Introduction

When the prostate becomes enlarged from non-cancerous natural growth, this is called benign prostatic enlargement. One of the treatments for this is a transurethral resection of the prostate (TURP). It is also called a prostate ‘rebore’. It is one of the most common types of surgery for the treatment of an enlarged prostate.

A TURP is an operation that is done internally with no open cuts. A resecting loop is passed down a thin instrument with a camera (cystoscopy) and the prostate is excised in chips. This opens the passageway for the urine to flow through. About 90% of patients will find an improvement in their symptoms.

The classic method of resection is with diathermy (electric current), which is described here. This technique still stands the test of time and is considered the gold standard. Techniques using laser (Green light laser TURP, Holmium laser) now have an increasing role, especially in those who are on blood thinners and cannot stop them for an operation, but will not be described here. Other treatments such as Urolift, Rezum water vapour therapy or microwave therapy are not described here.

Indications

Surgery is indicated in patients with benign prostatic enlargement who have:

• Lower urinary tract symptoms refractory to oral medical therapy.
• Recurrent urinary tract infections or prostate infections.
• Acute or chronic urinary retention (unable to empty bladder).
• Kidney damage from the obstruction.
• Bladder stones.
• Recurrent blood in the urine (haematuria) from the enlarged prostate.

Preoperative Instructions

If you are taking blood thinners or certain newer diabetic medications, please inform your doctor as these may have to be stopped before the surgery.

You will need to fast for at least 6 hours before the surgery.

Your doctor may require you to have blood tests or a urine test prior to the surgery.

See preparing for surgery, for more detailed instructions.

Procedure

It is performed under general or spinal anaesthesia. You will be given intravenous antibiotics. The operation time is about 40 - 60 minutes. The prostate is ‘shaved’ or ‘cored’ out from the inside chip by chip, with a resecting loop, to create an open passage. This allows easier urination post-operatively. The chips are sent off for analysis under the microscope (histopathology). The raw surface of the inner prostate is diathermied to control the bleeding.

At the end of the case, a catheter (drainage tube) is placed in the penis to drain the bladder. The catheter is a special one that allows continuous inflow and outflow of fluid (continuous bladder irrigation), which will constantly wash out any small clots that may form internally. The catheter is attached to your inner leg and drains into a large bag.

The estimated length of stay in the hospital is 2 – 3 days.

Postoperative Instructions

As there is no skin incision, there is not much post-op pain. You may get mild irritation from the catheter. Uncommonly, you may get bladder spasms from the catheter. The catheter can occasionally block up with clots and your doctor or nurse may have to manually flush these clots out.

On day 1, you are encouraged to sit out of bed, go to the toilet and go for short walks around the ward. This will prevent clots in the legs. You can walk around even with the catheter and its tubings as they can be placed on a mobile pole that you can bring with you. Deep breathing exercises will also prevent a chest infection.

By day 2 to 3, when the bladder irrigation shows reduced bleeding, the catheter is removed. You are then asked to drink lots of water and pass urine (trial of void). Every time you pass urine, it is done in a bottle so we can measure how much you pass, and a nurse will then scan your bladder to see if you are emptying properly. After a few satisfactory voids, most patients can go home.

The urinary flow will be strong when the catheter comes out. It may also ‘burn’ a bit but should settle down quickly. However, bladder frequency, urgency, leaking from urgency, and waking up at night to void, may still be bothersome. These are overactive bladder symptoms that may take some time to settle down spontaneously after the TURP. You may be put on bladder-calming oral medications for a short time if bothered. The majority (80%) of these symptoms will settle down in 3 to 6 months.

Follow the post-op instructions from your doctor, especially about resuming any blood thinning medications.

You can do light duties at home in the first 2 to 4 weeks. No driving for the first 2 weeks. No heavy lifting, gardening, or heavy exercises for the first 6 weeks. You can go for walks in the park or go to the shops.

Do not get constipated as straining can cause a secondary bleed in the urine. Take medications for the bowel (e.g., Coloxyl, Metamucil) if needed.

About 1 in 6 people get a secondary bleed in the first few weeks. This occurs when the healing scabs fall off the inner prostate surface and expose the underlying blood vessel. The vast majority of these will settle on their own with you drinking lots of water and passing urine repeatedly. By doing this, you are effectively ‘irrigating’ the bladder like the catheter system. If you have heavy blood clots that block you up and cannot pass urine (clot retention), then go to the emergency department as you may need a new catheter to be placed. It is uncommon that patients must return to the surgical theatre to stop the bleeding.

Check with your doctor when you can go back to work and whether there are any work restrictions in the early period.

Contact your surgeon immediately if you develop a fever or any other signs of infection.

Contact your surgeon if you have any concerns or questions about your recovery.

You should attend your post-op appointment so your doctor can check for any complications.

Risks

In most cases, TURP is a very safe operation with excellent results. However, there are always risks to be discussed with any surgery.

General risks:

• Anaesthetic risks such as heart or lung problems.
• Urine infection – you will be covered with antibiotics during the surgery.
• Bleeding – it is uncommon to need a blood transfusion (2%) for this surgery. Inform us if you have a bleeding disorder or cannot have a blood transfusion (e.g., Jehovah’s Witness).
• Clots in the legs (DVT) or pulmonary emboli.
• Chest infection.
• Allergic reactions (e.g., to dressings, drugs etc.) – inform us if you have any known allergies.
• Risk of death is a very rare complication that may arise from any surgery or anaesthetic. Modern medicine and anaesthesia have made this extremely rare. The risk varies with each individual’s general health conditions and the complexity of the surgery. The TURP surgery is not considered to be a major surgery.

Specific risks:

• ‘Water intoxication’ from the absorption of fluid (TURP syndrome) during the surgery, especially if it is a prolonged and difficult case. This causes a drop in the blood sodium level. It causes sensation of tingling in mild cases, and confusion or coma in severe cases. About one in 200 patients may require treatment for the syndrome. Deaths have been reported but are very rare.
• Stress incontinence due to damage to the urethral sphincter. This is uncommon (1%) and causes leaking with physical exertion such as during coughing, laughing or heavy lifting.
• Retrograde ejaculation (>70%) is common after a TURP and is permanent. During ejaculation, less volume is seen as some of it goes back into the bladder. This is due to the opening of the bladder neck and internal prostatic passage during the TURP to allow easier urination. The neck of the bladder therefore does not shut during ejaculation. It does not cause any pain, does not alter the orgasm sensation, or affect the erectile quality. If you are still trying to have children naturally, this will reduce your chances. Please inform us if this is the case.
• Impotence (2% to 4%) occurs due to potential heat damage to the nerves that are responsible for erections. These nerves go outside the prostate and can uncommonly be affected.
• Regrowth of the prostate may occur as you age. About 10% to 15% of patients may need another TURP within 10 years.

Treatment Alternatives

See benign prostatic enlargement for descriptions of treatment alternatives.