Prostatectomy

A prostatectomy is the surgical removal of all or part of the prostate gland.

Abnormalities of the prostate, such as a tumour, or if the gland itself becomes
enlarged for any reason, can restrict the normal flow of urine along the urethra.

There are several forms of the operation:

• Transurethral resection of the prostate

Also called a TURP, this is a cystoscope[A Resectoscope Rather, which has

30 degree of viewing angle, along with Resectoscopy Sheath & Working
Element] is passed up the urethra to the prostate, where the surrounding
prostate tissue is excised. This is a common operation for benign prostatic
hyperplasia (BPH) and outcomes are excellent for a high percentage of these
patients (80-90%). A more refined and safer operation is by means of a
holmium(Nd:YAG) high powered "red" laser. A related laser procedure for
relief of prostatic obstruction utilizes a potassium titanyl phosphate(KTP) laser
to vaporize the adenoma. More recently the KTP laser has been supplanted by
a higher power laser source based on a lithium triborate crystal, though it is
still commonly referred to as a "Greenlight" or KTP procedure. The specific
advantages of utilizing laser energy rather than a traditional electrosurgical
TURP is a decrease in the relative bloodloss, elimination of the risk of TUR-
syndrome, the ability to treat larger glands, as well as treating patients who are
actively being treated with anti-coagulation therapy for unrelated diagnoses.3,4

• Open Prostatectomy

A surgical procedure involving a skin incision and enucleation of the prostatic

adenoma, through the prostatic capsule (RPP-retropubic prostatectomy) or
through the bladder (SPP-suprapubic prostatectomy). Reserved for extremely
large prostates.

• Laparoscopic Radical Prostatectomy

a laparoscopic or four small incisions are made in the abdomen, and the entire
prostate for prostate cancer.

• Robotic-assisted Laparoscopic Radical Prostatectomy see also [3]

• da Vinci (Robot-assisted) Prostatectomy is the #1 choice for treatment of
localized prostate cancer* in the United States:Laparoscopic robotic arms are
controlled by a surgeon. The robot gives the surgeon much more dexterity
than conventional laparoscopy while offering the same advantages over open
prostatectomy: much smaller incisions, less pain, less bleeding, less risk of
infection, faster healing time, and shorter hospital stay.[1]. While the cost of
such procedures is high, costs are declining rapidly [2]. The manufacturer of the
da Vinci Surgical System, used for robotic-assisted prostatectomy, claims that
this is now the number one treatment choice for prostate cancer in the United
States[.[3]]
 • Radical perineal prostatectomy

an incision is made in the perineum, midway between rectum and scrotum,

and the prostate is removed. Radical prostatectomy is one of the key
treatments for prostate cancer.

• Radical retropubic prostatectomy

an incision is made in the lower abdomen, and the prostate removed, by going
behind the pubic bone (retropubic). Radical prostatectomy is one of the key
treatments for prostate cancer.

• Transurethral plasmakinetic vaporization prostatectomy

This is also called a TUPVP.

prostatectomy

Medical Encyclopedia: Prostatectomy

Home > Library > Health > Medical Encyclopedia

More about
Prostatectomy:
Purpose
Precautions
Preparation
Aftercare
Risks
Normal results
Resources

Definition

Prostatectomy is surgical removal of part of the prostate gland (transurethral

resection, a procedure performed to relieve urinary symptoms caused by benign
enlargement), or all of the prostate (radical prostatectomy, the curative surgery most
often used to treat prostate cancer).

Description

TURP

This procedure does not require an abdominal incision. With the patient under either
general or spinal anesthesia, a cutting instrument or heated wire loop is inserted to
remove as much prostate tissue as possible and seal blood vessels. The excised tissue
is washed into the bladder, then flushed out at the end of the operation. A catheter is
left in the bladder for one to five days to drain urine and blood. Advanced laser
technology enables surgeons to safely and effectively burn off excess prostate tissue
blocking the bladder opening with fewer of the early and late complications
associated with other forms of prostate surgery. This procedure can be performed on
an outpatient basis, but urinary symptoms do not improve until swelling subsides
several weeks after surgery.

Radical prostatectomy

RADICAL RETROPUBIC PROSTATECTOMY. This is a useful approach if the

prostate is very large, or cancer is suspected. With the patient under general or spinal
anesthesia or an epidural, a horizontal incision is made in the center of the lower
abdomen. Some surgeons begin the operation by removing pelvic lymph nodes to
determine whether cancer has invaded them, but recent findings suggest there is no
need to sample them in patients whose likelihood of lymph node metastases is less
than 18%. A doctor who removes the lymph nodes for examination will not continue
the operation if they contain cancer cells, because the surgery will not cure the patient.
Other surgeons remove the prostate gland before examining the lymph nodes. A tube
(catheter) inserted into the penis to drain fluid from the body is left in place for 14–21
days.

Originally, this operation also removed a thin rim of bladder tissue in the area of the
urethral sphincter—a muscular structure that keeps urine from escaping from the
bladder. In addition, the nerves supplying the penis often were damaged, and many
men found themselves impotent (unable to achieve erections) after prostatectomy. A
newer surgical method called potency-sparing radical prostatectomy preserves sexual
potency in 75% of patients and fewer than 5% become incontinent following this
procedure.

RADICAL PERINEAL PROSTATECTOMY. This procedure is just as curative as

radical retropubic prostatectomy but is performed less often because it does not allow
the surgeon to spare the nerves associated with erection or, because the incision is
made above the rectum and below the scrotum, to remove lymph nodes. Radical
perineal prostatectomy is sometimes used when the cancer is limited to the prostate
and there is no need to spare nerves or when the patient's health might be
compromised by the longer procedure. The perineal operation is less invasive than
retropubic prostatectomy. Some parts of the prostate can be seen better, and blood
loss is limited. The absence of an abdominal incision allows patients to recover more
rapidly. Many urologic surgeons have not been trained to perform this procedure.
Radical prostatectomy procedures last one to four hours, with radical perineal
prostatectomy taking less time than radical retropubic prostatectomy. The patient
remains in the hospital three to five days following surgery and can return to work in
three to five weeks. Ongoing research indicates that laparoscopic radical
prostatectomy may be as effective as open surgery in treatment of early-stage disease.

Cryosurgery

Also called cryotherapy or cryoablation, this minimally invasive procedure uses very
low temperatures to freeze and destroy cancer cells in and around the prostate gland.
A catheter circulates warm fluid through the urethra to protect it from the cold. When
used in connection with ultrasound imaging, cryosurgery permits very precise tissue
destruction. Traditionally used only in patients whose cancer had not responded to
radiation, but now approved by Medicare as a primary treatment for prostate cancer,
cryosurgery can safely be performed on older men, on patients who are not in good
enough general health to undergo radical prostatectomy, or to treat recurrent disease.
Recent studies have shown that total cryosurgery, which destroys the prostate, is at
least as effective as radical prostatectomy without the trauma of major surgery.

— David A. Cramer

Definition

Prostatectomy is surgical removal of part of the prostate gland (transurethral

resection, a procedure performed to relieve urinary symptoms caused by benign
enlargement), or all of the prostate (radical prostatectomy, the curative surgery most
often used to treat prostate cancer).

Purpose

Benign Disease

When men reach their mid-40s, the prostate gland begins to enlarge. This condition,
benign prostatic hyperplasia (BPH) is present in more than half of men in their 60s
and as many as 90% of those over 90. Because the prostate surrounds the urethra, the
tube leading urine from the bladder out of the body, the enlarging prostate narrows
this passage and makes urination difficult. The bladder does not empty completely
each time a man urinates, and, as a result, he must urinate with greater frequency,
night and day. In time, the bladder can overfill, and urine escapes from the urethra,
resulting in incontinence. An operation called transurethral resection of the prostate
(TURP) relieves symptoms of BPH by removing the prostate tissue that is blocking
the urethra. No incision is needed. Instead a tube (retroscope) is passed through the
penis to the level of the prostate, and tissue is either removed or destroyed, so that
urine can freely pass from the body.

Malignant Disease

Prostate cancer is the single most common form of non-skin cancer in the United
States and the most common cancer in men over 50. Half of men over 70 and almost
all men over the age of 90 have prostate cancer, and the American Cancer Society
estimates that 198,000 new cases will be diagnosed in a given year. This condition
does not always require surgery. In fact, many elderly men adopt a policy of
"watchful waiting," especially if their cancer is growing slowly. Younger men often
elect to have their prostate gland totally removed along with the cancer it contains—
an operation called radical prostatectomy. The two main types of this surgery, radical
retropubic prostatectomy and radical perineal prostatectomy, are performed only on
patients whose cancer is limited to the prostate. If cancer has broken out of the
capsule surrounding the prostate gland and spread in the area or to distant sites,
removing the prostate will not prevent the remaining cancer from growing and
spreading throughout the body.

Precautions
Potential complications of TURP include bleeding, infection, and reactions to general
or regional anesthesia. About one man in five will need to have the operation again
within 10 years.

Open (incisional) prostatectomy for cancer should not be done if the cancer has
spread beyond the prostate, as serious side effects may occur without the benefit of
removing all the cancer. If the bladder is retaining urine, it is necessary to insert a
catheter before starting surgery. Patients should be in the best possible general
condition before radical prostatectomy. Before surgery, the bladder is inspected using
an instrument called a cystoscope to help determine the best surgical technique to use,
and to rule out other local problems.

Description

Turp

This procedure does not require an abdominal incision. With the patient under either
general or spinal anesthesia, a cutting instrument or heated wire loop is inserted to
remove as much prostate tissue as possible and seal blood vessels. The excised tissue
is washed into the bladder, then flushed out at the end of the operation. A catheter is
left in the bladder for one to five days to drain urine and blood. Advanced laser
technology enables surgeons to safely and effectively burn off excess prostate tissue
blocking the bladder opening with fewer of the early and late complications
associated with other forms of prostate surgery. This procedure can be performed on
an outpatient basis, but urinary symptoms do not improve until swelling subsides
several weeks after surgery.

Radical Prostatectomy

Radical Retropubic Prostatectomy

This is a useful approach if the prostate is very large, or cancer is suspected. With the
patient under general or spinal anesthesia or an epidural, a horizontal incision is made
in the center of the lower abdomen. Some surgeons begin the operation by removing
pelvic lymph nodes to determine whether cancer has invaded them, but recent
findings suggest there is no need to sample them in patients whose likelihood of
lymph node metastases is less than 18%. A doctor who removes the lymph nodes for
examination will not continue the operation if they contain cancer cells, because the
surgery will not cure the patient. Other surgeons remove the prostate gland before
examining the lymph nodes. A tube (catheter) inserted into the penis to drain fluid
from the body is left in place for 14–21 days.

Originally, this operation also removed a thin rim of bladder tissue in the area of the
urethral sphincter—a muscular structure that keeps urine from escaping from the
bladder. In addition, the nerves supplying the penis often were damaged, and many
men found themselves impotent (unable to achieve erections) after prostatectomy. A
newer surgical method called potency-sparing radical prostatectomy preserves sexual
potency in 75% of patients and fewer than 5% become incontinent following this
procedure.

Radical Perineal Prostatectomy

This procedure is just as curative as radical retropubic prostatectomy but is performed
less often because it does not allow the surgeon to spare the nerves associated with
erection or, because the incision is made above the rectum and below the scrotum, to
remove lymph nodes. Radical perineal prostatectomy is sometimes used when the
cancer is limited to the prostate and there is no need to spare nerves or when the
patient's health might be compromised by the longer procedure. The perineal
operation is less invasive than retropubic prostatectomy. Some parts of the prostate
can be seen better, and blood loss is limited. The absence of an abdominal incision
allows patients to recover more rapidly. Many urologic surgeons have not been
trained to perform this procedure. Radical prostatectomy procedures last one to four
hours, with radical perineal prostatectomy taking less time than radical retropubic
prostatectomy. The patient remains in the hospital three to five days following surgery
and can return to work in three to five weeks. Ongoing research indicates that
laparoscopic radical prostatectomy may be as effective as open surgery in treatment of
early-stage disease.

Cryosurgery

Also called cryotherapy or cryoablation, this minimally invasive procedure uses very
low temperatures to freeze and destroy cancer cells in and around the prostate gland.
A catheter circulates warm fluid through the urethra to protect it from the cold. When
used in connection with ultrasound imaging, cryosurgery permits very precise tissue
destruction. Traditionally used only in patients whose cancer had not responded to
radiation, but now approved by Medicare as a primary treatment for prostate cancer,
cryosurgery can safely be performed on older men, on patients who are not in good
enough general health to undergo radical prostatectomy, or to treat recurrent disease.
Recent studies have shown that total cryosurgery, which destroys the prostate, is at
least as effective as radical prostatectomy without the trauma of major surgery.

Preparation

As with any type of major surgery done under general anesthesia, the patient should
be in optimal condition. Most patients having prostatectomy are in the age range when
cardiovascular problems are frequent, making it especially important to be sure that
the heart is beating strongly, and that the patient is not retaining too much fluid.
Because long-standing prostate disease may cause kidney problems from urine
"backing up," it also is necessary to be sure that the kidneys are working properly. If
not, a period of catheter drainage may be necessary before doing the surgery.

Aftercare

Following TURP, a catheter is placed in the bladder to drain urine and remains in
place for two to three days. A solution is used to irrigate the bladder and urethra until
the urine is clear of blood, usually within 48 hours after surgery. Whether antibiotics
should be routinely given remains an open question. Catheter drainage also is used
after open prostatectomy. The bladder is irrigated only if blood clots block the flow of
urine through the catheter. Patients are given intravenous fluids for the first 24 hours,
to ensure good urine flow. Patients resting in bed for long periods are prone to blood
clots in their legs (which can pass to the lungs and cause serious breathing problems).
This can be prevented by elastic stockings and by periodically exercising the patient's
legs. The patient remains in the hospital one to two days following surgery and can
return to work in one to two weeks.

Risks

The complications and side effects that may occur during and after prostatectomy
include:

• Excessive bleeding, which in rare cases may require blood transfusion.

• Incontinence when, during retropubic prostatectomy, the muscular valve
(sphincter) that keeps urine in the bladder is damaged. Less common today,
when care is taken not to injure the sphincter.
• Impotence, occurring when nerves to the penis are injured during the
retropubic operation. Today's "nerve-sparing" technique has drastically cut
down on this problem.
• Some patients who receive a large volume of irrigating fluid after TURP
develop high blood pressure, vomiting, trouble with their vision, and mental
confusion. This condition is caused by a low salt level in the blood, and is
reversed by giving salt solution.
• A permanent narrowing of the urethra called a stricture occasionally develops
when the urethra is damaged during TURP.

• There is about a 34% chance that the cancer will recur within 10 years of the
procedure. In addition, about 25% of patients experience what is known as
biochemical recurrence, which means that the level of prostate-specific
antigen (PSA) in the patient's blood serum begins to rise rapidly. Recurrence
of the tumor or biochemical recurrence can be treated with radiation therapy or
androgen deprivation therapy.

Normal Results

In patients with BPH who have the TURP operation, urination should become much
easier and less frequent, and dribbling or incontinence should cease. In patients
having radical prostatectomy for cancer, a successful operation will remove the tumor
and prevent its spread to other areas of the body (metastasis). If examination of lymph
nodes shows that cancer already had spread beyond the prostate at the time of surgery,
other measures are available to control the tumor.

Technology

Responding to spoken instructions, a specially engineered robot has assisted in more

than 500 operations to remove the prostate glands of cancer patients. Used by
surgeons in the United States and Europe, the AESOP system is the first surgical
robot approved by the Food and Drug Administration (FDA). By positioning a slender
optical tube (endoscope) that is passed through the patient's body, the robotic arm
allows the surgeon to view the minimally invasive surgery on a video monitor and use
both hands to improve surgical precision and results while minimizing side effects.
Patients spend about 12 hours in the hospital and return to work within two days.

Research
Early findings released by the Prostate Cancer Outcomes Study (PCOS) confirm that
radical prostatectomy results in significant sexual dysfunction and some loss of
urinary control. Initiated by the National Cancer Institute (NCI) in 1994, PCOS is the
first systematic evaluation of how primary cancer treatments affect patients' quality of
life.

Resources

Books

Beers, Mark H., MD, and Robert Berkow, MD, editors. "Prostate Cancer." Section 17,
Chapter 233 In The Merck Manual of Diagnosis and Therapy. Whitehouse Station,
NJ: Merck Research Laboratories, 2002.

Marks, Sheldon. Prostate Vancer: A Family Guide to Diagnosis, Treatment and

Survival. Cambridge, MA: Fisher Books, 2000.

Wainrib, Barbara, et al. Men, Women, and Prostate Cancer: A Medical and
Psychological Guide for Women and the Men they Love. Oakland, CA: New
Harbinger Publications, 2000.

Periodicals

Augustin, H., and P. G. Hammerer. "Disease Recurrence After Radical Prostatectomy.

Contemporary Diagnostic and Therapeutical Strategies." Minerva Urologica e
Nefrologica 55 (December 2003): 251–261.

Gomella, L. G., I. Zeltser, and R. K. Valicenti. "Use of Neoadjuvant and Adjuvant

Therapy to Prevent or Delay Recurrence of Prostate Cancer in Patients Undergoing
Surgical Treatment for Prostate Cancer." Urology 62, Supplement 1 (December 29,
2003): 46–54.

Nelson, J. B., and H. Lepor. "Prostate Cancer: Radical Prostatectomy." Urologic

Clinics of North America 30 (November 2003): 703–723.

Zimmerman, R. A., and D. G. Culkin. "Clinical Strategies in the Management of

Biochemical Recurrence after Radical Prostatectomy." Clinical Prostate Cancer 2
(December 2003): 160–166.

Organizations

Cancer Research Institute. 681 Fifth Ave., New York, NY 10022. (800)
99CANCER. .

Zero — The Project to End Prostate Cancer. 1156 15th St., NW, Washington, DC
20005. (202) 463-9455. .

Prostate Health Council. American Foundation for Urologic Disease. 1128 N. Charles
St., Baltimore, MD 21201-5559. (800) 828-7866. .
 —David A. Cramer, M.D.; Rebecca J. Frey, Ph.D.

Veterinary Dictionary: prostatectomy

Top
Home > Library > Animal Life > Veterinary Dictionary

Surgical removal of the prostate.

Wikipedia: Prostatectomy
Top
Home > Library > Miscellaneous > Wikipedia
This article may require cleanup to meet Wikipedia's quality standards.
Please improve this article if you can. (June 2008)
Intervention:
Prostatectomy
ICD-10 code:
ICD-9 code: 60.2 - 60.6
MeSH D011468
Other codes:

A prostatectomy is the surgical removal of all or part of the prostate gland.

Abnormalities of the prostate, such as a tumour, or if the gland itself becomes
enlarged for any reason, can restrict the normal flow of urine along the urethra.

There are several forms of the operation:

• Transurethral resection of the prostate

Also called a TURP, this is a cystoscope[A Resectoscope Rather, which has

30 degree of viewing angle, along with Resectoscopy Sheath & Working
Element] is passed up the urethra to the prostate, where the surrounding
prostate tissue is excised. This is a common operation for benign prostatic
hyperplasia (BPH) and outcomes are excellent for a high percentage of these
patients (80-90%). A more refined and safer operation is by means of a
holmium(Nd:YAG) high powered "red" laser. A related laser procedure for
relief of prostatic obstruction utilizes a potassium titanyl phosphate(KTP) laser
to vaporize the adenoma. More recently the KTP laser has been supplanted by
a higher power laser source based on a lithium triborate crystal, though it is
still commonly referred to as a "Greenlight" or KTP procedure. The specific
advantages of utilizing laser energy rather than a traditional electrosurgical
TURP is a decrease in the relative bloodloss, elimination of the risk of TUR-
syndrome, the ability to treat larger glands, as well as treating patients who are
actively being treated with anti-coagulation therapy for unrelated diagnoses.3,4

• Open Prostatectomy
 A surgical procedure involving a skin incision and enucleation of the prostatic
adenoma, through the prostatic capsule (RPP-retropubic prostatectomy) or
through the bladder (SPP-suprapubic prostatectomy). Reserved for extremely
large prostates.

• Laparoscopic Radical Prostatectomy

a laparoscopic or four small incisions are made in the abdomen, and the entire
prostate for prostate cancer.

• Robotic-assisted Laparoscopic Radical Prostatectomy see also [3]

• da Vinci (Robot-assisted) Prostatectomy is the #1 choice for treatment of
localized prostate cancer* in the United States:Laparoscopic robotic arms are
controlled by a surgeon. The robot gives the surgeon much more dexterity
than conventional laparoscopy while offering the same advantages over open
prostatectomy: much smaller incisions, less pain, less bleeding, less risk of
infection, faster healing time, and shorter hospital stay.[1]. While the cost of
such procedures is high, costs are declining rapidly [2]. The manufacturer of the
da Vinci Surgical System, used for robotic-assisted prostatectomy, claims that
this is now the number one treatment choice for prostate cancer in the United
States[.[3]]
• Radical perineal prostatectomy

an incision is made in the perineum, midway between rectum and scrotum,

and the prostate is removed. Radical prostatectomy is one of the key
treatments for prostate cancer.

• Radical retropubic prostatectomy

an incision is made in the lower abdomen, and the prostate removed, by going
behind the pubic bone (retropubic). Radical prostatectomy is one of the key
treatments for prostate cancer.

• Transurethral plasmakinetic vaporization prostatectomy

This is also called a TUPVP.

References
1. ^ Center for the Advancement of Health; August 29, 2005; Robot-assisted
Prostate Surgery Has Possible Benefits, High Cost [1]
2. ^ Cost Analysis of Radical Retropubic, Perineal, and Robotic Prostatectomy;
Scott V. Burgess, Fatih Atug, Erik P. Castle, Rodney Davis, Raju Thomas;
Journal of Endourology 2006 20:10, 827-830 [2]
3. ^ http://www.davinciprostatectomy.com/index.aspx

fightprostatecancer.org

Encyclopedia of Surgery: A Guide for Patients and Caregivers :: St-Wr

Transurethral resection of the prostate

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

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.

If the results of the DRE and PSA tests are indicative of a significant prostate
disorder, the examining
An enlarged prostate can cause urinary problems due to its location around the
male urethra (A). In TURP, the physician uses a cystoscope to gain access to the
prostate through the urethra (B). The prostate material that has been restricting
urine flow is cut off in pieces, which are washed into the bladder with water from
the scope (B). (
Illustration by GGS Inc.
)

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.

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.

Transurethral Resection of the Prostate (TURP)

Transurethral Resection of the Prostate (TURP)

Prostate Cancer Information:

Prostate Surgery and Prostatectomy
Prostate surgery or prostatectomy is the removal of the prostate gland. This
prostate cancer treatment is an invasive procedure that can be performed by a
single incision to the lower abdomen (retropubic) or perineum (perineal), or by a
series of small incisions (laparoscopic and robotic).

Surgery’s Role in the Treatment of Prostate Cancer

Prostate surgery is one of the oldest prostate cancer treatments. The premise:
“remove the cancerous organ to treat the patient.” Prostate surgery (the technical
term is prostatectomy) will help only those patients who have confined, localized
disease. The oldest type of surgery, the radical retropubic prostatectomy, uses
pelvic lymph node dissection (PLND) before surgery to ensure that the disease has
not metastasized out of the gland.

Radical prostatectomy is the removal of the entire prostate gland and possibly the
seminal vesicles and surrounding nerves and veins. The part of the urethra
travelling through the gland’s transition zone is also removed. The two ends of
remaining urethra are reattached in a connection called the anastomosis. Excising
part of the urethra may lead to a penile shrinkage or shortening.

Types of Prostate Surgery

There are three types of prostate surgeries: retropubic, perineal, and laparoscopic.
They are classified according to the incision site.

• Retropubic
The retropubic incision is made in the center of the lower abdomen and could be
called open prostate surgery. The incision is from 8 to 10 centimeters long. The
advantages of this technique include PLND and nerve-sparing.
• Perineal
The 4 centimeter perineal incision is made in the perineum which comprises
muscles and exterior skin between the scrotum and anal sphincter. Surgeons
cannot perform the PLND during this procedure but is considered acceptable
because PSA testing, DRE findings, and Gleason scoring are excellent indicators of
lymph node metastasis.
• Laparoscopic and Robotic
The laparoscope is a slender, tube-like instrument which allows the surgeon to see
inside the abdominal cavity and excise the prostate through a series of small
incisions rather than a long single one. The robotic procedure uses the same
incisions and tools but a surgeon uses robotic arms controlled by a console to
perform the surgery remotely. From the patient’s point of view, the two are virtually
identical.

Sex After Prostate Surgery

All prostate cancer treatments affect sexual potency. Physically, several factors
affect the mechanics of the erection such as diversion the blood flow or the nerve
stimulations that trigger erections. Surgeons try to preserve nerve function through
the nerve-sparing technique.
Nerve-sparing prostatectomy can be used only for patients who have small,
localized tumors that do not touch the neurovascular nerve bundles. The technique
helps men regain erectile function more quickly afterwards if they were potent
beforehand. Only the open field of view available through an abdominal incision
allows a surgeon to spare nerve bundles. Patients considering the nerve-sparing
technique should find an experienced surgeon.

The History of the Prostatectomy

The radical perineal approach has been in use since the early 20th century. Not the
until the 1940’s did doctors begin to uses the radical retropubic approach. Both of
 these approaches, however, engaged an unrefined surgical technique which resulted
in significant blood loss for the patient. Once surgeons began clamping veins and
refining surgical technique, patients immediately fared better. Until the 1980’s, the
retropubic approach was the most commonly used.

Today, the laparoscopic and robotic procedures are quickly becoming popular. Partly
because many doctors PLND is can be diagnosed with other testing. In this
procedure however conversion to the abdominal incision may be used if
complications arise during a laparoscope-assisted procedure

surgical treatment during which a surgeon inserts a

Author: Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research
Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio
Contributor Information and Disclosures

Updated: Oct 3, 2006

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Introduction

For most of the 20th century, from 1909, when Hugh Hampton Young performed his first cold-cut
prostatic punch operation, until the late 1990s, when effective medical therapy and newer, less
invasive technologies for prostatic obstruction were developed, the premier treatment for
symptomatic benign prostatic hypertrophy (BPH) was transurethral resection of the prostate
(TURP). It was the first successful, minimally invasive surgical procedure of the modern era. To
this day, TURP remains the criterion standard therapy for obstructive prostatic hypertrophy and is
both the surgical treatment of choice and standard of care when other methods fail.

Since the advent of medical therapy for symptomatic prostatic hypertrophy with 5-alpha reductase
inhibitors and alpha-adrenergic blockers, the need for immediate surgical intervention in
symptomatic prostatic obstruction has been reduced substantially. However, alpha-blockers do not
modify prostate growth, and even the use of prostatic growth inhibitors such as finasteride
(Proscar) or dutasteride (Avodart) often fails to prevent recurrent urinary symptoms of BPH and
retention. In the past, these patients would almost certainly have undergone transurethral prostate
surgery years earlier.

The modern role of transurethral prostatectomy and the current status of urology residency training
in TURP was perhaps best stated by J. Curtis Nickel in a recent editorial.
"Because of successful medical treatment and minimally invasive therapy, our transurethral
prostatectomy numbers have significantly decreased during the last decade. Our residents and
new urologists may not be as expert at doing the procedure as urologists were previously. Yet the
operation continues to be required in many patients worldwide and urologists must remain
competent in the procedure. Transurethral prostatectomy remains the "criterion" standard by
which all BPH management strategies must be compared."
History of the Procedure
Urinary obstruction from prostatic hypertrophy has been described for many centuries, starting with
the ancient Egyptians in the 15th century BC. The prostate was first described anatomically by
Vesalius in 1538 but was not called "prostate" until it was so named by Casper Bartholin in 1611.
The word "prostate" comes from the Greek prostat, which means "one who stands before or in
front of", which, in this case, means in front of the bladder.

The earliest useful therapy for urinary obstruction from prostatic enlargement was a catheter,
which was first used by the Romans Celsus and Galen in the first century AD. The earliest known
description of a flexible catheter was by Avicenna of Persia in 1036. Since then, some type of
urinary catheter made from a large variety of materials, including hollow leaves (eg, Allium
fistulosum used by the ancient Chinese), bamboo, wood, metal, and rubber, has been the primary
therapy for prostatic obstruction until the beginning of the 20th century.

Ambroise Pare performed the first transurethral operation for obstructed bladder outlet disease in
the 16th century, blindly using a curette and a sharpened hollow sound. The obstruction was from
urethral strictures, which were successfully opened by this maneuver.

The most successful surgical technique in the 18th and 19th centuries was described by La Faye
of Paris in 1726. It involved the use of a curved hollow sound with a sharp pointed stylet, which
was forcibly passed through the obstructing prostate into the bladder using a finger in the rectum
for guidance. The sound was left in place for several days to allow the false passage to
epithelialize. At about the same time, Lorenz Heister described his experience using a suprapubic
trocar for both temporary and permanent bladder drainage in cases of urinary retention.
Intermittent self-catheterization, with catheters made of various materials and using oil or butter as
a lubricant, was the standard treatment of the day. This "catheter life," even in the early 20th
century, had a reported mortality rate of 8% during just the first month.

In 1909, Hugh Hampton Young (see Image 1) developed a cold-cut punch for prostate resection,
which essentially was used blindly. A fenestration or hole near the end of a hollow tube allowed
prostatic tissue to enter (see Image 2). An internal cylinder with a sharp leading edge was then
passed through the inside of the tube, slicing off a small section of prostatic tissue. While it did
remove prostate tissue, it failed to control bleeding.

Electrical cautery that could work underwater was first demonstrated by Edwin Beer in 1909, when
it was used experimentally on bladder tumors. This was quickly added to Young's cold punch in
1911, but the diathermy and resulting hemostasis was still of poor quality, which limited its
usefulness. In 1931, Thomas J. Kirwin designed a modification that allowed placement of a needle
for electrical coagulation prior to the resection. This modified version of the cold-punch device
produced minimal bleeding and was reasonably successful.

Several factors were critical to the development of modern TURP. These included the following:

• Adequate endoscopic, transurethral, and intravesical illumination with the incandescent

lamp cystoscope (Phillip Bozzini, Antonin Jean Desormeaux, Maximilian Nitze, Josef
Leiter)
 • Electrical tissue resection using cutting current (Heinrich Hertz, Lee DeForest, Reinhold
Wappler, George Wyeth)
• Electrical cauterization using coagulating current (Edwin Beer, W.T. Bovie, G.H. Leibel)
• Wire loop resecting electrode (Maximilian Stern, Theodore M. Davis)
• Telescopic wide-field visualization and magnification (foroblique lens by Reinhold
Wappler, Hopkins rod lens system by Harold Hopkins)
• Consolidation of instrumentation into a single, practical, workable resectoscope
(Maximilian Stern, Joseph F. McCarthy)
• Detailed description of prostatic vascular supply (Rubin Flocks)
• Description of proper technique of transurethral resection (Reed M. Nesbit, William A.
Milner)
• Recognition and preventive treatment of postoperative complications such as dilutional
hyponatremia or transurethral resection syndrome (TUR syndrome) (Creevy and Webb)
• Modern refinements and improvements (Hopkins lens, fiberoptics, continuous flow, and
video)

The first true endoscope was designed and built by German physician Phillip Bozzini in 1805. It
was called the lichtleiter (light conductor) and consisted of various examining tubes, including a
special cannula for the urethra and bladder, plus a wax candle in a special holder or cradle for
illumination. While rudimentary, the lichtleiter did allow direct visual examination of various internal
body cavities, including the bladder, which was not otherwise possible at that time. Unfortunately,
the device was harshly ridiculed by Bozzini's medical contemporaries, which effectively halted
endoscopic development for almost 50 years.

In 1853, French surgeon Antonin Jean Desormeaux used a modified lichtleiter to examine patients
primarily for urological problems. A system of mirrors and lenses improved visualization. Instead of
a wax candle, he used a much brighter lamp flame from a burning mixture of alcohol and
turpentine as a light source, which unfortunately resulted in numerous burns. Nevertheless, this
version of the lichtleiter was considered reasonably successful.

The first electrically illuminated endoscope was made by Gustave Trouve in 1869. It used an
electrical current to create illumination from a white-hot, glowing, platinum wire and had the light
source at the distal tip of the instrument. His polyscope electrique used a rheostat to regulate the
electrical current from a battery to adjust the light intensity. It was not very successful as a
cystoscope because of heat production, limited duration of battery life, and the need for a dry
environment, but it was a start.

German physician Maximilian Nitze designed the first successful modern cystoscope in 1877 and
is credited as the father of cystoscopy. Built by Josef Leiter of Vienna and used exclusively for
bladder examinations, it also used incandescent lighting provided by an electrically heated
platinum wire; however, it added a cooling system of flowing ice water and telescopic lenses for
visualization, which solved many of the problems with earlier instruments.

Enrico Bottini performed the first electrical prostate surgery in 1874, when he used galvanocautery
to remove median bar tissue. Two insulated parallel brass arms were passed together blindly
through the prostate, and then a direct electrical current was applied. This caused coagulative
necrosis of the bladder neck and median bar tissue with relatively minimal bleeding and
complications. In 1897, Albert Freudenberg improved on this instrument by adding a telescope so
the procedure could be performed under direct vision, but it was still suitable only for smaller
prostates and median bars. Larger prostates were handled by open surgical suprapubic prostatic
removal at that time. The first successful total suprapubic prostatectomies were performed by
Eugene Fuller of New York in 1895.
Another important milestone was Heinrich Hertz's 1888 discovery regarding spark transmission
and spark-gap circuitry. This led others, such as D'Arsonval, Thompson, and Tesla, to recognize
some early clinical effects developed by Hertz's spark gap. This type of circuit was used to
generate heat and, therefore, could provide limited hemostasis.

Cutting currents were discovered much later, by accident, by Lee DeForest when he was using an
awkward Poulsen arc generator. DeForest invented the vacuum tube in 1906, which could
generate a continuous high-frequency current. However, its high manufacturing cost made it
impractical for medical applications at the time. DeForest suggested that this current could be used
to cut tissue during surgery. Not until improvements were made by Reinhold Wappler, W.T. Bovie,
and George Wyeth in 1924 did vacuum tube based electrosurgical generators become available;
however, they were initially of insufficient power to reliably cut under water. Wappler also later built
the excellent foroblique telescope used in the 1932 Stern-McCarthy resectoscope.

In 1926, Maximilian Stern designed an instrument he called a resectoscope, which featured a

movable electrified tungsten wire loop that could cut out a cylinder of tissue when a high frequency
current was passed through it. To create a cutting current, a continuously alternating high-power
electrical sine wave was generated. As the thin leading edge of the wire loop electrode passed
through tissue, cells were quickly heated, causing them to explode into steam, leaving a vaporized
space into which the cutting loop could then be easily advanced.

In 1931, Theodore M. Davis, who had been an electrical engineer before entering the field of
urology, combined the cutting current with a diathermy machine for hemostasis and reported good
results and no operative deaths in 230 patients using a modified version of Stern's resectoscope.
He thickened the movable tungsten wire cutting loop on Stern's resectoscope, which made it
stronger and less prone to breakage. He added additional insulation, which was badly needed.
Davis also introduced the first dual-action foot switch, allowing direct control of either cutting or
coagulating current, which is still in use today.

A reliable coagulating generator, using a heavily dampened electrical current for hemostasis, was
developed by W.T. Bovie of Harvard and G.H. Leibel of Cincinnati, Ohio. Coagulating current uses
relatively low power to generate short bursts of electrical sine waves with brief intermittent pauses.
A single unit with two separate generators, including an improved and more powerful vacuum tube
based cutting current that reliably cut tissue underwater, were combined into a single
electrosurgical unit (see Image 3) for the first time by Reinhold Wappler (see Image 4) in 1931.
This unit became the standard electrosurgical device until the 1960s, when modern solid-state
units became available.

In 1932, Joseph F. McCarthy introduced the first modern resectoscope (see Image 5) with a 2-
handed rack-and-pinion–style working element, improved Stern-type tungsten wire cutting loop,
Davis' dual-control foot switch, the Wappler foroblique direct-vision telescope, and an improved
Wappler electrical unit with both dampened spark-gap coagulating and vacuum tube–based cutting
currents.

One of McCarthy's major innovations was the addition of an insulating Bakelite resectoscope
sheath, which made possible directly visualizing and precisely controlling the movements of the
cutting loop safely, even while current was applied, without electrical risk to the surgeon. However,
the key to the success of this instrument was the wonderful foroblique telescope developed by
Reinhold Wappler. It provided both a wide-angle view and sufficient magnification to allow for
precise placement and manipulation of the cutting loop. The tip of the resectoscope sheath was
redesigned into a beak to make better use of this new telescope. This unit is essentially the same
one in use today. Its development marks the beginning of the modern era of transurethral prostate
surgery.

When first introduced, the standard transurethral prostate resection with the Stern-McCarthy
instrument involved removal of only a few segments from an obstructing median bar or lateral lobe.
A typical operative report of the era would state "adequate channel made,5 pieces burned out," or
"3 segments of prostate removed." Mortality rates from early transurethral prostate surgeries were
as high as 25%. Nathaniel Alcock described his experience with 50 cases in 1931. Twelve patients
died and all had problems with bleeding and infection, but this was still an improvement over the
even worse outcomes from open surgical prostatectomies of the time.

Common complications of early TURP surgery, as reported by John R. Caulk in 1933, included
rectourethral fistula, incontinence, excessive bleeding, sepsis, stricture formation, bladder rupture,
abscess formation, and even electrocution. The task of developing the techniques necessary to
safely remove large quantities of obstructive prostatic tissue by transurethral resection remained
for others, such as Reed M. Nesbit (see Image 6) of Ann Arbor, Michigan and William A. Milner
(see Image 7) of Albany, New York. This development was facilitated by the detailed description of
the arterial blood supply of the prostate by Rubin Flocks in 1937.

Further improvements followed. Notable among these was the development of the Foley
hemostatic bag (balloon) catheter in 1937, which allowed not only for self-retention but also for
tamponade of the prostatic fossa and the application of traction to help control venous bleeding by
direct compression. In 1939, Reed M. Nesbit placed an internal spring in the handle of the working
element to allow for one-handed operation (see Image 8). Jose Iglesias de la Torre designed a
more reliable external spring-loaded model that is the most popular resectoscope working element
style used today.

The main advantage of a resectoscope that allows the resection to be performed with a single
hand, as in the Nesbit and Iglesias designs, is that it leaves the second hand free to place a finger
in the rectum to help raise the apex and floor of the prostate. The primary disadvantage is that
some of the sensory perception from cutting the tissue is lost. The Iglesias working element uses
the thumb and the spring to do the actual cutting, while the older Stern-McCarthy model allows the
resection to be controlled by the thumb and first 2 fingers using a rack-and-pinion mechanism,
which provides finer motor control and excellent tactile sensory feedback. Most urologists today
use the Iglesias model, but a few prefer the original Stern-McCarthy design for these reasons.

Once modern transurethral surgical instruments became available in the early 1930s, the demand
for this new prostatic surgery was quite high by both physicians and patients. Broad dissatisfaction
with traditional surgical treatments for prostatic hypertrophy made any new procedure seem
attractive by comparison. The standard technique of prostatectomy before transurethral resection
involved a 2-stage procedure, as described by Pilcher in 1914, which started with the placement of
a suprapubic cystostomy. If the patient survived, an open suprapubic prostatectomy was
performed a few weeks later. Hospitalization typically lasted 6-8 weeks, and the reported mortality
rate was 50%. Many of these patients undoubtedly had uremia secondary to their urinary
obstructions, which would explain why some may have done better with a 2-stage procedure. A
number of somewhat unreliable early reports had created the erroneous impression that TURP
surgery was technically simple to perform with few complications.

What happened next is best described by Reed M. Nesbit in his landmark 1943 book on
transurethral prostatectomy.
"It soon became apparent, however, that the prostatic millennium had not actually arrived.
Resectionists throughout the country discovered that the operation could not be performed with
ease; that its technique was exceedingly difficult to acquire as well as to execute; that the
incidence of morbidity and mortality could be alarmingly high following transurethral resection; and
that unexpectedly poor end results were observed in a disconcerting number of patients.
The refined techniques which are now available, allow transurethral resection to be employed for
the treatment of all types of prostatic obstruction with the expectation of minimal postoperative
morbidity and mortality, and uniformly good functional results. Modern transurethral prostatic
resection is an exceedingly difficult operation to perform, and requires that one spend a long and
painstaking apprenticeship in acquiring its technique."

The next major development was the discovery of the danger in using distilled water as an
irrigating solution. This was first pointed out by Creevy and Webb in 1947 when they reported on
the danger of water intoxication leading to intravascular hemolysis causing increased morbidity
and death rates. They had observed bloody urine from intravascular hemolysis coming through the
ureteral orifices during resections while using water as an irrigating solution. They recommended
using a solution of 4% glucose for irrigation. In 1956, Harrison described hyponatremic shock and
dilutional hyponatremia. The benefit of nonhemolyzing solutions was confirmed in 1969 by
Emmett, who compared 2 large series from the Mayo Clinic and reported that the nonhemolyzing
solutions produced much better morbidity and mortality rates compared to plain-water irrigation.

Fiberoptic lighting systems, based on the 1956 work on fiberoptics by Lawrence E. Curtis, and the
Hopkins wide-angle rod lens telescopes were both introduced in the early 1970s. In particular, the
optical system designed by Harold Hopkins vastly improved visualization by substituting optical-
quality solid-glass rod lenses for the air spaces used in previous telescopes.

Continuous-flow transurethral resection using a suprapubic trocar was introduced first in Europe by
Hans Joachim Reuter in 1968 and then in the United States by Paul O. Madsen, but it never
became widely accepted despite its theoretical advantages and reported clinical success. The first
successful continuous-flow resectoscope was reported by Iglesias in 1975, but it was not until the
mid and late 1990s that practical continuous-flow resectoscopes using a coaxial sheathing system
became popular and widely available. Modern coaxial continuous-flow resectoscopes are currently
the overwhelming first choice of urologists for TURP instrumentation.

Problem
The prostate has been described as the organ of the body most likely to be involved with disease
of some sort in men older than 60 years. This statement characterizes any histological evidence of
BPH as a disease, which is certainly debatable, but there is no argument that BPH is an extremely
common clinical entity.

As the hyperplastic process increases the volume of the prostate, the urethral lumen is
compressed, causing outlet obstruction. An enlarged median lobe may cause relatively more
severe symptoms than lateral lobe hyperplasia of similar magnitude because it can act as a valve
at which increased bladder pressure may actually cause further obstruction. Intravesical extension
of the lateral lobes may act in a similar fashion. At the same time, a dynamic component involving
the stromal prostatic tissue and bladder is present, which is often more significant in causing
urinary symptoms than simple mechanical obstruction from an enlarged prostate. The precise
interaction of these two mechanisms, mechanical and dynamic, is not well understood.

Bladder trabeculation often follows because isolated muscle bundles hypertrophy in response to
the need for a higher intravesical pressure to overcome the increased resistance to voiding. The
spaces between these hypertrophied bundles tend to become thinner, with less functional muscle.
Eventually, this can progress to the point at which the bladder becomes almost nonfunctional.
Bladder trabeculation is usually graded on a scale of I-IV. When seen on cystoscopy images, it is a
relative indicator of the degree and duration of any bladder outlet obstruction (eg, BPH), although
any detrusor hyperactivity problem can possibly produce bladder trabeculations, even without an
identifiable obstruction. Initial symptomatic changes include increased bladder instability and
irritability, which can eventually progress to muscular decompensation with permanent loss of
detrusor contractile ability.

The goal of prostate surgery for BPH is to remove the obstructing tissue while minimizing damage
to surrounding structures, with as little discomfort to the patient as possible. The accessibility of the
obstructing prostate via transurethral endoscopy affords the opportunity to remove the obstruction
without open surgery. It also protects the surrounding organs from injury by removing the tissue
from the intraluminal surface of the prostate.

TURP is a surprisingly challenging procedure technically, with a protracted learning curve. The
procedure tends to be required in older, less healthy men. Continuing improvements in
instrumentation and technique allow accomplishment of this procedure more easily for the surgeon
and less dangerously for the patient.

Frequency
Once one of the most commonly practiced urological procedures, TURP is now performed much
less frequently because of the new availability of reasonable alternative medical and surgical
treatment options. In 1962, TURP operations accounted for more than 50% of all major surgical
procedures performed by urologists in the United States. By 1986, this had declined to 38%.

The 1985 Veterans Administration Normative Aging Study estimated the lifetime probability of
surgical intervention for prostatic enlargement at 29%, and the 1986 National Health Survey
estimated that 350,000 patients in the Medicare age group had a TURP that year, compared to
fewer than 200,000 in that same age group by 1998. These numbers should be considered within
the context that the median age of the typical patient is rising, the size of the average resected
prostate gland is increasing, and the typical patient has more comorbidities and is generally less
healthy than surgical patients of the past.

This decrease in the number of TURP procedures performed is even more dramatic when the
general aging of the population and the larger number of older men in society are considered. In
the United States, the number of older men with BPH-related symptoms is expected to increase
from 5 million to 9 million persons by the year 2025.

A comprehensive review of transurethral prostatectomy in the Medicare age group by Wasson and
associates from Dartmouth compared a national sample of Medicare beneficiaries from 1991-1997
to a similar group for the period 1984-1990. They found the more recent group demonstrated a
substantial decline in the number of TURP surgeries of 50% for white men and 40% for black men.
Compared to the peak period of TURP use in the 1980s, a higher proportion of the men
undergoing the procedure were older in the more recent period, with 53% aged 75 years or older.

Another factor that must be considered when evaluating the general decline in the number of
TURP procedures performed is the significant reduction in financial reimbursement to urologists for
TURP surgeries in the United States. Physician reimbursement from Medicare for a TURP has
dropped from a high of $2000-$3000 in the past to approximately $700 today, with a 90-day global
period that covers all postoperative care by the surgeon for 3 months. In many instances,
performing a TURP is simply not profitable for the urologist when office overhead, billing, and
malpractice costs are considered, especially when complications occur.

Alternative surgical procedures, such as microwave therapy and prostatic laser surgery, are
reimbursed at much higher levels, even though they may not be as durable or effective. This
creates a strong financial disincentive for urologists to perform TURP procedures, except when no
reasonable alternatives exist. A recent article by Donnell examines the history of Medicare policies
and the effect of changes in Medicare reimbursement on TURP.

In one large Canadian series reported by Borth and colleagues, the number of TURP procedures
dropped by 60% between 1988 and 1998, presumably because of medical therapy, despite an
increase of 16% in the male population older than 50 years. While the number of patients
presenting with urinary retention was significantly higher in the 1998 group compared to the earlier
cohort (55% in 1998 vs 23% in 1988), no significant difference was noted in their average age,
medical comorbidities, operative parameters, average size of prostate tissue resected, or
complication rates.

The criteria for performing TURP surgery are now more stringent than before. In general, TURP
surgery is reserved for patients with symptomatic prostatic hyperplasia who have acute, recurrent,
or chronic urinary retention; in whom medical management and less-invasive prostatic surgical
procedures failed; who have prostates of an unusual size or shape (eg, a markedly enlarged
median lobe, significant intravesical prostatic encroachment); who have azotemia or renal
insufficiency due to prostatic obstruction; or who have the most severe symptoms of prostatism.
Less common uses of TURP include intractable prostatitis or for tissue sampling when standard
biopsy techniques cannot be used.

African Americans more typically present for TURP surgery with urinary retention or urinary
infections and have a higher incidence of preexisting medical problems compared to the general
population. According to Kang et al, reports from the Prostate, Lung, Colorectal, and Ovarian
(PLCO) cancer screening trial indicate that Asian and Asian American men have the lowest overall
risk of clinical BPH and eventual TURP.

The average age of patients currently undergoing TURP is approximately 69 years, and the
average amount of prostate tissue resected is 22 grams. Risk factors associated with increased
morbidity include prostate glands larger than 45 grams, operative time longer than 90 minutes, and
acute urinary retention as the presenting symptom. The 5-year risk rate for a reoperation following
TURP is approximately 5%. Overall mortality rates following TURP by a skilled surgeon is virtually
0%.

The relative frequency of TURP compared to open prostatectomy in surgical patients varies from
country to country. In 1990, the relative frequency rate of TURPs in surgical patients with BPH in
the United States was 97%, with similar rates in Denmark and Sweden. The lowest rates of TURP
were noted in Japan (70%) and France (69%).

Etiology
BPH is thought to be caused by aging and by long-term testosterone and dihydrotestosterone
(DHT) production, although their precise roles are not completely clear. Histopathologic evidence
of BPH is present in approximately 8% of men in their fourth decade and in 90% of men by their
ninth decade. Loss of testosterone early in life prevents the development of BPH. The similarities
in presentation, pathological examination findings, and symptoms of BPH among identical twins
suggest a hereditary influence.
Once BPH has developed, it tends to progress. Cross-sectional studies based on cadaver
autopsies or consecutive patients seen in urology clinics suggest that the growth rate decreases
with age. In patients aged 31-50 years, the prostate doubling time averages 4.5 years. In men
aged 51-70 years, the prostatic doubling time is approximately 10 years, while in men older than
70 years, the doubling time increases to more than 100 years. Note that these findings may only
reflect a selection bias in the sample group.

A 5-year longitudinal study by Rhodes and colleagues of 631 community men aged 40-79 years
from Olmsted County, Minnesota demonstrated an average annual prostate growth rate of 1.6%.
This remained essentially constant regardless of age, although men with larger prostates tended to
have higher growth rates.

The average prostate weighs approximately 20 grams by the third decade and remains relatively
constant in size and weight unless BPH develops. The typical patient with BPH has a prostate that
averages 33 grams. Only 4% of the male population ever develops prostates of 100 grams or
more. (The largest recorded prostatectomy specimen weighed 820 grams. This prostate was
removed by open suprapubic prostatectomy. Unfortunately, the patient ultimately died of
hemorrhage.)

Symptoms of BPH tend to progress slowly over time in most individuals, with an average annual
increase of 0.14-0.44 points per year in the American Urological Association (AUA) symptom score
index for men aged 60 years and older. Once BPH has begun, the prostate grows an average of
0.6 mL in volume annually, with a mean decrease in average urinary peak flow rate of 0.2 mL per
second each year. Men older than 70 years and those with a baseline peak flow rate less than 10
mL/s tend to have a more rapid and dramatic decline in their peak flow rates over time.

DHT has an affinity for prostate cell androgen receptors that is 5 times greater than that of
testosterone. The levels of 5-alpha reductase are increased in the stromal tissue of men with BPH
compared to controls. This and other data indicate that DHT is much more important in the
development of prostatic hypertrophy than testosterone. The success of 5-alpha reductase
blockers, such as finasteride (Proscar) and dutasteride (Avodart), in reducing prostatic size and
relieving symptoms seems to confirm this, although it does not explain the relative lack of symptom
relief in those with smaller prostate glands treated with these agents.

Pathophysiology
When a bladder is trying to empty through a blocked outlet from an obstructing prostate gland, the
increased workload produces several changes to the bladder muscle. Initial changes include
increased instability and irritability, which progress to decompensation with permanent loss of
detrusor contractile ability. In patients with BPH, the intravesical pressure required to open the
bladder neck is increased. The bladder is initially able to produce a higher transitory voiding
pressure when required, but loses muscle tone over time.

Evidence also indicates that obstruction causes partial denervation of the bladder smooth muscle,
which results in further bladder irritability and involuntary detrusor contractions. Fortunately, most
of these hyperactive symptoms resolve over time with removal of the prostatic obstruction or with a
response to appropriate medications. The detrusor becomes less able to maintain a constant
voiding pressure over time, which leads to early termination of voiding, intermittency of the urinary
stream, and higher residual urine volume. This is accompanied by a loss of bladder compliance.

Overall bladder mass increases because of detrusor muscle hypertrophy, but collagen deposition
is also increased, which eventually contributes to decompensation, urinary retention, and
permanent loss of detrusor contractile ability.
A fact that has been known for many years is that prostate size alone is not a reliable or accurate
predictor of the presence or degree of urinary outlet obstruction. The failure of several purely
obstructive therapies, such as prostatic balloon dilatation, and the obvious success of alpha-
adrenergic blockers eventually led to the description of BPH as having both a dynamic
(neurogenic) and an obstructive (mechanical) component.

Alpha-adrenergic receptors are present and functional in the stromal smooth muscle of the
prostate and especially at the bladder neck. Many studies have documented the success of
various alpha-adrenergic blockers in relieving symptoms of BPH. Evidence from the Medical
Therapy of Prostate Symptoms Trial indicates that combination therapy with both an alpha-blocker
and a 5-alpha reductase inhibitor can delay the progression of symptoms and is more effective
over time than either medication alone for reducing symptom scores and improving peak urinary
flow rates.

Presentation
Classic symptoms of BPH include a slow, intermittent, or weak urinary stream; the sensation of
incomplete bladder emptying; double voiding (the need to void within a few seconds or minutes of
urinating); postvoid dribbling; urinary frequency; and nocturia. Patients may also present with acute
or chronic urinary retention, urinary tract infections, gross hematuria, renal insufficiency, bladder
pain, a palpable abdominal mass, or overflow incontinence.

Upon physical examination, the bladder may be palpable during the abdominal examination and
the prostate may be enlarged during the digital rectal examination. Symptoms are not necessarily
proportional to the size of the prostate on digital rectal examination or transrectal ultrasound
findings.

Indications

According to the Agency for Health Care Policy and Research guidelines for the diagnosis and
treatment of BPH and the recommendations of the Second International Consultation on Benign
Prostatic Hypertrophy, the absolute indications for primary surgical management of BPH are as
follows:

• Refractory urinary retention

• Recurrent urinary tract infections due to prostatic hypertrophy
• Recurrent gross hematuria
• Renal insufficiency secondary to bladder outlet obstruction
• Bladder calculi
• Permanently damaged or weakened bladders
• Large bladder diverticula that do not empty well secondary to an enlarged prostate

Most men who present for surgical correction of their urinary outlet obstruction are those in whom
medical therapy or alternative procedures have failed or are inappropriate for some reason. In
general, patients with moderate-to-severe lower urinary tract obstructive symptoms (AUA symptom
score >8) who have not responded to alpha-adrenergic blockers and/or 5-alpha reductase
inhibitors are also candidates for surgical intervention.

A study by Blanchard and associates showed that patients in whom alpha-blocker therapy is
ineffective or those in whom it has failed tend to have poorer outcomes after TURP compared to
men who proceed directly to a transurethral resection. This is presumably from preoperative
bladder damage and other risk factors that affect voiding rather than the size of the prostate. The
operating time and weight of resected tissue has been documented as the same between the two
groups; therefore, prostatic size alone does not account for the difference in outcomes.

Generally, TURP. While this is the most common indication, 70% of men undergoing the
procedure have multiple indications. Patients with prostates larger than 45 grams, who present
with acute urinary retention or who require operating times in excess of 90 minutes, are at
increased risk of postoperative complications.

Surgical treatment of BPH is also indicated in cases of renal failure or insufficiency secondary to
prostatic obstruction. Catheter drainage is usually recommended in such cases until the renal
failure resolves. As many as 10% of men with BPH present with some degree of renal
insufficiency.

The only absolute indication for an open prostatectomy over a TURP is the need for an additional
open procedure on the bladder that must be performed at the same time as the prostatectomy.
Such indications include open surgical resection of a large bladder diverticulum or removal of a
bladder stone that cannot be easily fragmented by intracorporeal lithotripsy.

A relative indication for the selection of an open prostate surgery over a TURP is generally based
on prostatic volume and the ability of the surgeon to complete the TURP in less than 90 minutes of
actual operating time (although <60 min is considered optimal). In general, open prostatectomy
can be justified in a patient with a prostate of 45 grams or larger, but this is totally dependent on
the skill and experience of the endoscopic urological surgeon. Most experienced urologists use a
prostatic volume of 60-100 grams as the upper limit amenable to endoscopic removal, but, for
some highly skilled resectionists, a 200-g prostate can be safely treated with TURP in less than 90
minutes.

Relevant Anatomy

The prostate is divided into zones. The peripheral zone is the largest and encompasses
approximately 75% of the total prostate glandular tissue in men without BPH. Most prostate
cancers originate in the peripheral zone. It is located posteriorly and extends laterally on either
side of the urethra.

The central zone is smaller and extends primarily around the ejaculatory ducts. It differs from the
peripheral zone primarily in cytologic details and architecture.

The transition zone is usually the smallest, consisting of two separate lobes on either side of the
urethra. The transition zone occupies only 5% of the prostate volume in men younger than 30
years. This is the zone thought to be the origin of BPH. It usually involves a small grouping of
ductal tissue near the central portion of the prostatic urethra near the internal sphincter. As the
transition zone expands, it can comprise 95% of the prostate volume, compressing the other
zones. Intraoperatively, the two enlarged lobes of the transition zone can be seen obstructing the
prostatic urethra on either side. Thus, the term lateral lobes is often used intraoperatively to
distinguish this tissue from any hyperplastic periurethral gland tissue.

The periurethral glands are less commonly involved with BPH but, when enlarged, can form what
is termed a median lobe, which appears as a teardrop-shaped midline structure at the posterior
bladder neck. This can ball-valve into the urethra, creating severe obstructive voiding symptoms.
Any significant intravesical extension of prostatic tissue can act as a valve when the detrusor
pressure increases and presses this tissue against the bladder neck or across the outlet to the
urethra, creating a functional obstruction (see Image 9).
The transition zone and periurethral region were called the central gland or inner gland, while the
peripheral and central zone were called the outer gland in some earlier jargon. This language
should be avoided because it is vague and creates confusion with the standard anatomical label of
the central zone.

Prostatic calculi occur between the transition zone and the compressed peripheral zone. In fact,
calculi can be used as a marker for this border. They are generally composed of calcium
phosphate and are not considered clinically significant. Chemical analysis is unnecessary. If a
channel is opened during surgery that allows these calculi to be expressed, they often flow out by
themselves if the opening is large enough. They can be milked out by using the end of the cutting
loop without current to gently press around the opening where the prostatic stones are seen and
can be pushed into the opened prostatic fossa. They can be rinsed into the bladder and evacuated
with the rest of the resected prostatic chips.

Prostatic calculi are formed from calcification of the corpora amylacea and precipitation of prostatic
secretions. While they may arise spontaneously, they also may be formed in response to an
inflammatory reaction or as a consequence of another pathological process that produces acinar
obstruction. Some practitioners believe that calcifications that form in response to bacterial
prostatitis may harbor bacteria that periodically flourish, causing recurrent prostatitis. Proponents
of this theory advocate TURP to liberalize these calcifications as a treatment for recurrent
prostatitis.

The prostate is thinnest and most narrow anteriorly (the 12-o'clock position when viewed through a
cystoscope). Care should be taken when operating in this area to avoid perforating the prostatic
capsule, especially if this portion of the prostate is resected early in the operation. Abundant
venous blood vessels are located in the area just anterior to the prostatic capsule, which can
cause significant bleeding that cannot be easily controlled if the vessels are damaged during
resection.

The external sphincter muscle tends to be slightly tilted, with the most proximal portion located
anteriorly, opposite the verumontanum. The external sphincter can be identified cystoscopically by
its wrinkling and constricting action as the resectoscope is withdrawn. Upon reinsertion, the
superficial mucosa in front of the telescope tends to bunch up. This is because the external
sphincter muscle is imbedded within the urogenital diaphragm, which is relatively fixed in position,
while the prostate has some limited mobility.

The single most important anatomical landmark in transurethral prostate surgery is the
verumontanum (see Image 10). It is a midline structure located on the floor of the distal prostatic
urethra just proximal to the external sphincter muscle. It appears as a small, rounded hump that is
best seen when withdrawing the telescope through the prostate while visualizing the prostatic floor
at the 6-o'clock position.

The orifices to the ejaculatory ducts emerge in the verumontanum (see Image 11). Its importance
lies with its position immediately proximal to the external sphincter muscle (see Image 12). This
allows it to be used as the distal landmark for prostate resection. The precise distance between the
verumontanum and the external sphincter demonstrates some slight individual variation and
should be verified visually before starting the resection and periodically during the surgery.

The proximity of the ureteral orifices to the cephalad margin of the hypertrophied prostate varies,
particularly in patients with an enlarged median lobe. This distance should be frequently assessed
throughout surgery.
The vascular anatomy of the prostate was accurately described in detail by Rubin Flocks in 1937.
The blood supply of the prostate comes primarily from branches of the inferior vesical artery, which
is a branch of the internal iliac artery (see Image 13). When the inferior vesical artery reaches the
prostate just at the vesicoprostatic border, it branches into 2 groups of arteries (see Image 14).
One penetrating group passes directly into the prostate toward the interior of the bladder neck.
Upon reaching the prostatic interior near the urethra, most of these branches turn distally and
parallel the prostatic urethra, while others supply the median lobe.

Vessels that parallel the prostatic urethra supply most of the blood to the hypertrophied lateral
lobes. The second large group of arteries follows the exterior of the prostatic capsule
posterolaterally, periodically giving rise to perforating vessels, and supplies the area around the
verumontanum.

Contraindications

Although TURP is the standard of care for the management of BPH, it is an elective procedure that
is not recommended for some patients. Most contraindications are relative, based on the
comorbidities of the patient and his ability to withstand the surgical procedure and anesthesia.
Some relative contraindications include unstable cardiopulmonary status and a history of
uncorrectable bleeding disorders. Patients with a recent myocardial infarction or coronary artery
stent placement should not have elective TURP surgery for a least 1 month because of the
increased risk of cardiovascular events and other complications. A reasonable minimum delay of 3
months is suggested, but waiting at least 6 months after any significant myocardial event is optimal
before performing an elective TURP.

Patients with myasthenia gravis, multiple sclerosis, or Parkinson disease in whom the external
sphincter is dysfunctional and/or the bladder is severely hypertonic should not have a TURP
because intractable incontinence invariably would result. Patients who have had major pelvic
fractures that involved damage to the external urinary sphincter also should not undergo a TURP
for similar reasons. Loss of the internal urinary sphincter from the TURP makes these patients
totally dependent on their external sphincter muscle function for continence. Should the external
sphincter be damaged, injured, or dysfunctional, they will have substantial problems with
incontinence.

Patients who have recently completed definitive radiation therapy for prostate cancer are
not candidates for TURP because of the unacceptably high rate of urinary incontinence
reported. If a TURP is absolutely necessary, it should be delayed at least 6 months after
definitive radiation therapy. Alternatives to TURP in such a situation include drainage
with a Foley or suprapubic catheter, intermittent self-catheterization, and various other
less-invasive prostatic surgical procedures. Patients with prostate cancer who are
considering brachytherapy (radioactive seed implantation) or cryotherapy as part of their
definitive treatment should not undergo a TURP because the resected tissue would be
necessary for optimal needle, probe, and seed placement. The patient is also at increased
risk for incontinence. Definition

This surgery involves removal of part or all of the prostate gland .

Pictures & Images

Male Prostate Gland

Reproductive
Anatomy

Prostatectomy - TURP - Series

Series
See all Pictures & Images

Overview & Description

The prostate gland is a fibrous organ that surrounds the urethra at the base of the
bladder in men. An enlarged prostate gland can compress the urethra, thus causing
problems with urination. Prostate enlargement may be caused by prostate gland
overgrowth (benign prostatic hypertrophy or hyperplasia) or prostate cancer.

Removal of the prostate gland can be performed in a number of different ways,

depending on the size of the prostate and the cause of the prostate enlargement
(such as prostate cancer).

The three most common procedures for surgically removing the prostate for benign
disease include: transurethral resection of the prostate (TURP), suprapubic
prostatectomy, and transurethral incision of the prostate (TUIP).

The decision regarding the type of prostatectomy to perform depends on the size of
your prostate gland. Generally, for prostates less than 30 grams, TUIP is
recommended.

For glands bigger than 30 grams and less than 80 grams (this number depends on
the experience of the surgeon), TURP is performed. If the prostate is bigger than 80
grams, open prostatectomy is recommended.

Instruments : TURP
Transurethral resection of the prostate is the gold standard treatment and most
common surgical procedure for benign prostatic hyperplasia (BPH). TURP is
performed using spinal or general anesthesia. A special kind of cystoscope (tubelike
instrument) is inserted into the penis through the urethra to reach the prostate gland.

A special cutting instrument is inserted through the cystoscope to remove the

prostate gland piece by piece. Blood vessels are cauterized (using heat to stop the
bleeding) with electric current during the surgery.

A Foley catheter (artificial tube to remove urine from the body) is placed to help
drain the bladder after surgery. The urine will initially appear very bloody, but will
clear with time.

A bladder irrigation solution may be attached to the catheter to continuously flush

the catheter, thus keeping it from becoming clogged with blood or tissue. The
bleeding will gradually decrease, and the catheter will be removed within 1-3 days.
You will remain in the hospital for 1 to 5 days.

OPEN PROSTATECTOMY
Although the transurethral approach is more commonly used, other surgical
approaches to removal of the prostate gland (such as the transvesical, retropubic,
and suprapubic approach) are sometimes used. The primary advantage of the
transurethral approach is that it does not create an external incision. However, it is
difficult to remove a large prostate using TURP.

To perform an open prostatectomy (sometimes called suprapubic or retropubic

prostatectomy), an incision is made in the lower abdomen between the umbilicus
(belly-button) and the penis through which the prostate gland is removed. This is a
much more involved procedure and usually requires a longer hospitalization and
recovery period.

Open prostatectomy is performed using general or spinal anesthesia. You will

return from surgery with a Foley catheter in place. Occasionally, a suprapubic
catheter will be inserted in the abdominal wall to help drain the bladder.

A bladder irrigation solution may be attached to the catheter to continuously flush

the catheter, thus keeping it from becoming clogged with blood. A drainage tube
may also be placed in the abdominal cavity to drain excess blood and fluids from
the area.

Your urine may initially appear very bloody, but this should resolve in a few days.
The Foley catheter and suprapubic catheters will remain in place for 5 days to a few
weeks until the bladder has sufficiently healed.

TUIP
Transurethral incision of the prostate (TUIP) is similar to TURP, but is usually
performed in people who have a relatively small prostate. This procedure is usually
performed on an outpatient basis and usually does not require a hospital stay.

A small incision is made in the prostatic tissue to enlarge the lumen (opening) of
the urethra and bladder outlet, thus improving the urine flow rate and reducing the
symptoms of BPH.

A Foley catheter may be placed to help drain the bladder after surgery. The catheter
will usually remain in place for a few days after surgery. Another key advantage to
the TUIP is the preservation of normal ejaculation.

Although orgasm is the same in both the TURP and TUIP, the TURP causes the
ejaculate fluid to be projected into the bladder instead of out the penis. The TUIP
usually continues to allow the ejaculate fluid to be expressed out the penis.
Unfortunately, many patients are not candidates for this surgery due to
configuration of their prostates.

NEWER TECHNIQUES
Transurethral laser incision of the prostate (TULIP) and visual laser ablation
(VLAP) are two newer procedures that use lasers to cut out or destroy the prostate
 tissue. These procedures are similar to the transurethral incision of the prostate
(TUIP). Laser is being evaluated for use in removal of prostatic tissue because of
the ability to easily control bleeding and decrease the amount of time required for
healing.

Other treatments being investigated for treating the symptoms of prostate

enlargement include: microwave therapy of the prostate, balloon dilation of the
prostatic urethra, and placement of prostate stents that stretch open the narrowed
urethral passage through the prostate gland.

These procedures have demonstrated short term efficacy in select patients, but have
not had adequate long-term testing.

Symptoms of prostate enlargement and blockage (obstruction) include:

• Frequent urination with small amounts of urine

• Recent need to urinate at night (nocturia)
• Difficulty starting a stream of urine
• Slow stream of urine
• Urine dripping out of urethra after urination (dribbling)
• Feeling that bladder is never empty

An active urinary tract infection is another contraindication for TURP surgery. Usually, the surgery
can be rescheduled following a course of appropriate antibiotics.

Prostate Removal: Indications

Prostate removal may be recommended for:

• inability to completely empty the bladder (urinary retention)

• recurrent bleeding from the prostate
• bladder stones (calculi) with prostate enlargement
• extremely slow urination
• stage A and B prostate cancer
• increased pressure on the ureters and kidneys (hydronephrosis) from urinary
retention

Prostate surgery is not recommended for men who have:

• blood clotting disorders

• bladder disease (neurogenic bladder)

With the exception of skin cancer, prostate cancer is the most common type of
cancer among men in the United States. Early detection may result from a blood
test called a PSA (prostate-specific antigen), and/or a digital rectal exam. The
digital rectal exam checks the rear surface of the prostate gland for any
 abnormalities. A lump or hardness found during the exam might be a sign of
prostate cancer

Prostatectomy - Series: Incision

There are two main surgical methods used for removing the prostate gland . The
first method is called the "perineal" method. An incision is made in the perineum,
which is the area between the base of the scrotum and the anus

The second surgical method of prostatectomy is called the "suprapubic" approach. An

incision is made in the abdomen, just below the umbilicus, which extends downward to
the pubic bone The suprapubic approach allows for removal of the lymph nodes and the
ability to perform a nerve sparing modification that might prevent impotence post
surgery

An enlarged prostate gland compresses the urethra, causing problems with

urination. Prostate enlargement is caused by prostate gland overgrowth (benign
prostatic hypertrophy or hyperplasia) or in some cases, prostate cancer

Diagnostic Tests
The PSA blood test determines whether you have cancer of the
prostate. The test measures how much of a protein essential to
human reproduction, PSA (prostate-specific antigen), is in your
blood. PSA turns your gelatinous pre-semen into a liquid, thus
supporting ejaculation. If your PSA is below 4, most doctors agree
that you needn't be tested again for a year. During annual tests,
remember that it is normal for your reading to go up by a few
tenths of a point every year. In general, only a drastic increase in
PSA (an increase of at least 0.75 points or 20 percent) is considered
a reason to worry. This test is recommended on an annual basis for
all men over 50 (and for men above 45 if there is a family history of
prostate problems).

A digital rectal examination (DRE) is a quick and safe

screening technique in which a doctor inserts a
gloved, lubricated finger into the rectum to feel the
size and shape of the prostate. The prostate should
feel soft, smooth, and even. The doctor checks for
lumps or hard, irregular areas of the prostate that
may indicate the presence of prostate cancer. The
entire prostate

TURP - Series: Procedure

 With an anesthetic (general anesthetic or spinal), a special kind of telescope, called
a resectoscope is inserted through the urethra into the prostate. The resectosope is
used to remove the blocking portions of the prostate. Transurethral resection of the
prostate (TURP) is the most common type of surgical procedure for benign
prostatic hyperplasia (BPH)

cannot be felt during a DRE, but most of it can be examined,

including the area where most prostate cancers are found.