SURGERY FOR BENIGN PROSTATIC HYPERPLASIA
Walter. O'Brien, M. D., Urologist

Invasive intervention may be required for benign prostatic hyperplasia when drug therapy has not worked. By far the most common indication for intervention is when the symptoms trouble a patient enough that he wants something done. Another common reason for intervention is the development of urinary retention which is the inability to urinate.

One of the most common surgeries for BPH is TURP which has remained the gold standard for addressing BPH.

For TURP an instrument called the resectoscope is introduced through the urethra, the tube in the penis. The resectoscope is a fiberoptic instrument used to look into the bladder. During the procedure, the enlarged portions of the prostate are trimmed away with the use of electric current. Bleeding from the vessels is controlled with cautery. A special irrigating fluid is used to keep the field of vision clear to allow the surgeon to identify the correct portion of the prostate to be removed. Surgery is done under a spinal or general anesthesia. After surgery, a catheter is typically left in the bladder for a period of one to four days. In this or any other of the procedures, only the enlarged portion of the prostate involved with the changes of BPH is removed, and the remainder of the prostate is left in place.

Complications of this surgery are very uncommon but can include bleeding from the prostate area, infection, and, very rarely, incontinence and impotence. One of the most common causes of bleeding after surgery is impaired clotting that occurs in patients after taking aspirin, Motrin, or similar compounds. For this reason, patients should stop these specific medications two weeks before their surgery. Severe bleeding could require the need for transfusion and its risks. The potential for infection is lessened with antibiotic therapy as needed. Incontinence, the inability to hold urine, is a very rare complication and happens less than one out of one hundred times. Impotence, the inability to achieve an erection, is another rare complication and occurs in less than five percent of all cases. The risk of general complications, such as heart and lung problems, is the same as for any other operation. A common change after a TURP is retrograde ejaculation. This means that when a man has orgasm and ejaculates, the ejaculated fluid flows back into the bladder rather than out through the tip of the penis. A man's sense of orgasm is not diminished. When there is retrograde ejaculation, a man becomes unable to cause pregnancy.

TURP is one of the most common operations done in this country. In some cases, a man will need a second procedure. This is because only the enlarged part of the prostate is removed and not the total prostate. As a result, the prostate left behind may enlarge again with time. One of the most famous patients. who had surgery on his prostate and then required a second TURP 20 years later was President Reagan.

Patients are usually in the hospital 1-3 days after surgery. In the period following surgery, patients are advised to rest at home for several weeks. Patients generally feel well and are likely to resume their regular activities. Usually, because they do feel so well, there is a tendency to overdo physical activity which can produce bleeding in the area of the operation. Patients are reminded to take it easy to allow themselves to heal.

In open prostatectomy, an abdominal incision is made to remove the enlarged prostate. Open surgery is done when the prostate gland is very large or when stones are present in the bladder, as can sometimes happen in patients with BPH.

Recently, a new technique called laser coagulation has been developed. In this operative procedure, a laser fber is used to coagulate the enlarged portion of the prostate. With laser coagulation, it is not necessary to trim the prostate as is done during a TURP. The hospital stay and post operative recovery are usually shorter. Surgery may be done as an outpatient. The catheter may be left in for a week or more. During the first two to three months after surgery, there is increased frequency and urgency of urination and occasionally uncomfortable urination, which can be bothersome until it subsides as healing occurs.

Other techniques include transurethral microwave therapy (TUMT) and transurethral needle ablation (TUNA). Both of the treatments use a form of energy to raise the heat of the prostate which results in coagulation and shrinking of the enlarged portion of the prostate. TUMT is done on an outpatient basis under light sedation. The TUNA procedure uses high frequency energy to elevate the temperature of the prostate and eventually lead to the shrinking of the enlarged portion of the prostate. This can be done on an outpatient basis but requires a regional or general anesthetic. Like laser, TUMT or TUNA, require a catheter for at least several days after treatment.

In conclusion, BPH is a common problem among middle and older aged men. Fortunately, it can be managed very effectively and most men can be helped by a urologist.