about this. In the first 2 weeks any strenuous activity may result in bleeding, so it is perhaps prudent to avoid anything during this period. After this you may have a go at it and see what happens.

Things to remember after the operation….

Urinary frequency and urgency does occur following the procedure and may get worse for some before it gets better. Some things to follow during the 6 weeks period:

DON’T

lift heavy weights or engage in strenuous activity
ride any two wheelers
drive any automobiles in the first 2 weeks
go on long journeys
go to remote locations

drink plenty of fuids
avoid constipation
take gentle exercise eg walking
return to normal activities after the 6 weeks period

In case of any problems or if you have any unresolved queries please do not hesitate to contact your urologist or the hospital.

Laser Prostatectomy

What is laser prostatectomy?

Essentially this is the same as TURP, but instead of electrical energy, light energy (LASER) is used to cut or vaporize the prostate. For an explanation about LASER please refer to: http://en.wikipedia.org/wiki/Laser.

The two most common lasers currently used by urologists are the Holmium:YAG laser and the KTP (potassium titanyl phosphate) laser. The holmium laser when used for treating the prostate is used at the 100-120 Watt level, and at the 20 Watt level when treating urinary stones. The holmium laser typically cuts the prostatic tissue and the cut pieces then have to be extracted out, similar to the TURP procedure. The KTP laser (or Greenlight laser as it is sometimes called because of it’s green colour – see picture below), on the other hand, typically vaporizes the prostate tissue.

What are the advantages of laser prostatectomy?

With laser prostatectomy, the fluid used during resection (cutting) of the prostate is saline whilst in standard TURP glycine is used. Glycine,when it gets absorbed into the circulation can cause certain problems for the patient. Although this is a rare event, this risk is entirely avoided when saline is used (TURP can also be done using saline but this requires special electrical equipment and cutting loop – see separate question below).

Also, with the use of laser energy, there is less blood loss, although clinically this may not be relevant. Specific advantages exist for each type of laser. Holmium laser – very large glands can be treated safely. Greenlight laser –can be done as a day case and there is no need to stop the blood thinners.

So, is laser prostatectomy better than TURP?

No. TURP has been in existence for several decades whilst the laser procedures have become popular in the past decade. Just like there are different horses for different courses, each modality has its own application under specific situations (see previous question/answer). Whilst TURP has time limitation for the duration of resection, the laser procedures do not have such restriction (within limits!). Also, TURP uses standard electrical energy and is available universally. LASER units are quite expensive and may not be widely available.

The advantage with laser prostatectomy though is early removal of catheter (with Greenlight laser especially, the procedure is usually done as a day case or 1 night stay). Also, blood loss with laser prostatectomy is virtually non-existent.

Saline TURP

What is saline TURP?

In standard TURP, monopolar electric current is used and for this to work requires a solution like glycine. But, as mentioned above, TURP can be done using saline as the irrigant, but it requires special equipment using bipolar electric current.

What is the advantage of saline TURP?

It avoids the potential complication of TUR syndrome that can happen in standard TURP, where glycine, when absorbed in large quantities into the circulation can cause problems. Also, saline is cheaper than glycine.

Are the effects and post-operative care / advice different with laser prostatectomy?

Essentially the side effects, results, post-operative course and advice are the same as for TURP.