Transurethral Resection of the Prostate (TURP)
The usual operation for benign prostate enlargement (BPH) is Transurethral Resection of the Prostate (TURP). TURP is the surgical removal of part of the prostate gland to relieve symptoms of the enlarged prostate.
The immediate aim of the operation is to remove that inner part of the prostate (adenoma) which is pressing on the urethra. We do not attempt to remove the outer part of the prostate (the capsule) as this is a much more serious operation and is not necessary. Occasionally, just making a cut (incision) in the bladder neck is sufficient to relieve all problems. The operation is performed by the passage of an instrument along the penis and into the bladder, along the urethra. The instrument has a telescope and an electrical cutting attachment and a miniature TV camera is attached. The surgeon can see the prostate and then removes the blocking portion piece by piece, as shown in the diagram. This operation (TURP) is fast, safe, relatively painless and usually only requires a hospital stay of a couple of days. There are no cut and no stitches.
Unfortunately, the TURP is not suitable for a few very large prostate glands, and occasionally we have to perform open surgery. This is called open or retropubic prostatectomy. This requires stitches and the patient is in hospital for several days longer. It is important to understand that these operations are not designed to treat Prostate Cancer. If we are trying to cure prostate cancer, we do a different type of operation called a Radical Prostatectomy (refer to cancerous section of the prostate). It is a much bigger procedure that the TURP, removing the capsule and adenoma together and has more potential side effects.
Modern anaesthetics are very safe. Usually you will have a spinal anaesthetic, where after having an injection in the back, you become numb from the waist down. The spinal anaesthetic provides excellent operating conditions. Most patients have some form of sedation as well, so they are not upset or frightened by what is happening.
As well as being very safe, the spinal anaesthetic allows you to have a cup of tea as soon as you get back to your ward. For a variety of different reasons, the anaesthetist may recommend a general anaesthetic (particularly for people who have had prior back problems). You will have an injection in the arm and go to sleep. Nowadays, the time it takes to wake up after the operation is much less than in the years gone by.
It is standard practice to administer a single dose of a broad spectrum antibiotic during the procedure.
It is important that you tell your urologist of any medications you are taking. This includes any that your doctor has prescribed, as well as any you have purchased for yourself. Warfarin, Aspirin and other anti-platelet drugs such as Plavix, Iscover or Prodaxa may cause significant bleeding during the TURP. We generally ask patients to cease taking Aspirin and the other anti-platelet drugs one week prior to prostate surgery, and restart it about a week after the operation as long as there is not too much bleeding. If you are taking any blood thinning medications, please tell us! Some arthritic medicines also promote bleeding but are not as much of a problem as aspirin.
Many of our patients now take the above medications and operating on a ‘bleeder’ can been quite difficult, requiring careful consultation with GP’s, cardiologists and anaesthetists for each individual. For some, stopping the above medications is not possible. Green Light Laser (refer to Greenlight laser section) is another surgical procedure which allows us to operate on such patients.
What happens in the hospital after the operation?
Catheter and bladder washout
After the operation there is a raw surface left inside the prostate. Because this bleeds a catheter (tube) is left in the bladder (via the penis) to drain away the blood and urine. In the post-operative stage, the bleeding may be heavy and clots can form and block the catheter. Thus a bladder washout is used to wash the blood away before clots form. This means that there are extra bags of clear fluid hanging near the end of your bed. The amount of blood in the catheter gradually gets less and the washout is usually stopped on the day following surgery. By this stage you can usually drink enough fluid to keep the urine free of clots. The catheter is usually removed on the first or second day after surgery. This is quite a simple and painless process.
Most patients have an intravenous drip in their arm for a day after the operation. This may be used to give medicines or fluids, but it just a precautionary measure in most cases.
Eating and Drinking
You will most likely be able to eat and drink on the night after the operation. As soon as possible we would like you to begin drinking a large amount of fluid.
This is the single most important thing you can do to hasten your own recovery.
It is most important to keep the bowels as regular as possible. If you become constipated, you will have to strain and this often causes the prostate to bleed more. It is important you eat a high fibre diet and drink adequate fluids before and after your surgery. If you require assistance with management of this, please contact the Practice Nurse.
While the catheter is in, you do not have to pass urine yourself. The catheter will drain it away. Often it feels as though you have a full bladder, but this is usually just a ‘bladder spasm’, where the catheter irritates the bladder. If you get this feeling, the nurse will check to ensure that the bladder is not full with a bladder scanner. If not blocked these spasms, although uncomfortable, are harmless and should not worry you. If they are painful, medication can be given to reduce them.
When the catheter is removed
The day the catheter is taken out is often a worrying time. Many patients notice some scalding initially, and also some difficulty controlling the flow of urine. The most common problem is for the flow of urine to start with little warning, therefore, it is wise not to try to hold back the urine at first, but to go to the toilet immediately. The nurses will usually ask you to pass your urine into a urinal (‘bottle’) so that it can be measured, tested and recorded. The nurse will then check how well you have emptied your bladder using the bladder scanner.
We try to collect a urine specimen on the day the catheter is removed, mainly to check for infection. As most men are being discharged from hospital within 24 hours of catheter removal the result will not usually be available until after you have left the hospital. If there is a problem, we will contact you.
What happens at home after the operation?
Discomfort and urgency
You will usually go home the day the catheter is removed or the next day. Most men notice some discomfort when urinating. This is often felt at the tip of the penis. Pain that continues after urinating, producing a sensation that the bladder hasn’t emptied, may also occur. These are normal and usually disappear after a week or two. For some patients, this may take a little longer.
Many men have quite marked urgency that is having to rush to the toilet. This is because the bladder has become overactive from straining to empty prior to surgery. This urgency gradually settles and may take a few weeks, although in some men it may take several months. If urgency is a particular problem, there are medications which can help.
The raw surface of the prostate takes about six weeks to heal completely. You may pass some blood in the urine, particularly in the first or second week after you go home. Do not worry about this. If the urine gets blood stained, then just drink some extra fluid to wash it out. However, if bleeding becomes heavier, especially if you are passing clots or if you are unable to pass any urine, contact the Practice Nurse or your Urologist immediately.
It is wise to continue to drink extra fluids for a few weeks following the procedure, particularly, if you see any blood appearing in the urine.
You should usually stay indoors for a week or so after discharge. It is usually wise not to drive a car for a couple of weeks. Do not indulge in any strenuous activity for four weeks. Avoid heavy lifting, gardening and golf. Refrain from horse riding, motor cycle or bicycle riding. You may return to work after four weeks unless you have a heavy manual job, where it is wise to wait an extra two weeks.
It is important to keep the bowels soft and regular. A high fibre diet incorporating Bran often helps as well as adequate fluid intake.
Most patients have excellent control of their bladder when they leave hospital, there are a few who still have some problems controlling the flow of urine. This is usually due to damage already done to the bladder by the prostatic obstruction. With time, all such cases improve. Permanent loss of continence is a very rare complication of TURP.
Some men who have presented with retention may have trouble passing urine or emptying their bladders completely after the operation. This occurs because the bladder has been overstretched and becomes weak. These patients may require a period of indwelling or intermittent catheterization at home while their bladders recover.
Many men are concerned that a prostate operation will end their sex lives. However, with today’s techniques this is very uncommon. The only difference is that after the operation, there is no emission with ejaculation (nothing comes out). This is due to the removal of the bladder neck. This means semen passes backwards into the bladder during ejaculation and you may note that the urine you pass after intercourse appears a little cloudy. This is nothing to worry about as the fluid will do no harm. The ability to maintain an erection is nearly always retained and sexual intercourse can be resumed a few weeks after surgery. Patients often say that their sensation of orgasm is not as strong as it was before the operation.