Endoscopy | Transurethral Resection of Prostate (TURP)

Description of Procedure

A TransUrethral Resction of the Prostate (TURP) is a minimally invasive surgical procedure designed to relieve outflow obstrution of the bladder from the prostate. The obstruction is usually as a result of benign prostatic hyperplasia - sometimes so severe that men are unable to void at all. TURP is an excellent option for men who have urinary retention or symptoms unresponsive to medication. TURP removes the obstructing prostate tissue (adenoma of the transitional zone) but leaves the capsule behind - it does not remove the entire prostate like a radical prostatectomy. The prostate forms part of the internal urinary sphincter (valve) and as a consequence urinary control becomes dependent on the remaining external urinary sphincter. Leakage of urine (incontinence) after TURP is rare.

 

A TURP is very different than a Radical Prostatectomy which removes the entire prostate and is used for cancer. The risks of urinary and sexual dysfunction after radical prostatectomy are very different than with a TURP.

 

Procedural Details

  • A TURP is done in the operating room with either overnight stay or home same day
  • Anesthesia: Spinal or general anesthetic means that you will not have pain during the surgery. A 'spinal anesthetic' freezes the area from the abdomen down but allows you to remain awake (something can be given to make you drowsy if you like). A 'general anesthetic' will put you completely asleep. An anesthesiologist will discuss which option is best for you.
  • Resection: All the surgery is 'internal' - there are no outwardly visible marks from the surgery. An nstrument called a resectosope is placed through the urethra. Using an electrical resecting loop prostate tissue is removed in pieces small enough to remove through the scope. The eventual result is marked increase in the size of the urinary pipe. The external sphincter is purposefully avoided.
  • Irrigation: At completion of the procedure, an irrigation urethral catheter is placed to allow flushing of blood from the bladder. This prevents the development of clot.

 

Post-Operative In Hospital Details

  • Some patients are able to go home the same day, but many will have an over-night hospital stay - especially elderly men and those with large prostate glands
  • If you have a spinal anesthetic you will need to remain in the recovery room until it wears off - this takes about 3 hours. 
  • Once the urine is clear, the catheter can be removed. Sometimes this is done before the patient is sent home. Other times, the catheter will be removed in the office a few days after the patient has gone home.

 

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After Procedure

If you have questions that are not answered here, please contact us.

 

What to Expect

Please see our section on Catheter Care if you are sent home with a catheter.

 

Temporary changes in urination are expected following surgery and will gradually improve over 3-6 weeks. The irritative symptoms (urgency, frequency) tend to settle quickly in the first few weeks.

 

If your stream is strong, you are not leaking with activity and your symptoms are gradually improving you can rest assured that that things are heading in the right direction.

 

The following is considered NORMAL:

  • Strong stream: your stream should be strong - though may be weak until your bladder can hold more urine. If it tapers off, let us know

  • Burning and urinary urgency: pain or discomfort when passing urine or at the end of urination. This may be intense for the first few days following surgery. Call if you do not see any improvement at all over the first few weeks.

  • Blood in the urine: some blood, clot and debris is normal for up to about 6 weeks after surgery. The bleeding may appear heavy, but the blood loss is usually very small as most of what you are seeing is urine. Bleeding tends to be worse if your are more active. If you see increasing bleeding, reduce activities, drink more fluids and urinate frequently. In general, it is the clot that is the biggest issue as this may obstruct the urethra. 

  • Urinary frequency and urgency: some men have a little, some lots. You may find that you have a need to urinate every 15-30 minutes. The need to urinate may be so strong that you may start urinating before you can reach the toilet ('urgency incontinence'). This should improve. Call if you do not see any improvement at all over the first few weeks. It may take 1-2 months for everything to completely settle. 

  • You may experience occasional leakage of urine associated with urgency for several days. If you leak a few drops of urine when you move, cough or sneeze this generally gets better.

  • Minor fatigue

 

Long Term:

  • RETROGRADE EJACULATION: virtually everyone who has the surgery done properly can expect permanent retrograde ejaculation (this is also mentioned in the booklet). Ejaculate is still present but the surgery allows the ejaculate to go backward into the bladder rather then forward out the urethra. Retrograde ejaculation is commonly seen with every surgical intervention for BPH. If you have maintained antegrade ejaculation, the bladder neck is likely to be too tight.
  • Slow stream: let us know if your stream is not as strong as you think it should be - at the very least it should be no weaker than it was prior to surgery and you should expect it to be much stronger. Slow stream can result from regrowth of bladder tissue, a scar within the urethra or bladder neck. Early slowing of stream in the first 6-12 months is usually from urethral stricture or bladder neck contracture. If your stream slows, splays/sprays and it seems to be restricted at the tip of your penis you likely have a meatal stenosis - we can sort this quickly with an office visit. Cystoscopy may be necessary to diagnose the site of obstruction.
  • Incontinence (loss of urine). Fortunately, permanent stress incontinence is uncommon - about 1 in 200 men undergoing TURP have this issue. Stress incontinence is leakage that occurs with activity that 'squeezes' the abdomen and bladder - such as coughing, laughing, sneezing or lifting. 
    • Another type of incontinence known as urgency incontinence is not uncommon after surgery - an urgent need to void and go to the washroom. This tends to settle within the first few weeks after surgery. If it persists, we check for infection and persistent obstruction. If no underlying cause is identified, the urgency incontinence will typically improve. In some situations it can take many months and bladder relaxants to reduce urinary frequency and urgency will be employed.

 

Special Circumstances

 

There are a few circumstances which warrant special attention so that expectations of outcomes are realistic. These circumstances apply to a small number of men thinking about TURP.


Special Circumstance #1: Pre-Existing "Storage Lower Urinary Tract Symptoms"


Some men have a significant amount of urinary urgency, frequency and getting up at night (nocturia) as part of the BPH symptom complex. Studies extimate that over 50% of men with BPH will have such symptoms. These are called 'storage' type symptoms because they occur when you are NOT wanting to urinate. They are also called 'overactive bladder' (OAB) symptoms.

 

Many of these changes arise becaue changes that have occurred within the bladder muscle in response to obstruction from the prostate (bladder-outlet obstruction induced overactive bladder).If you have OAB symptoms, they can take time to resolve following  (as opposed to slow flow which improves almost immediately). The good news is that many patients will see a marked improvement in these symptoms - espcially if incomplete emptying is present (residual urine has the effect of reducing the functional capapcity of the bladder and fixing this is one thing that TURP does very well). In some cases, however, these changes are permanent - that is, even relief of the obstruction does not result in improvement in the urinary urgency and frequency. Permanant storage LUTS persist in 30-50% of patients despite TURP. Increasing age is a risk factor for persistence of these symptoms after TURP. The more severe the storage symptoms and the longer you have had them, the longer they are likely to take to improve. There is also a weak correlation between findings on urodynamic testing with patients having more bladder spasticity (high amplitue and at lower volumes) being more likely to have persistent symptoms.

 

One important thing to note is that OAB symptoms rarely improve on their own when the obstruction is not relieved - so avoidance of medication or surgery to address the BPH may allow things to deteriorate further. In addition, the risk of precipitating urinary retention is increased when antispasmodics are used in the presence of high-grade obstruction so they must be used with caution. Once the obstruction is relieved, however, antispasmodics can be given with little fear of precipitating an inability to urinate.

 

It bears repeating that in some cases, it may take up to a year to determine the the final verdict of OAB symptoms following TURP. In the interim, we will trouble-shoot the problem and may prescribe some medication while things correct on their own. We generally take a few steps to give you the best possibility of these types of symptoms to improve:


  1. Cystoscopy: check to make sure the outflow tract is wide open. If obstruction persists, the storage urinary symptoms are unlikely to go away (since often they resulted from obstruction in the first place)
  2. Urine culture: to check for infection

 

Reference: Cornue and Grise. Current Opinion in Urology 26 (1) January 2016

 

Special Circumstance #2: Failure of the bladder muscle.

 

The bladder muscle is called the detrusor muscle. It is responsible for contracting to squeeze the urine through the outflow tract. If the muscle is chronically obstructed and there has been scarring within the bladder wall or damage to the nerves it may not function normally. In some cases this is manifest as a failure to empty the bladder even if the outflow tract has been made open by surgery. This sort of scenario is more likely if you have chronic urinary retention with an elevated residual urine, a concomitant neurologic issue or diabetes.

 

Unfortunately, it can be difficult to determine what if any muscular function remains in the bladder muscle. Urodynamic testing is sometimes undertaken but even if the bladder muscle does not show any contractility at that time, there may be some function or even some recovery of function if the obstruction has been relieved. There is no medication or surgery that can strengthen the bladder muscle if the muscle itself has failed. Therefore, in most circumstances TURP will still be undertaken in the hopes that resumption of spontaneous urination will occur once the outflow obstruction has been relieved. The alternative to proceeding with the surgery is to accept self-catheterization or an indwelling catheter for the remainder of your life. If self-catheterization is not done, the kidneys can be placed in jeopardy such that renal failure can occur. For most men, this presents a fairly straighforward choice to give the surgery a try since despite the increased risk of the surgery being ineffective compared to men who do not have failure of the bladder muscle, the surgery and its possible benefits are much more attractive than the alternative. It would be uncommon for a man with a catheter to be left in a worse state following surgery then they are already in.

 

It can take weeks or months for the muscle to start functioning again. During that time he may need to self catheterize. If the residual urine (the amount LEFT in the bladder after you urinate) is decreasing then the bladder function is returning. Those more likely to have failure of therapy tend to be older, present with high residual urines (over 1500 mL) or have no or weak bladder contractions (<28 cmH2O) on bladder function testing.

 

We will always do a cystoscopy to ensure the surgery has been successful in opening the outflow tract if a patient is unable to void after TURP (assuming a satisfactory length of time has elapsed for one or more trials of void).

 

Reference: Negro and Muir British Journal of Urology International 2012; 110: 1590-1594

 

Special Circumstance #3: Incomplete emptying of the bladder prior to surgery.

 

A common indication for surgery is incomplete emptying of the bladder. Sometimes this is complete absence of emptying (urinary retention) or partial retention (an elevated 'post-void residual' urine or PVR). For those men in retention and who have failed a trial of void (TOV), often in conjunction with an alpha-blocker medication, the potential restoration of spontaneous voiding with surgery is rarely declined. For men who are still able to void but are retaining urine, however, the surgery can be thought of as more 'optional'. The question becomes 'what amount of residual urine is acceptable?' and furthermore 'what is to be lost by delaying surgery?' (assuming medical therapy has already been optimized).

 

What amount of residual urine is acceptable? Normal men should be able to empty their bladder completely - that is, to the point where the is virtually nothing remaining in the bladder (less than 50 mL). However, the measurement of a post void urine (PVR) is not as simple as one might expect. PVR measurements are often done under circumstances that can artifactually increase the amount of residual urine. Having an overfull bladder (common with routine ultrasound where the instruction is to drink several glasses of water and hold the urine for an excessively long duration of time) as well as voiding in an unfamiliar environment can contribute to incomplete emptying. Having said that, if a reasonable measurement can be made, higher residual seem to be associated with an increased risk of progressive urinary symptoms leading to surgery. There is no magic number but PVRs in the range of 200-300 are associated with a significantly higher risk of needing surgery. One caveat is that the men who were suffering from renal insufficiency, recurrent infections and other complications already had surgery. 

 

What is lost by delaying surgery? This is a difficult question to answer since it is not just the PVR that determines outcome.  Baseline symptom score, prostate size, age and other factors seem to be important. The bottom line is that an elevated PVR can be observed and carefully monitored but that some patients will have long term irreversible injury to the bladder. This is something to ponder if you expect to be alive for more than a few years - but somewhat reassuring if you are older.

 

in 2003, Bates published a series of men with a PVR >250 mL. Importantly, men with renal failure or other complications were excluded. Over the course of about 5 years, the men were followed. One in 3 ultimately required TURP because of worsening symptoms (about half), frank retention or increasing PVR (about half) or renal failure (a very small number). Just over hal of patients continued without any surgery. It was difficult to predict who might run into a problem.

 

In the 1990, the Veterans Affairs randomized men to TURP or watchful waiting. Of note, none of these men carried a substantial PVR but this study highlights the point that leaving high grade obstruction can result in irreversible damage to the bladder. After 5 years of follow-up, about 1/3 of patients assigned to watchful waiting ultimately had a TURP. Patients who underwent initial TURP were compared to those who required TURP at a later date. It bears emphasizing that 2/3 of patients who did not undergo surgery did perfectly well over the following 5 years. However, those who ultimately required surgery on a delayed basis were more likely to have failure of surgery to alleviate their symptoms (20% vs. 10%), had a lower degree of symptom relief, more likelty to have persistent urinary frequency (12% vs. 6%), less improvement in flow (about 50% that of those who underwent immediate TURP) and less reduction in residual urine (by about 25%). Patients who had more severe symptoms to start were much more at risk of having a worse outcome. The incidence of very severe complications In short, there are some men in who delay in surgery is harmful but others in whom it is not - keep your urologist close!

 

References: 

Flanigan et al. Journal of Urology 1998; 160: 12-17

Bates et al. British Journal of Urology International 2003; 92: 581-583

Mochtar et al. Journal of Urology 2006; 175: 213-216

 

 

Special Circumstance #4: TURP with prior radiation for prostate cancer.

 

All forms of radiation can permanently and irreversible affect the function of the 2 urinary sphincters and the blood supply to the bladder, prostate and pelvic floor. Radiation tends to compromise both the internal and external sphincters. This may not be apparrent initially because the combined function of the 2 sphincters may be enough to prevent incontinence.

 

Some men who have been treated with radiation for prostate cancer develop an inability to urinate because of obstuction. TURP may be the only option to allow a man to urinate without resorting to lifelong intermittent catheterization or living with a catheter and bag for the rest of their life.  Any deficiency in the external sphincter will be unmasked by a TURP. In addition, proper healing of the operative site is dependent on good blood supply and is compromised. Specific issues that arise in men who have had prostate radiation undergoing TURP:

  • Urinary incontinence: The risk is increased in this setting with roughly 1 in 10 men undergoig TURP after radiation developing some degree of incontinence compared with  1 in 200 men who have not had radiation. In most men, then severity of incontinence is minor (a few drops of urine with heavy activity) but in about 1 in 50 it will be severe enough to require permanent use of diapers.
  • Stricture: the risk of stricturing of the urethra through the operative site (resulting in a bladder neck contracture) or urethral stricture 
  • Longer healing time: the reduced blood supply can mean it takes longer for blood and debris to clear.

 

Cautions

Report any of the following to your doctor:

  •  You cannot pass urine.

  •  Fever over 38.5 C.

  •  Severe pain unrelieved by medication and not improving with time

  • Catheter blocked or dislodged.

 

Diet

  •  Advance to usual diet as tolerated. Avoid foods which constipate you.

  • Drink enough water to keep your urine reasonably clear, usually 8-10 glasses of water per day.
  • You can resume your regular diet and fluids as soon as you leave hospital. Feel free to drink coffee, tea, etc. unless you think it is causing you to urinate more frequently or causing pain (it causes no problems in most patients).
  • Be sure you are able to have easy bowel movements, as straining on a constipated stool can risk serious bleeding after TURP.

 

Activity

  •  Get up and about as soon as possible after surgery.

  •  Walk as tolerated.

  •  Avoid any heavy physicial activity or 'exercise' for about 6 weeks after surgery. This will increase the risk of bleeding and risks a return trip to the hospital. Heavy activity and exercise will be different for everyone but in general: 

     

    No lifting anything more than 20-30 lbs

    No bicycle riding

    No going to the gym

     

  •  Avoid pressure on your perineum (the ‘saddle’ area behind the scrotum).
  •  You may start showering the day after surgery, even if you have a catheter. Do not submerge in a tub bath until the catheter is removed.
  •  If a catheter is in place, please review catheter care instructions. 

  • Avoid driving while catheter is in place.


Medications

  • Take antibiotics as prescribed.

  •  Use prescription pain medication as needed.

  •  Take a stool softener (obtain over the counter at local pharmacy) starting the night of your surgery.  Stop taking stool softeners once having soft bowel movements.  Do not take stool softeners if diarrhea occurs.

  •  If you have not had a bowel movement by the 3rd day after your surgery, take a laxative (obtain at your local pharmacy over the counter).

  • You may begin your regular medications when you leave the hospital unless instructed otherwise. If you are on blood thinners, your doctor will tell you when it is safe to resume them.

 

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