Treatments for BPH
What Are My Surgical Options for BPH?
Medically reviewed by Dr. J. Kellogg Parsons M.D
Advances in medical technology have made surgery for BPH less common, now that clinicians can blast, vaporize, and burn away extra prostate tissue using invasive nonsurgical BPH treatment techniques. But surgery for BPH is still an option if you have severe symptoms that do not respond to other approaches or you have experienced complications that make surgery a wiser choice. Surgical procedures available to deal with BPH include:
- Transurethral incision of the prostate (TUIP)
- Transurethral resection of the prostate (TURP), the traditional gold standard of surgery for BPH
- Transurethral vaporization of the prostate (TVP)
Why Choose Surgery for BPH?
After talking with your doctor, you may be advised to undergo one of the various surgical options for BPH. This is a decision that should not be made without fully understanding the reasons why surgery has been recommended, as well as what the procedure involves, its side effects, and prognosis. You may want or need to choose a surgical option for BPH for one of the following reasons:
You have failed to respond to drugs for BPH. Along with lifestyle changes, many men choose to try one or more of the different drugs available for treatment of BPH, including alpha blockers, 5-alpha reductase inhibitors, a combination of these two drugs, and phosphodiesterase-5 inhibitors (e.g., Cialis). Unfortunately, they don’t always provide the relief they are looking for.
The sexual side effects of BPH drugs are unacceptable to you. Erectile dysfunction, retrograde ejaculation, reduced libido, orgasm difficulties, and breast enlargement—these are the sexual side effects associated with BPH drugs like finasteride. If these drug side effects have been extremely disruptive for both you and your partner, you may choose a surgical procedure rather than put up with these problems.
You have not responded to other treatments for BPH. In addition to medications, other treatments for BPH include lifestyle changes (e.g., adequate sleep, regular exercise, not smoking, healthful diet, maintain healthy weight, limiting alcohol), use of natural and/or herbal supplements, acupuncture, prostate massage, and stress management, among others. While these approaches can be quite effective for many men, others continue to have unresolved symptoms.
You have health issues that make surgical options the wisest choice. For example, if you are unable to urinate (an emergency situation), have a partial blockage of your urethra that causes you to experience bladder stones or repeated urinary tract infections, present with blood in your urine that does not go away, or have kidney damage, then surgery is recommended.
You want to avoid the unacceptable side effects of BPH drugs other than sexual ones. These can include fatigue, fainting, headache, nasal congestion, testicular pain, swelling of hands and feet, and dizziness. In the case of finasteride (Proscar) and other 5-alpha reductase inhibitors (i.e., Avodart, Jalyn), there is also an increased risk of developing high-grade prostate cancer.
What Is Transurethral Incision of the Prostate (TUIP)?
This surgical procedure is typically recommended for men whose prostate is only slightly enlarged (less than 30 g). If you choose this procedure, you will be given either general or spinal anesthesia. The doctor will insert a narrow instrument through the urethra and thread it to where the prostate and bladder meet. The instrument delivers a laser beam or electrical current that makes several cuts in the prostate muscle tissue. These cuts relax the muscles that control the opening and closing of the bladder neck, which in turn allows for urine to flow easier into the urethra.
After the procedure, you will stay in the hospital one day and a catheter will be placed. Often the catheter is needed for up to three days, so you may be released home with the catheter still intact. About 80 percent of men who undergo TUIP experience symptom relief. Possible side effects include retrograde ejaculation (6-55%), erectile dysfunction (4-25%), and urinary incontinence (<1%). About 10 percent of men will need another TUIP in about 15 years.
What is Transurethral Resection of the Prostate (TURP)?
TURP is the gold standard of surgery for an enlarged prostate, although its popularity is declining as other surgical options enter the playing field. This surgical procedure can be used if your prostate is larger than 30 grams and/or your symptoms are severe. It is also sometimes used for men with other conditions such as prostatitis.
You will be placed under spinal or general anesthesia before the surgeon threads a thin instrument called a resectoscope through your urethra to the prostate so he can view the gland. A thin wire loop is then threaded through the urethra and an electrical current is passed along the wire. The surgeon uses the electrified loop to slice away prostate tissue that is blocking the urethra.
Once the instrument is removed, a catheter is placed in the urethra and you will remain in the hospital for about two days or until there is no significant blood or clots in your urine. Symptom improvement rate is about 70 to 85 percent and relief is usually good for 15 years or longer.
Side effects include retrograde ejaculation (25-99%), erectile dysfunction (3-35%), urinary tract infections immediately after surgery (5-10%), and urinary incontinence (5-10%).
Other possible complications include rectal perforation, ruptured bladder, sepsis, sphincter damage, and a condition (TUR syndrome) in which the sterile irrigation fluid used during surgery gets into the bloodstream and reduces sodium levels, resulting in nausea, vomiting, disorientation, and possible seizures. Full recovery takes about four to six weeks
What Is Transurethral Vaporization of the Prostate (TVP)?
TVP is also called transurethral electrovaporization of the prostate and is usually reserved for men whose prostate is 30 grams or less. Unlike TURP, which uses an electrified coil or loop to cut away excess prostate tissue, TVP involves a tiny electrified cylindrical roller or loop electrode.
The procedure can be done under general or local anesthesia. An electrified roller or electrode is attached to a resectoscope that the surgeon guides through the urethra to the prostate. Once the roller reaches the prostate, the roller is heated up to vaporize the excess tissue. During this process, tiny blood vessels in the prostate are cauterized, which reduces the risk of bleeding during and after the procedure. A continuous flow of water is passed through the resectoscope to reduce the heat.
The surgeon will place a urinary catheter that may be removed within 24 hours or more. Men typically can go home within 1 to 3 days.
Retrograde ejaculation is a common side effect. Others can include erectile dysfunction, blood in the urine (usually goes away within 3 weeks), clotting (men may need recatheterization), and urethral stricture (rare).
Because of a lower risk of bleeding, TUVP may be used for men who are taking blood thinners
What Is a Simple Prostatectomy?
A simple prostatectomy means removal of the inner core of the prostate, making it the most radical of the surgical options for BPH. This surgical procedure for BPH is typically reserved for men who have a severely enlarged prostate (75 grams or larger), a damaged bladder, frequent bleeding from the prostate, kidney damage, extremely slow urination, or other serious health problems. Only about 2 to 3 percent of men with BPH get this procedure.
There are four simple prostatectomy approaches to remove the prostate in men with BPH:
- Open retropubic simple prostatectomy, in which the surgeon makes an incision below your belly button. Once inside, the surgeon moves your bladder to the side, cuts into the prostate, and removes the core of the gland.
- Open suprapubic simple prostatectomy, in which the surgeon makes an incision just below your belly button, cuts into your bladder, and removes the prostate tissue through the bladder.
- Laparoscopic simple prostatectomy, in which the surgeon makes five tiny incisions in your abdomen. He or she than inserts lighted magnifying instruments and cameras into the incisions to guide the way to the prostate and removal of its core.
- A simple robot-assisted prostatectomy utilizes the precision of a robotic arm. Compared with the open simple prostatectomies, the robotic technique allows the surgeon more accurate removal of the inner part of the prostate using smaller cuts. This translates into less blood less, less pain, faster recovery, and shorter hospital stay.
During any of these prostatectomy procedures, you will have a drain tube inserted near the surgical site that will remove any fluid that accumulates around the prostate shell and let it collect in a bulb attached to a tube on the outside of your body.
Complications following simple prostatectomy may include bleeding, urinoma (encapsulated urine), and accumulation of urine in the scrotum or penis. Urinary incontinence is rare, and erectile dysfunction and bladder neck contracture occur in about 2 to 3 percent of patients who have suprapubic prostatectomy. Retrograde ejaculation has occurred in up to 80 to 90 percent of men after prostatectomy.