ENLARGED PROSTATE (BPH)

When the cells of prostate cells increase in number and if this multiplication is non-malignant then it is called Benign Prostatic Hyperplasia (BPH). Once this process gets initiated it cannot be stopped, unless some medication has been started. Two growth mechanisms have been observed, one in which the cells surrounding the urethra grow, and then this growth squeezes the urethra. In the second mechanism, the cells grow into the urethra and bladder outlet region. The patients with the second type of mechanism need to undergo surgical intervention.

SIGNS AND SYMPTOMS OF ENLARGED PROSTATE (BPH)

  • Hematuria (blood during micturition due to straining)
  • Dribbling of urine post void;
  • Feeling of bladder fullness even after urination;
  • Increase in the number of frequency, especially during the night;
  • Urinary hesitancy or urine stream weakness
  • Urinary incontinence;
  • Pressure (push or strain) to start urination;
  • Need for sudden urination

DIAGNOSIS OF ENLARGED PROSTATE (BPH)

  1. Digital Rectal Examination (DRE): It is performed by the doctor by inserting the lubricated gloved finger into the patient’s rectum to feel the contour of the prostate gland. If the examination shows unhealthy tissue, then the doctor advises for additional tests.
  2. AUA Symptom Index: The severity of urinary problems is assessed by AUA symptom index, which is rated on a scale of 1 to 5. A score of 0 to 7 means mild condition, 8 to 19 means moderate, and 20 to 35 means severe.
  3. PSA Test: The higher level of PSA levels indicates a higher probability of having prostate cancer.
  4. Uroflowmetry Test: Bladder emptying time is calculated by the uroflowmetry test. It also measures the amount of urine and the rate of urine flow. A slow flow rate of urine usually indicates BPH.
  5. Post-Void Residual (PVR): The remaining quantity of urine after urination is called post-void residual, which is ascertained by ultrasonography. A quantity of more than 100 ml indicates obstruction.

TRANSURETHRAL RESECTION OF THE PROSTATE (TURP)

It is a surgical procedure that is performed to treat BPH (enlarged prostate). This surgical procedure is performed using a resectoscope that is inserted into the urethra. It is the commonest procedure being performed to treat BPH. It is performed either under general or spinal anesthesia.

Types of TURP

Monopolar TURP: Conventional TURP removes tissue with a wire loop that has electrical current flowing in one (monopolar) direction to cut the tissue through the resectoscope. The surgical site is irrigated with fluid that is not conductive. This fluid prevents electrical current from affecting the surrounding tissues, but prolonged exposure may damage the tissues and cause TUR syndrome. And hence, the time for surgery has to be limited.

Bipolar TURP: A newer technique to extract the tissue Bipolar TURP requires bipolar current. Since it makes saline irrigation (instead of non-conducting glycine as in monopolar TURP), complications such as TUR syndrome are reduced. It requires a longer duration of intervention.

Plasmakinetic resection: PK or Button resection uses a semi-spherical button to vaporize the tissue from the inside. This button is heated by low voltage electricity that forms ionized vapor. Among all the techniques that use electricity, this is considered least manipulative with good outcomes and early recovery.

RISKS OF TURP

Temporary difficulty urinating: Post-procedure the patient complains of difficulty in urination, for which a catheter is inserted in the penis to flush the urine out. It is kept until the patient is able to urinate by self.

Urinary tract infection: This form of infection after any prostate operation, is a potential complication. The longer a catheter is in place, the possibility of infection is also high. The majority of the patients suffer from this.

Dry orgasm: A typical and long-term effect of any form of prostate surgery is to release semen into the bladder, rather than out of the penis, during ejaculation, known as retrograde ejaculation, dry orgasm is not harmful and doesn’t affect sexual pleasure in general. But it can hamper the ability to father a child.

Erectile dysfunction: The risk is very small but after treatment, erectile dysfunction may occur.

Heavy bleeding: In the majority of the patients, there is very little blood loss during the TURP and does not require a blood transfusion. But patients with large prostate size are at higher risk for blood loss and may require a blood transfusion.

Difficulty holding urine: Incontinence (loss of bladder control) is rarely a long-term complication of TURP.

Low sodium in the blood: Rarely, in TURP, the body absorbs too much of the fluid used to wash the surgical area. The disorder can be life-threatening if untreated, known as TURP syndrome or transurethral resection (TUR) syndrome. A technique called bipolar TURP reduces this risk.

Need for re-treatment: Following TURP some people need follow-up therapy because symptoms do not improve or they worsen over time. Re-treatment is often required because TURP causes the urethra or the neck of the bladder to narrow (strict).

Post-TURP syndrome:

In rare cases, the post-TURP syndrome occurs. This is where too much of the fluid used for surgical flushing is absorbed by the body, leading to the major electrolyte, fluid, and blood volume imbalances.

Early signs of post-TURP syndrome include:

  • nausea
  • dizziness
  • restlessness
  • abdominal pain
  • tightness in the chest
  • Signs of the severe post-TURP syndrome include:
  • confusion
  • difficulty breathing
  • blurred vision
  • seizure
  • coma

While rare, if not treated early enough, the post-TURP syndrome may be fatal.

ADVANTAGES OF BIPOLAR TURP

In the monopolar system, the current passes through the patient’s body from the active electrode, placed on the resectoscope, toward the return plate placed on the patient’s leg, causing heating of deeper tissue, nerve, or muscle stimulation and may also lead to malfunction of the cardiac pacemaker. While in the bipolar system the active and return electrodes are placed on the same axis on resectoscopes using high current locally but with limited negative effects at a distance. (Kellow NH, 1993)

The other advantages of bipolar resection are improved hemostasis, better intraoperative visualization, and the use of saline as an irrigant, which reduces the risk for TUR syndrome. (Starkman et al, 2005) Some studies also reported shorter catheterization time and reduced hospital stay. (De Sio et al, 2006).

PREPARATION FOR SURGERY

Prior to surgery, the doctor might recommend stopping the use of certain medications like those which are used for blood thinning, analgesics, etc. and may prescribe antibiotics for prevention of urinary tract infection. The patient is also guided about the arrangement of the transport facility, bringing along some known person to assist.

What you can expect

It takes some 60 to 90 minutes to perform the TURP procedure which is done under general anesthesia i.e. the patient is unconscious during the whole procedure or under spinal anesthesia, when the patient remains conscious during the procedure.

During the procedure

The resectoscope is inserted through the tip of your penis and extended through the prostate area through the urethra. No incision is made over the body. Tissue trimming from inside the prostate gland is done using a resectoscope. An irrigating fluid pushes these tissues into the bladder and from there it is removed at the procedure ends.

After the procedure

The patient is hospitalized for nearly 1 to 2 days and more if the clinical condition of the patient does not allow to be discharged. The catheter is placed for nearly 24 to 48 hours until the swelling subsides which is caused due to blocking of urine flow.  This catheter is removed once the patient is able to urinate by self.

ADVISE POST SURGERY

  • Drink plenty of water to drip the bladder out.
  • Eat high-fiber foods during a bowel transfer, to prevent constipation and pressure. A stool softener might also be recommended.
  • Holding anticoagulants (blood-thinning medication) until advised by the doctor.
  • Avoid strenuous exercise for 4 to 6 weeks, till approved by the doctor.
  • Avoid intercourse for 4-6 weeks.
  • Avoid driving until the catheter has been removed.

RECOVERY TIME

Post TURP generally the patient is able to return to normal activities by 1 to 2 weeks and is able to perform heavy activities within 2 months.

After the bladder has been completely flushed, the catheter is removed. This usually takes around 2-3 days of post TURP intervention.

RESULTS

TURP usually alleviates the symptoms easily. In a few days, most people undergo a noticeably stronger flow of urine. Sometimes follow-up treatment is needed to ease the symptoms, especially after several years have passed.

WHEN TO CONTACT 

If the patient sees thick blood in urine, with the deteriorating condition or feels there is blocking of urine or unable to urine, immediately contact the doctor.

If the urine is still tinged even after taking sufficient fluid for 24 hours.