TURP

This is the operation used to remove the middle part of the prostate gland that is causing a blockage to the urinary flow.  It has been around for over 80 years and is usually very successful.  It is important to realise that in this operation not all of the prostate is removed.  The whole prostate can be removed but this is a much bigger operation with more side effects that is used to treat prostate cancer.

It is hoped that these notes will help you in preparation for the operation.  If you have any questions please do not hesitate to ask your doctor.

What is the prostate gland?

The prostate is a small organ that lies between the bladder and urethra (the tube we pass water through) – see picture.  It can vary in size from a walnut to an orange and tends to get bigger in most men as we age.  The main function of the prostate is to produce the fluid that is ejaculated with sperm.        

Bladder outflow obstruction

This is the term used when there is a blockage to the urine flow.  The commonest cause of the blockage is prostate enlargement though a blockage anywhere from the bladder to the foreskin can cause the same symptoms.  Usually the urinary flow is slow, the bladder may not empty properly, you may pass water very frequently and wake up often at night to pass water.  If left untreated it can cause damage to the kidneys by back-pressure from the bladder or it may not be possible to pass water at all (retention).

Tablets can be used to try and improve symptoms.  The common types are either alpha-blockers (prazosin/Minipress, tamsulosin/Flomaxtra) or 5 alpha reductase inhibitors (finasteride/Proscar).  There is a combination drug (Duodart) which theoretically both shrinks the prostate and opens the bladder neck.  These can be helpful if the blockage is not severe but if you have tried these and are still getting problems then an operation is often the best treatment.

Other operations

There are a number of other operations that have been used to treat bladder outflow obstruction. 

Bladder neck incision (BNI) is a simpler procedure that can be used when the prostate is small – if possible this will be done instead of TURP.  The hospital stay is shorter and complications less frequent. 

Laser prostate operations are possible – either cutting away the prostate (HoLEP) or vapourising the prostate (Green light laser or PVP).  The attraction of these operations is that they may be done as day case procedures but patients often go home with catheters draining their bladder for a few days and the long term results are not known.  With the Green light operation there is the possibility of missing some cases of prostate cancer.   They are very good operations for patients who have to be on blood thinning medication.  They can be discussed in more detail if you like.

A host of other procedures have been developed using microwaves, needle ablation, staples (UroLift) and more recently, steam (Rezum).  These have often been proposed by small numbers of urologists and not stood up to long-term scrutiny.  As with a lot of conditions, if there are a large number of procedures then there is suspicion if any of them work.  Both Rezum and UroLift may be suitable for younger men with small prostates but are only available in limited private hospitals.

Radical prostatectomy/Robotic prostatectomy are reserved for patients known to have prostate cancer and are much more major procedures.

The operation

Most procedures are performed through telescopes with no external cuts.  Very rarely the prostate gland is so big that it is safer and quicker to perform a cutting operation where the middle part of the prostate is removed (retropubic prostatectomy).  In these cases an extra night or two is required in hospital.

At the time of the operation the bladder and internal part of the prostate are examined with the telescope.  A special cutting telescope (resectoscope) is then put into the penis and down into the prostate and the middle part of the organ is removed by cutting away small “chips” – see picture.  These are then washed out, any bleeding stopped and a catheter put inside to drain the bladder and any remaining blood.  All the “chips” are sent to the pathology lab and analysed to check whether there is prostate cancer.

The operation can be performed with either a full general anaesthetic or a spinal anaesthetic, where you are awake but temporarily have no feelings below your belly button.  Please speak to the anaesthetist if you have any questions about the type of anaesthesia.

After the operation

There will be some big bags of fluid attached to the catheter for the first day or so.  These help to wash out any blood clots.  You will be encouraged to drink plenty of fluid, ideally about 3 litres for the first 24 hours, before returning to a more normal amount.  Usually the catheter is removed after 1 or 2 days and you are kept in hospital until you are passing water well.  There may be some stinging and some blood when you first pass water but this settles down fairly quickly.

Once at home there may still be occasional blood in the water, sometimes some clots will pass and there may be occasional pain when you pass water.  If this happens drink a little more fluid to wash the bladder out.  You do not generally have to see your own local doctor unless your problems are unbearable.  If it becomes impossible to pass water please ring up or return to hospital.  Heavy lifting, work and any driving should be avoided for the first 2 weeks following the operation and after that time can be gently reintroduced.  Most men admit that they feel a bit miserable for 6-8 weeks following the operation, and there can be symptoms similar to a urinary infection, so do take it fairly easy.  It is important to remember that despite there being no external cuts this operation is classified as major surgery. 

Possible complications

As with any operation there are a number of possible complications.  Every effort is made to minimize the risk of these occurring and it is important to realise that the majority of men do not suffer any long term problems related to the surgery.

There can be problems related to having an anaesthetic or being immobile for a period – these include chest infections and swelling of the legs, which rarely can be due to deep venous thrombosis (DVT).  As such it is important that you try and get up and out of bed as soon as possible.  You will also be given some special stockings which will help prevent DVT.

Bleeding.  There is always some bleeding with this operation but it usually settles quickly and rarely causes trouble.  Less than 10% (1 in 10) men require a blood transfusion.  Very rarely it is necessary to return to the operating theatre to wash out some blood clots.

Retrograde ejaculation.  This means that the fluid normally ejaculated during orgasm passes into the bladder and is expelled with the next urine which can therefore look a bit cloudy.  It is also known as dry ejaculation.  This occurs very commonly after the operation.  It may prevent you fathering any more children so if you are thinking of this please let your doctor know.

Erections.  As the nerves to the penis are very close to the prostate gland there can be an effect on erections.  About 10% of men can have problems with erections after TURP.  If this becomes a problem there are various ways it can be improved.  About 5% (1 in 20) of men get improved erections as the urinary problems were effecting the erections.

Recurrence of symptoms.  Between 2-5% (1 in 20-50) men notice that their urinary flow slows down quite quickly shortly after the operation.  This can be due to scar tissue forming either in the urethra (stricture) or the bladder neck (stenosis).  This can be fixed with a fairly simple operation.  The prostate gland can regrow and cause more problems but this is rare and generally only 20% (1 in 5) men have further problems after 10 years.

Incontinence.  This means the urine can leak away with little control.  It is very rare after TURP, occurring in less than 1% (1 in 100) operations.  If it does occur let your doctor know as there are a number of ways it can be improved.

Prostate cancer.  This operation is not usually performed as a treatment for prostate cancer, but all the samples removed at surgery are analysed.  If prostate cancer is found you will be informed by your doctor and any necessary further treatment will be discussed.  Whilst it is reassuring if no prostate cancer is found, you may still develop prostate cancer later.  You can discuss this further with your doctor.

Sue McCracken has very kindly allowed me to use this poem and I hope you enjoy it.

TURP-EE or not TURP-EE

It started in the morning,
When I booked in, so unsure,
For a little bit of 'plumbing work'-
The much needed 're-bore'.

‘Twas sweet when out of theatre,
The epidural made me numb,
But as it started wearing off-
My thoughts were changing some!

The nurses came to check the bag,
The contents looked like wine;
They graded it -'like a Shiraz-
The colour's looking fine'.

When they removed the catheter,
It  gave me quite a scare!
I wondered how they managed
To fit all that up there!

And since that 'dreaded TURP day'
That embarrassed me a-plenty,
In all it was a good thing-
I can pee like I was twenty!

 By Sue McCracken

I wrote this poem for Rob  after his TURP operation at Warragul hospital on June 20th 2011.