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Benign enlarged prostate: Surgery: Advantages and disadvantages

Last Update: January 15, 2014; Next update: 2017.

Surgery can very effectively reduce the problems associated with a benign enlarged prostate. But side effects are common. Surgery is considered if, for instance, other treatments do not provide enough relief, or if the enlarged prostate keeps causing medical problems such as urinary tract infections.

There is usually no urgent need for men who have a benign enlarged prostate to have surgery. So they can generally take their time to consider whether they think a surgical procedure will have more pros or more cons for them. Men might decide to have surgery for various reasons:

  • The prostate-related problems are very distressing, and other treatments have not lead to a big enough improvement.
  • The enlarged prostate frequently causes other medical problems, such as recurring urinary tract infections or bladder stones.
  • Treatment with medication is not possible for medical reasons.

An enlarged prostate can occasionally lead to a fairly rare complication called acute urinary retention. This happens when the prostate pushes against the urethra so much that the man can hardly urinate any more, or can no longer urinate at all. Then the bladder has to be emptied using a catheter. Surgery is usually needed afterwards too. Sometimes surgical treatment is not an option, or not advisable, because of other medical conditions or particular risks. For example, general anesthetics may be too risky in some people.

What happens during surgery?

Surgical treatment of enlarged prostates does not usually involve completely removing the prostate, but makes it smaller so that it no longer pushes against the bladder and urethra. Most of the procedures are done by guiding tiny instruments through the urethra (transurethral) until they reach the prostate, and then either removing tissue or widening the urethra. This kind of procedure is called “closed surgery.” In “open prostate surgery,” the prostate is operated on through an incision (cut) in the abdominal wall. This is only rarely necessary, for example if the prostate is very enlarged.

Many different surgical techniques and many different instruments and devices can be used to remove prostate tissue in different ways.

What types of surgery are considered to be “standard”?

A technique called transurethral resection of the prostate (TURP) is considered to be the standard surgical approach. This procedure involves inserting a thin tube called a resectoscope into the urethra and guiding it through to the prostate. The resectoscope is equipped with a tiny camera and an electrical loop that is used to mechanically remove prostate tissue. The loop produces heat at the same time, which quickly seals off the blood vessels. The resectoscope also has a valve that regulates the release of fluid to flush the removed tissue out. TURP takes about 90 minutes and is done under local or general anesthetic. Men who have had this procedure usually need to have a urinary catheter (a tube that drains the bladder) for a few days after, and stay in the hospital for two to seven days. After that it can take a few weeks before everything returns to normal.

Some variations of TURP are also considered to be standard treatments and have similar outcomes and consequences to conventional TURP. These include transurethral electrovaporization (TUEVP), transurethral vaporesection (TUVRP) and plasmakinetic enucleation of the prostate (PkEP).

There is another well-established surgical procedure called transurethral incision of the prostate (TUIP). In this approach, the pressure on the urethra is relieved without removing any prostate tissue. To do this, the surgeon makes one or two small incisions (cuts) where the bladder meets the prostate. This frees up a little space for the narrow urethra, relieving the pressure. The advantage of this technique is that certain side effects, such as bleeding, are less common. But TUIP is only suitable for men whose prostate is not very enlarged. And the procedure might have to be repeated after a while.

How effective is TURP and what consequences can it have?

Studies have shown that TURP can permanently reduce prostate-related problems. Nine months after having TURP, about 75 out of 100 men only have mild symptoms. For example, at night they only need to get up to go to the bathroom once, or not at all. The other men still benefit from TURP, but the effect is smaller. Also, compared with some of the other approaches, it is less likely that a TURP procedure will have to be repeated. But side effects are common.

The most common side effect of TURP is “dry orgasm" or "dry climax" (retrograde ejaculation). This is where no semen, or much less than usual, leaves the penis during ejaculation. Instead, the semen flows into the bladder. This can happen if the muscles that normally close the entrance of the bladder during ejaculation are damaged during surgery. Although dry orgasms are not harmful and usually do not affect men’s sexual pleasure during orgasm, they do reduce fertility. Many men worry that they will develop erection problems after surgery. These concerns are not unfounded: they may indeed experience erection problems in the time following surgery. But research has shown that surgery only rarely leads to permanent problems in this area.

Other possible consequences of TURP include urinary tract infections and temporary loss of bladder control (incontinence). And - like with most operations -– there is a risk of bleeding that needs to be treated. In rare cases, surgery can cause narrowing of the urethra. Long-term effects such as permanent incontinence are rare too.

TURP can also lead to "TUR syndrome" – a condition associated with temporary nausea, vomiting or confusion. Although this complication is rare, it can be life-threatening. It can develop if some of the fluid that is used during surgery to flush away the removed prostate tissue gets into the bloodstream. In rare cases, TUR syndrome can cause cardiovascular problems. The studies in this area found that 2 to 3 out of 100 men developed TUR syndrome, but it did not have any serious health consequences.

What other techniques are used?

As well as the standard approaches, there are a number of other surgical techniques. They mainly differ in terms of the instruments and sources of energy used to remove or destroy the prostate tissue. Some techniques use lasers, others use heat (thermotherapy). Like in TURP, the instruments are inserted into the urethra and guided to the prostate.

Laser treatments

The laser treatments include:

  • holmium laser enucleation of the prostate (HoLEP)
  • holmium laser resection of the prostate (HoLRP) / thulium laser resection of the prostate (TmLRP)
  • visual laser ablation of the prostate (VLAP)
  • contact laser ablation of the prostate (CLAP)
  • photoselective vaporization of the prostate (PVP) / green laser therapy

The two holmium techniques are about as invasive as TURP is.  Research suggests that they are probably about as effective as TURP too. The holmium techniques somewhat reduce the amount of time people need to stay in hospital and have a catheter. And there is no risk of developing TUR syndrome.

Visual laser ablation and contact laser ablation of the prostate are believed to be less effective in the long term. PVP might be about as effective as TURP, but the research results in this area are not clear.

Heat therapy

In heat therapy (thermotherapy), the prostate tissue is destroyed by heating it to temperatures between 40°C and 80°C. Heat therapy that uses radio waves is called transurethral needle ablation (TUNA), and heat therapy that uses microwaves is called transurethral microwave thermotherapy (TUMT). Both of these approaches can be done under local anesthetic and without having to stay overnight in a hospital.

Microwave thermotherapy is not as effective as the conventional surgical techniques. Compared to TURP, it is also more common for microwave thermotherapy to have to be repeated. A further disadvantage of TUMT is that men need to have a catheter for much longer after the procedure. But it also has some advantages: ejaculation problems and bleeding are less common afterwards. So TUMT is a suitable alternative option for some men. Needle ablation also seems to be a more gentle technique. But there is not much good research on how effective it is.

Which approach is most suitable?

You can discuss the pros and cons of the various surgical techniques with a doctor to help you decide which approaches would be possible options for you. This decision will depend on the size of your prostate, but also on personal factors such as your age and how healthy you are otherwise.

With some of the less invasive techniques, the associated side effects are less common and not as serious as those associated with TURP. For example, some laser and other treatments are less likely to cause heavy bleeding. This could be an important decision factor for men who are taking blood-thinning medication. If a man still wishes to have children, microwave thermotherapy might be more suitable than TURP or a holmium laser technique because these often lead to ejaculation problems.

Not every hospital will use every single technique, though, which means that a man's choice of surgical approach will also depend on what is available. As with any surgical intervention, the surgeon's level of experience with a certain approach and the hospital's area of specialization will play an important role.

What happens after surgery?

Most kinds of prostate surgery are carried out in hospital. The amount of time you will have to stay in hospital will depend on the type of treatment you have and how quickly you recover. To prevent the healing wound from coming into contact with urine, a urinary catheter is needed for a few days after surgery. A catheter is a thin plastic tube that drains the bladder through the urethra. The tube is held in place by a small water-filled balloon in the bladder. This can lead to painful bladder spasms, mainly in the first few hours and days. Antibiotics are sometimes used to prevent infections.

In the first two days after surgery your urine might have blood or clumps of blood in it –  particularly following TURP. It is important to drink a lot of water in the first few days in order to rinse the bladder and speed up the healing process. Mild bleeding may occur later too, for example when scabs break away and are flushed out.

Even if you no longer have any pain, it will take some time for the wound to heal completely. That is why it is important to take care in the first few weeks: strenuous physical activity, sudden movements and lifting heavy objects increase the risk of the wound bleeding. You can talk to your doctor about what you can do in everyday life to recover more quickly.

It can take a few months to recover completely. During this time you may have urinary problems, such as an urge to urinate or temporary loss of bladder control. Your organs need some time to adjust to the changes in the operated area and to start working normally again. Patience is needed during this time. A good doctor can help you to cope with the problems that arise during the healing process.

Sources

  • Hoffman RM, Monga M, Elliott SP, Macdonald R, Langsjoen J, Tacklind J, et al. Microwave thermotherapy for benign prostatic hyperplasia. Cochrane Database Sys Rev 2012; (9): CD004135. [PubMed: 22972068]
  • Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG). Nichtmedikamentöse lokale Verfahren zur Behandlung des benignen Prostatasyndroms – Update: Abschlussbericht; Auftrag N09-01.14.12.2009 (IQWiG-Berichte; Band 69).
  • Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG). Nichtmedikamentöse lokale Verfahren zur Behandlung der benignen Prostatahyperplasie: Abschlussbericht; Auftrag N04-01. 02.06.2008 (IQWiG-Berichte; Band 33).
  • National Institute for Health and Clinical Excellence (NICE). Lower urinary tract symptoms. 05.2010. (NICE Clinical Guidelines; Band 97).
  • Thangasamy IA, Chalasani V, Bachmann A, Woo HH. Photoselective vaporisation of the prostate using 80-W and 120-W laser versus transurethral resection of the prostate for benign prostatic hyperplasia: a systematic review with meta-analysis from 2002 to 2012. European Urology 2012; 62(2): 315-323. [PubMed: 22575913]
  • IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

    Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. We do not offer individual consultations.

    Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.

© IQWiG (Institute for Quality and Efficiency in Health Care)

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