Transurethral Resection of Prostate:
resection of the prostate (TURP)
is a surgical procedure by which
portions of the prostate gland are
removed through the urethra.
prostate is a gland that is part of the
male reproductive system. It consists of
three lobes, and surrounds the neck of the
bladder and urethra (tube that channels
urine from the bladder to the outside through
the tip of the penis). The prostate weighs
approximately one ounce (28 g), and is walnut-shaped.
It is partly muscular and partly glandular,
with ducts opening into the urethra. It
secretes an antigen called prostate-specific
antigen (PSA), and a slightly alkaline fluid
that forms part of the seminal fluid (semen)
that carries sperm.
common prostate disorder is called benign
prostatic hyperplasia (BPH) or benign prostatic
enlargement (BPE). BPH is due to hormonal
changes in the prostate, and is characterized
by the enlargement or overgrowth of the
gland as a result of an increase in the
number of its constituent cells. BPH can
raise PSA levels two to three times higher
than normal. Men with increased PSA levels
have a higher chance of developing prostate
cancer. BPH usually affects the innermost
part of the prostate first, and enlargement
frequently results in a gradual squeezing
of the urethra at the point where it runs
through the prostate. The squeezing sometimes
causes urinary problems, such as difficulty
urinating. BPH may progress to the point
of generating a dense capsule that blocks
the flow of urine from the bladder, resulting
in the inability to completely empty the
bladder. Eventually, this could lead to
bladder and kidney malfunction.
resection of the prostate (TURP) is the
treatment of choice for BPH, and the most
common surgery performed for the condition.
"Transurethral" refers to the
procedure being performed through the urethra.
"Resection " refers to surgical
Prostate disease usually occurs in men over
age 40. BPH eventually develops in approximately
80% of all men. Prostate cancer occurs in
one out of 10 men. In the United States,
more than 30,000 men die of prostate cancer
TURP is a type of transurethral surgery
that does not involve an external incision.
The surgeon reaches the prostate by inserting
an instrument through the urethra. In addition
to TURP, two other types of transurethral
surgery are commonly performed, transurethral
incision of the prostate (TUIP), and transurethral
laser incision of the prostate (TULIP).
The TUIP procedure widens the urethra by
making small cuts in the bladder neck (where
the urethra and bladder meet), and in the
prostate gland itself. In TULIP, a laser
beam directed through the urethra melts
actual TURP procedure is simple. It is performed
under general or local anesthesia. After
an IV is inserted, the surgeon first examines
the patient with a cystoscope, an instrument
that allows him or her to see inside the
bladder. The surgeon then inserts a device
up the urethra via the penis opening, and
removes the excess capsule material that
has been restricting the flow of urine.
The density of the normal prostate differs
from that of the restricting capsule, making
it relatively easy for the surgeon to tell
exactly how much to remove. After excising
the capsule material, the surgeon inserts
a catheter into the bladder through the
urethra for the subsequent withdrawal of
BPH symptoms include:
- increase in urination
frequency, and the need to urinate during
- difficulty starting
- a slow, interrupted
flow and dribbling after urinating
- sudden, strong
urges to pass urine
- a sensation that
the bladder is not completely empty
- pain or burning
In evaluating the prostate gland for BPH,
the physician usually performs a complete
physical examination as well as the following
rectal examination (DRE). Recommended
annually for men over the age of 50,
the DRE is an examination performed
by a physician who feels the prostate
through the wall of the rectum. Hard
or lumpy areas may indicate the presence
Prostate-specific antigen (PSA) test.
Also recommended annually for men over
the age of 50, the PSA test measures
the levels of prostate-specific antigen
secreted by the prostate. It is normal
to observe small quantities of PSA in
the blood. PSA levels vary with age,
and tend to increase gradually in men
over age 60. They also tend to rise
as a result of infection (prostatitis),
BPH, or cancer.
the results of the DRE and PSA tests are
indicative of a significant prostate disorder,
the examining physician usually refers the
patient to a urologist, a physician who
specializes in diseases of the urinary tract
and male reproductive system. The urologist
performs additional tests, including blood
and urine studies, to establish a diagnosis
for TURP, patients should:
- Select an experienced
TURP surgeon to perform the procedure.
- Purchase a mild
natural bulk-forming laxative.
- Wear loose clothing
on the morning of surgery.
- Ask friends or
family to be available for assistance
- Schedule a week
off from work.
- Get sufficient
sleep on the night before surgery.
the patient awakens in the recovery room
after the procedure, he already has a catheter
in his penis, and is receiving pain medication
via the IV line inserted prior to surgery.
initial recovery period lasts approximately
one week, and includes some pain and discomfort
from the urinary catheter. Spastic convulsions
of the bladder and prostate are expected
as they respond to the surgical changes.
The following medications are commonly prescribed
- B&O suppository
(Belladonna and Opium). This medication
has the dual purpose of providing pain
relief and reducing the ureteral and bladder
spasms that follow TURP surgery. It is
a strong medication that must be used
only as prescribed.
laxative. Because of the surgical trauma
and large quantities of liquids that patients
are required to drink, they may need some
form of laxative to promote normal bowel
Detrol. This pain reliever is not as strong
as B&O. There may be wide variations
in its effectiveness and the patient's
response. It also controls involuntary
- Macrobid. This
antibiotic helps prevent urinary tract
- Pyridium. This
medication offers symptomatic relief from
pain, burning, urgency, frequency, and
other urinary tract discomfort.
discharged from the hospital, patients are
- Refrain from alcoholic
- Avoid sexual
activities for a few weeks.
- Avoid driving
a car for a week or more.
- Keep domestic
activities to a minimum.
- Avoid weight
lifting or strenuous exercise.
- Check their temperature
and report any fever to the physician.
- Practice good
hygiene, especially of the hands and penis.
- Drink plenty
complications are less common for prostate
surgery patients because of advances in
operative methods. Nerve-sparing surgical
procedures help prevent permanent injury
to the nerves that control erection, as
well as injury to the opening of the bladder.
However, there are risks associated with
prostate surgery. The first is the possible
development of incontinence, the inability
to control urination, which may result in
urine leakage or dribbling, especially just
after surgery. Normal control usually returns
within several weeks or months after surgery,
but some patients have become permanently
incontinent. There is also a risk of impotence,
the inability to achieve penile erection.
For a month or so after surgery, most men
are not able to become erect. Eventually,
approximately 40–60% of men will be able
to have an erection sufficient for sexual
intercourse. They no longer ejaculate semen
because removal of the prostate gland prevents
effect is related to many factors, such
as overall health and age. Other risks associated
with TURP include:
loss requiring transfusion
postoperative urinary tract infection
unsatisfactory long-term outcome
TURP syndrome effects 2–6% of TURP patients.
Symptoms may include temporary blindness
due to irrigation fluid entering the
bloodstream. On very rare occasions,
this can lead to seizures, coma, and
even death. The syndrome may also include
toxic shock due to bacteria entering
the bloodstream, as well as internal
TURP patients usually notice urine flow
improvement as soon as the catheter is removed.
Other improvements depend on the condition
of the patient's prostate before TURP, his
age, and overall health status. Patients
are told to expect the persistance of some
pre-surgery symptoms. In fact, some new
symptoms may appear following TURP, such
as occasional blood and tissue in the urine,
bladder spasms, pain when urinating, and
difficulty judging when to urinate. TURP
represents a major adaptation for the body,
and healing requires some time. Full recovery
may take up to one year. Patients are almost
always satisfied with their TURP outcome,
and the adaptation to new symptoms is offset
by the disappearance of previous problems.
For example, most patients no longer have
to take daily prostate medication, and quickly
learn to gradually increase the time between
urinating while enjoying uninterrupted and
more restful sleep at night.
post-operative symptoms include:
at night and reduced flow
mild burning and stinging sensation while
reduced semen at ejaculation
bladder control problems
mild bladder spams
urination linked to bowel movements
To eliminate these symptoms, patients
are advised to:
Retrain their bladder
Take all medications that were prescribed
Inform themselves via support groups or
Get plenty of rest to facilitate the post-surgery
and mortality rates
TURP reduces symptoms in 88% of BPH patients.
TURP mortality rates are 0.2%, but they
can be as high as 10% in patients over 80
years of age. Following surgery, inadequate
relief of BPH symptoms occurs in 20–25%
of patients, and 15–20% require another
operation within 10 years. Urinary incontinence
affects 2–4%, and 5–10% of TURP patients
Conventional surgical alternatives for BPH
laser coagulation. In this procedure,
a laser beam inserted in the urethra
via a catheter heats and destroys the
extra prostate capsule tissue.
Transurethral needle ablation (TUNA).
This technique was approved by the FDA
in 1996. It uses radio waves to heat
and destroy the enlarged prostate through
needles positioned in the gland. It
is generally less effective than TURP
for reducing symptoms and increasing
Transurethral electrovaporization. This
procedure is a modified version of TURP,
and uses a device that produces electronic
waves to vaporize the enlarged prostate.
Photoselective vaporization of the prostate
(PVP). This procedure uses a strong
laser beam to vaporize the tissue in
a 20–50 minute outpatient operation.
Transurethral incision of the prostate
(TUIP). In this procedure, a small incision
is made in the bladder, followed by
a few cuts into the sphincter muscle
to release some of the tension.
Transurethral microwave thermotherapy
(TUMT). TUMT uses microwave heat energy
to shrink the enlarged prostate through
a probe inserted into the penis to the
level of the prostate. This outpatient
procedure takes about one hour. The
patient can go home the same day, and
is able to resume normal activities
within a day or two. TUMT does not lead
to immediate improvement, and it usually
takes up to four weeks for urinary problems
to completely resolve.
Water-induced thermotherapy (WIT). WIT
is administered via a closed-loop catheter
system, through which heated water is
maintained at a constant temperature.
WIT is usually performed using only
a local anesthetic gel to anesthetize
the penis, and is very well tolerated.
The procedure is FDA approved.
Balloon dilation. In this procedure,
a balloon is inserted in the urethra
up to where the restriction occurs.
At that point, the balloon expands to
push out the prostate tissue and widen
the urinary path. Improvements with
this technique may only last a few years.
BPH patients have experienced improved prostate
health from the following:
supplements. This mineral plays an important
role in prostate health because it decreases
prolactin secretion and protects against
heavy metals such as cadmium. Both prolactin
and cadmium have been associated with
Saw palmetto. Saw palmetto has long
been used by Native Americans to treat
urinary tract disturbances without causing
impotence. It shows no significant side
effects. A number of recent European
clinical studies have also shown that
fat soluble extracts of the berry help
increase urinary flow and relieve other
urinary problems resulting from BPH.
Garlic. Garlic is believed to contribute
to overall body and prostate health.
Pumpkin seed oil. This oil contains
high levels of zinc and has been shown
to help most prostate disorders. Eating
raw pumpkin seeds each day has long
been a folk remedy for urinary problems,
but German health authorities have recently
recognized pumpkin seeds as a legitimate
Pygeum bark. The bark of the Pygeum
africanus tree has been used in Europe
since early times in the treatment of
urinary problems. In France, 81% of
BPH prescriptions are for Pygeum bark
Recent developments in BPH treatment
Urologix Targis TM System.
is a microwave device that uses
the same heating method as TUMT.
The procedure takes about an hour,
and requires no anesthesia. The
urologist inserts a flexible tube
into the penis. This tube contains
a unique microwave antenna that
is able to generate very localized
hot spots while cooling the surrounding
areas. Diseased prostate tissue
is destroyed with very little discomfort
and a short recovery time. To date,
men who have had this procedure
have yet to develop impotence or
Dornier MedTech Urowave. This
device is another proprietary microwave
heating device, similar to the Targis
alcohol treatment. This recent
development is very promising for the
treatment of BPH. The procedure involves
injecting ethyl alcohol into the lateral
and middle lobes of the prostate. The
alcohol kills prostate tissue, which
the body then absorbs. Early results
are encouraging, and show that all patients
(who were originally scheduled for TURP)
were able to urinate freely after 24
hours. More studies are required to
assess long-term outcomes.
Prostatic stents. Stents are wire devices
shaped like small springs or coils.
They are placed within the prostate
channel to maintain its patency (keep
it open). These devices are currently
under investigation and are not yet
This inhibitor drug suppresses excess
levels of estrogen in the blood. In
many men, estrogen is the primary growth-stimulating
agent that causes prostatic overgrowth.
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