Transurethral Resection of Prostate (TURP)

Lower urinary tract is comprised of a pump (the bladder, which also acts as a reservoir) and a pipe (the urethra, which in males is surrounded by the prostate). There is a separate control valve below the prostate called the external urethral sphincter. The pump ‘turns on’ (contracts) when a patient decides to urinate) and the valve (external sphincter and prostate) open. This is called the voiding reflex.

Bladder outlet obstruction is usually caused by benign prostate hyperplasia (BPH). In BPH, the prostate enlarges and/or fails to relax completely and chokes off the pipe. An enlarged prostate is common but not a pre-requisite to this problem. Normal prostate size is 15-20 grams (or cubic centimeters - cc’s). The size can increase and may reach several hundred cc’s. However, an enlarged prostate is considered anything over about 30 grams and a very large prostate would be over 80 grams or so.

Some of the consequences of bladder outlet obstruction are obvious but some are not. The following symptoms may indicate a problem with the prostate but there may be other causes for similar symptoms (e.g. urethral strictures, medications, and neurological conditions).

Problems arise when the prostate chokes off urethra. Urinary symptoms are the most common problem caused by BPH:

• Difficulty initiating urination (hesitancy).

• Slow/weak stream.

• Straining to urinate.

• Urinary stream stops and starts (intermittency).

• Difficulty emptying the bladder or incomplete emptying.

• Urine keeps dribbling after completion (post-void dribble).

• Needing to return to the washroom soon after you have urinated (double or triple voiding).

• Frequent urination (day and/or night).

• Leakage of urine (urinary incontinence).

• Inability to postpone urination (urinary urgency).

Urinary retention: This is an inability to empty the bladder. It may be partial or complete and acute or chronic. When the bladder cannot be emptied it may back up to the kidneys and causes life-threatening complications such as kidney failure. Continuous leakage (incontinence day and night) may result from ‘overflow urinary incontinence’. The bladder is so full and unable to empty that it simply leaks out through the bladder - urine often backs up to the kidney which may cause kidney failure.

Urinary frequency: The 2 causes for urinary frequency are overactive bladder and urinary retention. If the bladder does not completely empty the ‘functional capacity’ is reduced. The kidneys continue to fill the bladder with urine but the amount of urine that the bladder can accept before it reaches capacity is limited because it was unable to empty completely. While patients may feel they have a small bladder, in reality the bladder capacity is normal but cannot be completely emptied the functional capacity is reduced. This may feel like a small bladder, but the bladder is normal size but that capacity is inaccessible.

Urinary Urgency and Incontinence: The bladder may respond to obstruction by becoming spastic and making it difficult to postpone urination (urinary urgency). Some men may experience a severe urge to urinate and start to leak before reaching the toilet. This sort of overactive bladder type symptom is typically in response to long standing obstruction. See the Special Circumstances section below.

Bladder remodeling: Bladders are dynamic and can ‘remodel’ in response to the increased work load caused by obstruction. The ability of the bladder to adjust to obstruction does have limits and sometimes decompensation of the bladder will occur resulting in renal failure.

Bladder remodeling comes in 2 primary forms:

1. Detrusor hypertrophy: thickening of the muscle. The bladder develops an increased sensitivity to filling and in the most severe cases replacement of muscle with non-contractile scar tissue.

2. Detrusor fibrosis: scarring in the bladder wall. This may result in a hypocontractile/atonic bladder). Detrusor fibrosis is an irreversible condition. Patients must decide to either live with a urethral catheter for the rest of their lives or emptying the bladder several times a day by inserting a tube into the penis (self-catheterization).

It is very important to note that the lower urinary tract may not tell its owner (the patient) that it is having problems. While most men present with urinary symptoms, sometimes the effects of BPH may be insidious and barely noticeable because they develop slowly or do not produce symptoms until the condition is far advanced. Just like a man may feel fine until the moment they have a heart attack, a man with severe BPH may not recognize that a serious problem is happening until a severe complication has occurred. These include following:

1. Kidney failure: Urine may back up to the kidneys and the back pressure may cause failure. May not cause any symptoms until over 80-90% of kidney function is lost. Metabolic abnormalities can be life-threatening and may be irreversible.

2. Loss of bladder function and strength: As described in the previous section, the bladder may remodel with chronic obstruction. These changes may go unrecognized (and can be difficult to quantify with testing). One presentation is the atonic or hypocontractile bladder that has burnt out. The bladder looses its ability to contract and expel the urine. Basically the pump is broken. Patients may require life long use of a catheter and drainage bag or do life-long clean intermittent self-catheterization inserting a catheter in the bladder several times a day. There is no medication or surgery that can restore strength to the bladder.

3. Overactive bladder: The bladder may respond to obstruction by becoming spastic and overly sensitive to filling. Urinary frequency and urgency may result. The longer that obstruction is present, the less likely it is that these symptoms will improve even with surgery.

4. Urinary tract infections.: Inability to empty the bladder will predispose to infections of the urinary tract. Infections may involve the bladder, prostate or kidneys. In the most severe cases life-threatening urosepsis or septic shock can occur when bacteria enter the blood stream.

By the time that surgery is being discussed, you will have received a full assessment of your symptoms (exam, lab tests and likely a cystoscopy or ultrasound).

There are 2 general categories of patients who form a good fit for TURP (or surgical relief of obstruction).

1. To address urinary SYMPTOMS unresponsive to medication or patient preference avoid life-long medications necessary to control those symptoms. Bothersome symptoms are the most common reason why men choose surgery.

2. A serious COMPLICATION of BPH, some of which may have no associated symptoms until well advanced. In these cases, anything short of surgery is unlikely to address the problem adequately and for this reason, surgery is sometimes described as ‘absolutely indicated’. These complications include the following:

   1. Urinary retention or incomplete emptying that are most likely related to bladder outlet obstruction and NOT the result of a reversible condition (e.g. constipation, medication, recent surgery).

   2. Renal failure from bladder outlet obstruction. Often associated with back-up of urine to the kidneys (hydronephrosis). When this happens, one chooses between the prospect of death from kidney failure or surgery. Men who are not candidates for surgery are relegated to long term urethral catheter/bag or to clean intermittent catheterization (CIC). Virtually all men choose surgery.

   3. Recurrent or intractable bleeding from BPH. The process of BPH involves the formation of new blood vessels and these may bleed profusely. For minor bleeding, one might attempt a trial of a 5ARI medication for 3-6 months.

   4. Troublesome bladder stones. Bladder stones in males typically result from incomplete emptying of the bladder. While some choose only to treat the stone, this does not address the primary problem and recurrent stones are likely. Both stone and prostate will usually be treated at the same time but in some cases the stone will be removed first and the prostate treated at a later date.

      There may be technical limitations that preclude this surgical approach. Every urologist will have a ‘maximum size limit’ for what they are comfortable operating on. Most urologists will restrict this approach to prostate sizes less than 80 cc. Speak to your urologist about this - your urologist may offer bipolar TURP for prostate volumes 200-300 cc.

Relief of urinary symptoms is the primary reason men select TURP. In properly selected patients, surgery for BPH provides significant symptom relief. Men often describe a feeling that the urethra ‘no longer feels like it is being strangled’ and typically experience resolution in urinary hesitancy, the need to strain, start and stop urination, and inability to empty. In men who were struggling to empty the bladder completely prior to surgery, urination may be less frequent and they may not need to wake as frequently at night. Men with overflow incontinence may not need to wear diapers. All men who have surgery can stop their BPH medications (e.g. 5-alpha reductase inhibitors or alpha blockers), thereby reducing their medication burden. The majority of well selected men are very satisfied and happy with the results of surgery - after they’ve gotten through the first 3-6 weeks of recovery.

In men who need surgery because of a complication of BPH (renal failure or bleeding), the surgery may be life-saving.

When there is a strong need for surgery, such as when there is a risk of urinary symptoms becoming permanent or the side-effects may become irreversible, it is advisable to proceed sooner rather than later.

Efficacy of bipolar and monopolar TURP are similar though bipolar TURP has a substantially reduced the risk of TURP syndrome. Durability, improvements in flow rates, and other symptoms are similar.

Please review the detailed description of risks in the section below. Risks may be categorized as:

1. Failure to alleviate symptoms. In many cases this is because the injury to the bladder (pump) is irreversible because of delayed surgical intervention including failure of the bladder muscle to contract (atonic bladder) or persistent urinary frequency and urgency (overactive bladder). Studies have shown that patients that delay surgery are twice as likely to be dissatisfied with the surgery than those who have earlier intervention (20% vs. 10%).

2. Immediate surgical complication: bleeding, infection, worse than normal post-operative symptoms, urethral stricture.

3. Temporary post-operative symptoms. Urinary urgency, frequency (often severe every 15-30 minutes), burning during and at the end of urination, and debris are common during the initial healing phase. These are expected to completely resolve over the course of 3-6 weeks.

4. Long-term complications: involuntary loss of urine (incontinence - urgency or stress types), erectile dysfunction, loss of ejaculation, need for revision surgery (regrowth, urethral stricture or bladder neck contracture).

All of the different types of surgical procedures for BPH are meant to unblock and open the urethra. Some have likened it to unclogging a drain, doing a ‘Roto-Rooter’ or using an auger to open the channel. The surgery is a bit more refined than this but the general concept applies.

A resectoscope is placed into the urethra and the landmarks of the ureteral orifices, bladder neck, verumonatnum and external sphincter are identified. With the use of either normal saline (bipolar TURP uses a sterile salt solution) or glycine (monopolar TURP) the obstructing prostate tissue in the central part of the gland is removed. This involves removing the part of the urethra which passes through the prostate (though this does heal). The prostate chips are irrigated free and the bleeding is controlled. A catheter is placed at the completion of the surgery and normal saline is used to irrigate the blood out (continuous bladder irrigation, CBI). Patient is delivered to recovery room and remains there for 1-3 hours until they are safe to transport to the ward.

Total operating time is between 30 and 90 minutes. Typically overnight hospital stay. Patients may be sent home with a catheter with instructions on how to remove the catheter. In select circumstances, your urologist will schedule you to remove the catheter in their office or by the urology specialty nurse in hospital.

There are a multitude of general, medical and surgical option to address BPH. However, surgery in one form or another is largely unavoidable for the most serious complications of BPH (renal failure, urinary retention, bleeding or bladder stones). This is a list of general management options for BPH plus other types of surgery.

1. Lifestyle changes: high vegetable, low fat diet, exercise. These are long term behaviours and only have modest benefit once men are symptomatic and no benefit if a serious complication has occurred

2. Medications: patients may elect to remain on medication rather than proceed with surgery. Alpha blockers, 5 alpha reductase inhibitors, muscarinic receptor antagonists, beta3 blockers, PDE5 inhibitors.

3. Surgical alternatives: transurethral incision of the prostate (small glands only), laser vaporization (PVP, thulium), enucleation (open, HOLEP, ThuVEP), MIS simple prostatectomy, prostatic artery embolization (investigational), Rezum (steam ablation), Prostatic urethral lift (Urolift).

4. Long term Foley catheter or clean intermittent self catheterization. These are generally reserved for men who are not surgical candidates.

There are a very large number of surgical procedures which are too numerous to describe here. Each of the different approaches come with its own inherent strengths and weaknesses. They will differ in efficacy, durability of result, bleeding risk, hospital stay, duration of catheterization, duration of recovery, etc. - but the most important determinants of success are patient selection and the surgeon’s skill and familiarity with whatever surgical approach is being used. No urologist is competent in all the different of BPH surgery - instead they develop expertise in a few different types of prostate surgery.

A TURP is done in the operating room with either overnight stay or day care surgery - the later can be used in healthy men with smaller prostates.

Patients are admitted the day of surgery.

You will be informed of the date of surgery well in advance of the date. You will be advised of the time that you need to come to hospital one business day prior to surgery.

An anesthesiologist will discuss options for pain control during surgery along with risks and benefits of the various approaches. Please direct questions about the anesthetic to them. They will help you decide which anesthetic option is best for you. Whatever type of anesthetic you decide upon you should not experience pain during the surgery. In addition, you can specify how ‘awake’ you would like to be.

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). You are feel free to observe on the operating room screen but please keep conversation to a minimum.

A 'general anesthetic' will put you completely asleep and you will be unconscious during the surgery.

The patient is positioned on their back with legs held in stirrups.

See above

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.

Irrigation. At completion of the procedure, an urethral catheter is placed to allow flushing of blood from the bladder. An irrigation system is used for Continuous Bladder Irrigation (CBI). This flushes out the blood before it has an opportunity to clot and block the catheter. The bleeding will settle and once the outflow is clear, the CBI can be stopped.

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.

If you are discharged home with a catheter you will:

• Receive instruction on how to drain the collection bag.

• Be provided information on either how to remove the catheter on your own or have an appointment scheduled with either your urologist or the urology specialty nurse to remove the catheter for you (either in the office or hospital - we will let you know).

• You may be discharged home with a prescription for antibiotics or pain medication.

We recommend avoiding constipation by modifying your diet and taking laxatives (e.g. Restoralax, metamucil, etc.) as preventative measures.

All surgery is associated with some risk and TURP is no different. These risks can be separated into 2 general categories.

ANESTHETIC RISKS

These are issues that may arise as a result of the specific anesthetic technique or your general health (including your respiratory and cardiac status) and medications (e.g. blood thinners). Anesthesia and, if necessary, internal medicine will assess your risk prior to surgery and inform you of those risks. In some cases, the. risk may be prohibitive and surgery may not be possible. Everything possible to optimize your health will be done prior to surgery and you may require additional testing before we can schedule surgery.

PROCEDURE-SPECIFIC RISKS

• Bleeding. Some bleeding is expected. Blood transfusion may be necessary. The risk is very low at less than 1% - close to 1 in 300. Blood transfusion is far more common when a combination of very large prostate and pre-existing anemia is present.

• Infection. The risk is 5% or less. Men are routinely administered antibiotics prior to surgery. Patients with indwelling catheters will be at increased risk of infection.

• TUR syndrome. This occurs with excessive fluids, especially hypotonic fluids, are absorbed during surgery. May result in disorientation, congestive heart failure, electrolyte imbalance. This risk is very small with the use of bipolar TURP. With monopolar TURP the risk is slightly higher but can be reduced by minimizing pressure of the irrigation, minimizing operative time and good surgical technique to minimize the risk of capsular perforation.

• Perforation. Minor perforations of the capsule are not uncommon and the vast majority will heal uneventfully and not require any deviation from standard post-operative care. Serious perforations may require leaving the catheter in place for a week or two.

• Rare risks (<1%): deep venous thrombosis, septic shock, bladder perforation, death, other. The risk of these sorts of complications is very low. The risk of death within 30 days of surgery, for example, is much less than 1 in 1000. It is exceptionally rare for a patient to need open surgery or a trip to the ICU following TURP.

We currently offer monopolar TURP, bipolar TURP, monopolar and bipolar vaporization of the prostate with rollerball, and transurethral incision of the prostate with thulium laser or monopolar/bipolar electrode. If you have another form of prostate surgery in mind which we do not offer (e.g. Greenlight PVP), please enquire with your family physician for referral elsewhere or inform your urologist as soon as possible. We would be happy to send you for another surgical opinion

TEMPORARY

Patients invariably have a host of bothersome urinary symptoms after surgery. The severity of the symptoms will vary quite a bit between patients and range from minimal to severe. These symptoms include:

• Sudden need to urinate and difficulty postponing urination (urinary urgency). Sometimes accompanied by urinary leakage if one cannot reach the toilet quickly enough.

• Frequent urination; this may occur day and night (nocturia).

• Pain and burning with urination (dysuria).

• Pain at the end of urination (stranguria).

All of these symptoms generally resolve gradually within 3-6 weeks after surgery.

Call if you the symptoms fail to improve or worsen. Patients should not have urinary urgency or frequency on a long term basis. An exception is those patients who have pre-existing overactive bladder (see below).

TEMPORARY IN MOST PATIENTS.

Long-term incontinence is uncommon occurring in approximately 1 in 200 patients.

Patients do not need to purchase diapers for use after surgery.

Incontinence is the involuntary urinary leakage and comes in 2 forms: stress urinary incontinence and urgency urinary incontinence. Some urinary leakage associated with urgency (urgency incontinence) may occur immediately following surgery. Urgency incontinence is usually low volume and should improve rapidly. Stress incontinence is leakage associated with activity will generally settle as well if it is mild but may become permanent. Stress incontinence is leakage that occurs with activity that 'squeezes' the abdomen and bladder - such as coughing, laughing, sneezing or lifting.

Permanent stress incontinence is uncommon - about 1 in 200 men undergoing TURP have this issue.

Kegel exercises can be helpful for minor degrees of urinary incontinence.

Men with very large prostates or underlying neurological issues or frailty are more likely to experience incontinence after surgery.

TEMPORARY

Some blood, clot and debris is normal for up to about 6 weeks after surgery. In many cases, the bleeding will be mostly gone within a couple of weeks. Do not be surprised if you see blood on and off within the first 6 weeks. The urine may be crystal clear one day and have blood the next. The highest risk of bleeding is within the first 1-2 weeks so avoid excessive activity during that time. Walking is fine but avoid heavy lifting and most definitely do not exercise, ride a bike or return to the gym for 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. If you see more bleeding you should (1) rest and reduce activities, (2) drink more fluids (including at night) and (3) urinate frequently all in an attempt to have the bleeding settle and minimize the risk of clot formation. In general, it is the clot that is the biggest issue as this may obstruct the urethra.

If there is NO urine in the drainage bag, you may have clot retention (see below in the ‘Drink Lots’). So long as there is some urine from the catheter it is likely that everything is OK. You may have a sensation of needing to urinate and occasionally a bit of bypassing (urine comes around the catheter) but so long as you are seeing most of the urine come into the bag you should not be concerned.

USUALLY TEMPORARY.

Any difficulty emptying the bladder is uncommon following surgery and when it does occur it tends to be short lived. If you are unable to urinate you should head to the nearest emergency to have the catheter replaced. Most patients can urinate after removing the catheter a few days later.

The exception to this rule are patients who needed a catheter prior to the surgery or were carrying a large post-void residual before the surgery. These patients may have an atonic or hypo contractile bladder (see below). Inability to urinate may not be the result of technical failure of the surgery.

Inability to urinate after surgery may result from 4 causes:

1. Blockage of catheter or urethra by clot. Usually develops suddenly within the first few weeks of surgery.

2. Obstruction by bladder neck contracture or urethral surgery. Usually develops gradually in the first few weeks to months after surgery.

3. Bladder on temporarily ‘vacation’. Temporary loss of bladder function may result from the surgery or medications used from anesthetic. This will pass in days to weeks but you may require a temporary catheter.

4. Atonic or hypocontractile bladder. See Indications for TURP above. This is the most serious reason as loss of the bladders ability to contract may be permanent. Most patients who have atonic or hypo contractile bladders either required a catheter prior to surgery or had pre-existing inability to empty the bladder (elevated post-void residual).

If you are unable to urinate after surgery please head to your nearest Emergency (ideally where you had the surgery) for evaluation.

Ensure you drink copious fluids following surgery, especially in the first week including at night.

Transient inability to urinate with the first few weeks after surgery is typically self-limited. Replacement and removal of the catheter a few days later will usually suffice.

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 (urethral stricture) 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.

PERMANENT

Virtually all men who undergo TURP can expect permanent loss of forward (antegrade) ejaculation. Men still ejaculate but it goes backward into the bladder (retrograde ejaculation). This is not inherently harmful and men can still orgasm. Retrograde ejaculation is commonly seen with all types of BPH surgeries. Loss of ejaculation results in the loss of a man’s ability to conceive with intercourse but does not cause any other harm. Men are still able to climax.

TEMPORARY. RARELY PERMANENT.

Loss of erections is not a common side-effect of TURP but it can occur. The risk of any decrease in erections is thought to be 10% at most with a range of 1-10%. Most studies do not show a significant difference in the prevalence of incontinence in men who have to those who have not had TURP. However, most of these studies were done on men who were older and less likely to be sexually active in the first place. Because the nerves that cause erections travel on the outside of the prostate, all forms of prostate surgery (monopolar and bipolar TURP, Greenlight laser PVP, HOLEP, simple prostatectomy, radical prostatectomy, etc.) have the potential to result in the permanent loss of erections. Men who start with weak erections are more likely to lose erections. Rare studies have shown improvement in erectile function - mainly in men who have severe urinary symptoms prior to surgery or have medication-related erectile dysfunction.

THE LARGE MAJORITY OF PATIENTS DO NOT REQUIRE REPEAT SURGERY

Repeat surgery following TURP occurs at a rate of about 1% per year. This means roughly 1 in 10 patients will have repeat surgery within the first 10 years the initial surgery. The common early reasons are bladder neck contracture or urethral stricture. Late recurrence of symptoms are most commonly from regrowth of prostate tissue.

This is the most single important action following TURP.

Executive summary: Avoidance of clot urinary retention is the key to a smooth post-operative course. Drink lots of fluids, including at night when you wake to void, until the bleeding subsides. Any fluid will do. Be especially diligent in the first week after surgery. Taper fluid intake after 1-2 weeks but drink more and urinate more anytime you see more blood. Do not exceed 5 liters of fluid per day.

A patient’s primary job after surgery is to prevent clot urinary retention. Clot urinary retention is when a blood clot plugs the urethra (or the catheter) so that urine cannot pass a results in urinary retention. Urinary retention is painful as the bladder becomes stretched and in may be life-threatening if not treated quickly as it may lead to kidney failure.

Blood is expected in the urine after surgery and this may continue for up to 6 weeks. In patients who require an anticoagulant, the bleeding may persist for a few months. The amount of blood is usually very small since most of the fluid is urine. The real risk is the formation of clot which can obstruct the catheter or urine. Once one clot obstructs the urethra (or catheter) more clot will form behind the first clot and create more problems.

Bleeding always stops (return trips to the operating room are rarely required) but clot retention always requires intervention and a trip back to the hospital. This may involve irrigating the clot from the bladder, restarting the continuous bladder irrigation or a trip back the operating room.

We may leave a catheter in for several days to facilitate continuous drainage of urine to minimize the risk of clot formation.

Many patients will be sent home with a urinary catheter and drainage bag. These are easy to look after on your own and the nursing staff will show you how to look after them at home.

General catheter advice

• DO shower with the catheter if you want. Everything can get wet.

• DO NOT go into a bath until the catheter is out.

• DO clean the catheter where it exit the bladder. Apply Polysporin or similar where the catheter enters the bladder.

• DO empty the drainge bag before it becomes too full. Empty the bag before coming to the office of hospital for removal.

Removing the catheter.

We will specify if you should (1) remove the catheter on your own, (2) come to the office for removal, or (3) come to the hospital for removal.

Removing ones catheter is very easy is can be done by virtually all patients. Nurses will show you how to remove it. Link to video on catheter removal.

Tips for catheter removal:

• REMOVE ALL OF THE WATER FROM THE RETENTION BALLOON. This is the most critical point. There will be anywhere between 5 and 50 mL in the balloon. If you have a syringe, ensure you withdraw fluid until there is no more fluid with aspiration (you may need to empty the syringe multiple times). Cutting he inflation port is another option - DO NOT cut the drainage port or across the catheter where it exits the penis.

• You may stand or sit on the toilet to remove. Once the balloon is deflated, it should almost fall out with gravity.

• There may be some blood immediately after catheter removal. This should clear quickly.

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

Drink enough water to keep your urine reasonably clear! This the the more important thing that patients must do. As the urine clears over the days and weeks following surgery you may decrease the fluid intake. Adjust your fluid intake based on the appearance of the urine and ensure that you drink more, urinate more frequently and rest if you see more blood in the urine. Most patients should drink 8-10 glasses of water (or other fluid) per day and should drink at night (especially for the first week or so).

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 because straining because of constipation may lead to bleeding.

Get up and about as soon as possible after surgery.

Be reasonable and use your judgement.

Walk as tolerated.

Avoid any heavy physical 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.

Review catheter care instructions. 

Aside from a single dose prior to surgery antibiotics are NOT routinely prescribed after surgery.

Pain management: most patients do not need anything more than acetaminophen (Tylenol). Use prescription pain medication as needed.

Take a stool softener should be taken regularly (obtain over the counter at local pharmacy). Stop taking stool softeners once you are 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.

Regular Medications. 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. Generally 4 weeks after surgery but your doctor may advise you to start sooner.

Blood Thinners. This includes anticoagulants and antiplatelet medications. Most patients may start LOW dose aspirin (ASA) on discharge from hospital.

Anticoagulants (e.g. coumadin, apixaban, rivaroxaban and other NOAC/DOAC medications) should be held following surgery. Your doctor will let you know when it is safe to re-start the medication.

When restarting blood thinners (antiplatelets and anticoagulants), note the following:

• You are likely to see blood in the urine even if your urine was clear beforehand.

• The blood in the urine may last for 2-3 months; patients not on blood thinners will usually have clear urine after a month if not sooner.

• HOLD the blood thinner for 1 week if there is more clot of if you cannot see through the urine - cranberry juice colored urine is fine, tomato soup is not.

• If you need to hold the blood thinner, restart in 1 week. If the bleeding is heavy, contact your surgeon or family doctor.

• If you see more blood or clot, drink more fluid and pee more often to prevent blockage by blood clot.

Patients who undergo surgery of any kind may need acute medical care during their recovery and are subject to temporary risks directly related to the surgery. Please note that the medical conditions that form the reason for such surgery also pose a number of specific risks.

We advice patients who undergo TURP to have readily accessible medical care for about 6 weeks following the procedure. For patients who develop a complication, this time may be longer.

Travel in country: Patients are generally able to travel by car or plane within days of surgery. They should have easy access to a washroom and follow the instructions as listed above. No heavy lifting, drink fluids and urinate frequently.

Travel out of country: The same advice any travel pertains here but it is very important that you have a good understanding of how you might obtain medical assistance while out of the country. Please review your travel insurance policy and we strongly recommend that you understand what disclosures are necessary under that policy. We are unable to ‘clear you for travel’ or determine if you are eligible for travel insurance but are happy to complete any forms that are necessary for the insurance company to assess your application or claim. Fees will apply.

Please note that most travel insurance policies require full disclosure of all pre-existing medical conditions and any recent changes (including but not limited to surgery and medications). Failure to disclose such information may render your policy void.

We recommend you speak with the insurance company and/or consult a lawyer to answer any questions you have.

This applies to men who urinate frequently or have difficulty postponing urination prior to surgery that is not the result of incomplete bladder emptying (elevated post-void residual urine).

Executive Summary: Urinary urgency and frequency may arise from chronic obstruction. Bladder remodeling may cause such symptoms to become ‘baked in’ (permanent) as a result of bladder remodeling despite surgery. In some cases, prolonged post-operative urgency and frequency (similar to that experienced prior to surgery) may persist for months. In severe cases, leakage of urine associated with a strong desire to void may occur (urgency incontinence) or the urine may drip constantly (overflow incontinence).

Long Explanation: Some men have a significant amount of urinary urgency, frequency and getting up at night (nocturia) as part of their BPH symptom complex. Studies estimate 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 because 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 - especially if incomplete emptying is present (residual urine has the effect of reducing the functional capacity 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. Permanent 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 amplitude 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.

3. Optional: urodynamics.

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

This applies to men with weak bladders identified on urodynamic testing and is more likely in those presenting with elevated residual urine after voiding or conditions affecting bladder strength (e.g. diabetes or neurological conditions.

Executive Summary: Loss of muscular strength in the bladder is a consequence of long-term obstruction resulting in remodeling of the bladder with scar. This process is irreversible. If the pump (the bladder) is broken, opening the pipe (urethra) may not fix the problem. Patients may be relegated to a life long catheter and bag or needing to perform life-long clean intermittent catheterization.

Long Explanation: The bladder muscle is called the detrusor muscle. The bladder contracts and pushes the urine through the urethra. If the bladder muscle is chronically obstructed it will initially accommodate and become stronger. However, with prolonged high-grade obstruction the muscle can become replace by scar tissue and it can permanently loose its ability to contract (i.e. loose its strength). Quantifying loss of bladder contractility can be challenging but some evidence may be apparent at the time of cystoscopy. Loss of some contractility is almost always present in men carrying high residual urines - for example, in those men who have a post-void residual (PVR) or over a litre. Loss of bladder strength may result in an inability to void even if the obstruction is relived. Stated another way, blockage of the pipe (the prostatic urethra) may result in permanent damage to the pump (the bladder). In order to empty the bladder not only must the pipe be able to open but the pump must also be functional. 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 straight forward 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 than they are already in.

It can take weeks or months, if ever, for the muscle to start functioning again. During that time you 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 pressure) on bladder function testing.

If you are unable to void we will typically do a cystoscopy to ensure the surgery has been technically successful. In some cases we will also do urodynamic testing.

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

This applies to men who present with a urinary catheter because they were unable to urinate at all or those men found to have incomplete emptying of the bladder based on testing (on physical exam, ultrasound, cystoscopy or urodynamic testing).

Executive Summary: Patients with urinary retention are more likely to have an atonic or hypocontractile bladder (see consequences of this elsewhere).Even if patients are able to urinate after a trial void (removal of the catheter) before doing surgery they are much more likely to go back into urinary retention. If a patient is retaining urine, they are better off doing the surgery earlier rather than waiting for the condition to progress and reducing the success of surgery.

Long Explanation: 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 half 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 and if you expect to be alive for more than 5 years, you should strongly consider having surgery to preserve your bladder!

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

Executive Summary: Prior radiation markedly increases the risk of several complications of TURP including incontinence, dysuria, bleeding and urethral stricture. Men who have bladder outlet obstruction and are planning on radiation are generally much better off having TURP prior to receiving radiation. Patients should allow for 3 months of healing after surgery before proceeding with radiation.

Long Explanation: 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 apparent 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 obstruction. 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 incontinenc : The risk is increased in this setting with roughly 1 in 10 men undergoing 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.

• Stone formation: If the surgical site is delayed in healing, stone may form on the surface. This calcification may cause bleeding, pain and obstruction.

A retourethral fistula is an injury almost exclusively seen in men who require TURP following brachytherapy. This is a devastating complication where the urinary and fecal streams become admixed. The consequences can be life-changing require both urinary and fecal diversions to a ill conduit and colostomy, respectively. Major reconstructive surgery may be required. Men who develop urinary retention after brachytherapy are advised to wait a minimum of 1 year after having the brachytherapy before proceeding with TURP.