Transurethral Resection of Prostate:

Transurethral resection of the prostate (TURP) is a surgical procedure by which portions of the prostate gland are removed through the urethra.

Purpose

The 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.

A 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.

Transurethral 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 removal.

Demographics

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 each year.

Description

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 the tissue.

The 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 urine.

Diagnosis/Preparation

BPH symptoms include:

• increase in urination frequency, and the need to urinate during the night
• difficulty starting urine flow
• 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 during urination

In evaluating the prostate gland for BPH, the physician usually performs a complete physical examination as well as the following procedures:

• Digital 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 of cancer.
• 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.

To prepare 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 after surgery.
• Schedule a week off from work.
• Get sufficient sleep on the night before surgery.

Aftercare

When 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.

The 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 after TURP:

• 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.
• Bulk-forming 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 movements.
  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 bladder contractions.
• Macrobid. This antibiotic helps prevent urinary tract infections.
• Pyridium. This medication offers symptomatic relief from pain, burning, urgency, frequency, and other urinary tract discomfort.

When discharged from the hospital, patients are advised to:

• Refrain from alcoholic beverages.
• 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 of liquids.

Risks

Serious 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 that process.

This effect is related to many factors, such as overall health and age. Other risks associated with TURP include:

• blood 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 hemorrhage.

Normal results

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.

Normal post-operative symptoms include:

• urination at night and reduced flow
• mild burning and stinging sensation while urinating
• reduced semen at ejaculation
• bladder control problems
• mild bladder spams
• fatigue
• urination linked to bowel movements

To eliminate these symptoms, patients are advised to:

• Exercise.
• Retrain their bladder
• Take all medications that were prescribed after TURP
• Inform themselves via support groups or pertinent reading
• Get plenty of rest to facilitate the post-surgery healing process

Morbidity 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 become impotent.

Alternatives

Conventional surgical alternatives for BPH patients include:

• Interstitial 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 urine flow.
• 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:

• Zinc 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 BPH.
• 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 BPH treatment.
• 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 extract.

Recent developments in BPH treatment options include:

• The Urologix Targis TM System.
  • This 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 incontinence.
• The Dornier MedTech Urowave. This device is another proprietary microwave heating device, similar to the Targis System.
• Transurethral 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 FDA-approved.
• Aromatase. 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.