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BPH: Surgical Management (Benign Prostatic Hyperplasia/Enlarged Prostate)

Throughout a man's life, his prostate may grow and start to cause problems as he ages. But what are some of those problems? Why are many urologists recommending surgery as a way to fix those problems? What are some of the surgical options available? The following should help answer those questions.

What is the prostate?

The prostate is part of the male reproductive system, is about the same size and shape as a walnut and weighs about an ounce. It is located below the bladder and in front of the rectum and surrounds the urethra, the tube-like structure that carries urine from the bladder out through the penis. The main function of the prostate is to produce ejaculatory fluid.

What is BPH?

Benign prostatic hyperplasia (BPH), previously referred to as prostatism, is a common urological condition caused by the non-cancerous enlargement of the prostate gland in aging men.

What are some of the risk factors for BPH?

Risk factors for developing BPH include increasing age, obesity, depression, race (African American men have an increased risk) and a family history of BPH.

What are some of the symptoms associated with BPH?

Since the prostate surrounds the urethra just below the bladder, its enlargement can result in symptoms that irritate or obstruct the bladder. A common symptom is the need to frequently empty the bladder, especially at night. Other symptoms include difficulty in starting the urine flow or dribbling after urination ends. Also, size and strength of the urine stream may decrease.

Fill out the AUA Symptom Score and share the results with your health care provider.

How is BPH diagnosed?

In order to help assess the severity of such symptoms, the American Urological Association (AUA) BPH Symptom Score Index was developed. This diagnostic system includes a series of questions that target the frequency of the urinary systems identified above, and as a result, helps identify the severity of the BPH—ranging from mild to severe.

There are a number of diagnostic test procedures that can be used to confirm BPH. The tests vary from patient to patient, but the following are the most common: digital rectal examination (DRE), PSA test, rectal ultrasound, urine flow study and cystoscopy.

When is surgical treatment suggested as a form of treatment?

When medical therapy fails, surgery is required to remove the obstructing tissue. Surgery is almost always recommended for men who are unable to urinate, have kidney damage, frequent urinary tract infections, significant bleeding or stones in the bladder.

What are the different surgical treatments available?

Removal of the prostate can be accomplished in several different ways. The location of the enlargement within the prostate and the patient's general health will help the urologist determine which of the three following procedures to use.

Transurethral resection of the prostate (TURP): Transurethral resection is the most common surgery for BPH. In the United States, approximately 150,000 people have TURPs performed each year. This can be done using electric current or with laser light. After the patient receives anesthesia, the surgeon inserts an instrument called a resectoscope through the tip of the penis into the urethra. The resectoscope contains a light, valves for controlling irrigating fluid and an electrical loop that cuts tissue and seals blood vessels. The removed tissue pieces are carried by the irrigating fluid into the bladder and then flushed out and sent to a pathologist for examination under a microscope. At the end of the procedure, a catheter is placed in the bladder through the penis. The bladder is continuously irrigated with fluid through the catheter in order to monitor bleeding and prevent blood from clotting and obstructing the catheter. Since there are no surgical incisions with this procedure, patients normally stay in the hospital only one to two days. Depending on surgeon preference, the catheter may be removed while the patient is still in the hospital or the patient may be sent home with the catheter in place, attached to a leg bag for convenience and removed several days later as an outpatient procedure.

Transurethral incision of the prostate (TUIP): Transurethral incision is used for men with smaller prostate glands who suffer from significant obstructive symptoms. Instead of cutting and removing tissue to relieve the obstructed bladder, this procedure widens the urethra by making several small cuts in the bladder neck where the urethra joins the bladder and in the prostate itself. This reduces the pressure of the prostate on the urethra and makes urination easier. Patients normally stay in the hospital one to three days. A catheter is left in the bladder for one to three days after surgery.

Minimally Invasive Surgical Treatments

Newer surgical modalities for the treatment of BPH have been aimed at providing a one-time minimally invasive therapy that is associated with fewer complications than TURP.

Transurethral microwave thermotherapy (TUMT): Transurethral microwave thermotherapy is a minimally invasive surgical treatment which uses a device to apply heat to the prostatic tissue causing necrosis and relief of bladder outlet obstruction. While the improvements in some outcomes following TUMT have not quite reached those associated with TURP, significant improvements in urinary symptoms have been reported for long time periods. In addition, re-treatment rate for recurrent lower urinary tract symptoms occurring secondary to BPH during a 3 year follow up period has been reported to be close to 25%. Another study reported that by two years after treatment with TUMT, 46.9% of patients were using medical therapy with an alpha-adrenergic antagonist and 17.6% of patients elected for re-treatment with TURP. Overall, it is still unclear as to the long term effectiveness in the relief of lower urinary symptoms after treatment with TUMT. One of the major advantages of TUMT is that it can be performed in a single 1-hour session as an outpatient procedure without any general or spinal anesthesia. Reports of complications vary, and range from 0 to 38%, based on the study and the investigators? criteria for complications.

Transurethral needle ablation (TUNA): Another technique currently approved for treating patients with symptoms of BPH uses high-frequency radio waves to cause thermal injury to the prostate. Transurethral needle ablation is a relatively new procedure that uses needles to deliver interstitial low-level radio frequency energy to produce a temperature above 100oC and subsequently cause prostatic cell tissue necrosis. The procedure duration averages approximately 30-45 minutes. TUNA can be performed under local anesthesia, IV sedation or transperineal prostate block. Therefore, TUNA does not require an additional hospital stay and is generally performed as an outpatient procedure. The most common intra-operative complication reported is a burning sensation, which can be significant to cause the termination of the procedure in !1% of patients. However, this can be managed by a prostatic nerve block prior to beginning the procedure. Like many of the other minimally invasive procedures, TUNA avoids significant intra-operative bleeding by heat coagulation. The overall incidence of peri- and post-operative complications following TUNA is ~25%, a rate that is significantly lower than TURP.

Open prostatectomy: When a transurethral procedure cannot be done, open surgery may be required. Open prostatectomy for BPH is also performed for a prostate that is too large to remove through the penis. Other reasons for choosing an open prostatectomy include patients with large bladder diverticula, with large bladder stones and who cannot physically tolerate having their legs placed in stirrups for TURP/TUIP surgery.

An incision is made in the abdominal wall from below the belly button to the pubic bone. The prostate gland can then be removed in its entirety through either an incision in the fibrous capsule surrounding the prostate (retro pubic prostatectomy) or through an incision made in the bladder (suprapubic prostatectomy). Postoperative pain is mild to moderate. Patients usually stay in the hospital for several days and go home with a urinary catheter. In some cases a second catheter draining the bladder through the lower abdominal wall is used.

What can be expected after treatment?

Postoperatively, patients typically experience significant improvement in their symptoms (table 1). As with any operative procedure, complications do exist. Some occur in the early postoperative period (table 2) while others may occur many years later (table 3).

Table 1: Overall improvement in patient symptoms

TURP

TUIP

Open

88%

80%

98%

Table 2: Immediate post-operative complications

 

TURP

TUIP

Open

Infection

15%

13%

13%

Bleeding requiring transfusion

5-10%

1%

8%

Impotence

14%

12%

17%

Retrograde ejaculation

73%

25%

77%

Incontinence

1%

<1%

<1%

Table 3: Late post-operative complications

 

TURP

TUIP

Open

Stricture and bladder neck contracture
(scar tissue causing obstruction)

4%

3%

4%

Additional surgery within 5 years

10%

9%

2%

Frequently asked questions:

Will surgery for BPH affect my ability to enjoy sex?

Most urologists say that even though it takes a while for sexual function to return fully, most men are able to enjoy sex again. Most experts agree that if you were able to maintain an erection shortly before surgery, you will probably be able to do so after surgery. Most men find little or no difference in the sensation of orgasm although they may find themselves suffering from retrograde ejaculation.

Is BPH a rare condition?

No, it is very common. It will affect approximately 50 percent of men between the ages of 51 and 60 and up to 90 percent of men over the age of 80.

Does BPH lead to prostate cancer?

No, BPH is not cancer and cannot lead to cancer. Still, both problems can happen at the same time. There may not be any symptoms during the early stages of prostate cancer. So whether their prostate is enlarged or not, men should talk to their health care providers about whether prostate cancer screening is right for them.

Where can I get more information?

Benign Prostatic Hyperplasia (BPH) Treatment Choices

BPH: Diagnosis

BPH: Management

BPH: Medical Management

BPH: Minimally Invasive Management

AUA Guidelines Patient Guides: BPH: A Patient's Guide

Hormone Health Network's Enlarged Prostate Fact Sheet

Common terms for BPH: enlarged prostate, big prostate



Reviewed: January 2011

Last updated: July 2013

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BPH: Surgical Management (Benign Prostatic Hyperplasia/Enlarged Prostate) Glossary
  • abdominal: in the abdomen, the cavity of this part of the body containing the stomach, intestines and bladder.

  • ablation: Removal of diseased or unwanted tissue from the body by surgery or other means.

  • anesthesia: Loss of sensation in any part of the body induced by a numbing or paralyzing agent. Often used during surgery to put a person to sleep.

  • bladder: The bladder is a thick muscular balloon-shaped pouch in which urine is stored before being discharged through the urethra.

  • bladder diverticula: They are pouches in the bladder wall that a person is born with (congenital) or later acquires. A congenital bladder diverticulum represents an area of weakness in the bladder wall through which some of the lining of the bladder is forced out. (A small balloon squeezed in a fist will create a diverticular-like effect between the fingers.) Bladder diverticula may be multiple and they often occur at the entrance of the upper urinary system into the bladder.

  • bladder neck: Area of thickened muscle fiber where the bladder joins the urethra. Acting on signals from the brain, bladder neck muscles can either tighten to hold urine in the bladder or relax to allow urine out and into the urethra. These muscles also tighten during ejaculation to prevent backflow of semen into the bladder.

  • bladder neck contracture: Scarring of tissue at the bladder neck as a complication of surgery. May lead to urinary problems that require further surgery to correct.

  • BPH: Also known as benign prostatic hyperplasia. An enlarged prostate not caused by cancer. BPH can cause problems with urination because the prostate squeezes the urethra at the opening of the bladder.

  • cancer: An abnormal growth that can invade nearby structures and spread to other parts of the body and may be a threat to life.

  • catheter: A thin tube that is inserted through the urethra into the bladder to allow urine to drain or for performance of a procedure or test, such as insertion of a substance during a bladder X-ray.

  • continence: The ability to control the timing of urination or a bowel movement.

  • contract: To shrink or become smaller.

  • contracture: A permanent abnormal tightening or shortening of a body part often resulting in deformity.

  • cyst: An abnormal sac containing gas, fluid or a semisolid material. Cysts may form in kidneys or other parts of the body.

  • cystoscopy: Also known as cystourethroscopy. An examination with a narrow, flexible tube-like instrument passed through the urethra to examine the bladder and urinary tract for structural abnormalities or obstructions, such as tumors or stones.

  • depression: A disorder characterized by feelings of extreme sadness, guilt, helplessness and hopelessness, and thoughts of death.

  • digital rectal examination: Also known as DRE. Insertion of a gloved, lubricated finger into the rectum to feel the prostate and check for any abnormalities.

  • diverticula: Plural of diverticulum. A pouch or sac in the lining of the mucous membrane of an organ.

  • DRE: Also known as digital rectal examination. Insertion of a gloved, lubricated finger into the rectum to feel the prostate and check for any abnormalities.

  • ejaculation: Release of semen from the penis during sexual climax (orgasm).

  • ejaculatory: Involved in or related to the structure involved in the release of semen from the penis during orgasm.

  • ejaculatory fluid: Semen.

  • erection: Enlargement and hardening of the penis caused by increased blood flow into the penis and decreased blood flow out of it as a result of sexual excitement.

  • erection: Enlargement and hardening of the penis caused by increased blood flow into the penis and decreased blood flow out of it as a result of sexual excitement.

  • fibrous: Consisting of or resembling fibers.

  • frequency: The need to urinate more often than is normal.

  • gas: Material that results from: swallowed air, air produced from certain foods or that is created when bacteria in the colon break down waste material. Gas that is released from the rectum is called flatulence.

  • gene: The basic unit capable of transmitting characteristics from one generation to the next.

  • gland: A mass of cells or an organ that removes substances from the bloodstream and excretes them or secretes them back into the blood with a specific physiological purpose.

  • hyperplasia: Excessive growth of normal cells of an organ.

  • incision: Surgical cut for entering the body to perform an operation.

  • infection: A condition resulting from the presence of bacteria or other microorganisms.

  • invasive: Not just on the surface; with regard to bladder cancer, a tumor that has grown into the bladder wall.

  • invasive: Having or showing a tendency to spread from the point of origin to adjacent tissue, as some cancers do. Involving cutting or puncturing the skin or inserting instruments into the body.

  • ions: Electrically charged atoms.

  • IV: Also referred to as intravenous. Existing or occurring inside a vein.

  • kidney: One of two bean-shaped organs that filter wastes from the blood and discharge these waste products in urine. The kidneys are located on either side at the level of the 12th ribs toward the back. The kidneys send urine to the bladder through tubes called ureters.

  • laser: Device that utilizes the ability of certain substances to absorb electromagnetic energy and re-radiates as a highly focused beam of synchronized single wave-length radiation.

  • liver: A large, vital organ that secretes bile, stores and filters blood, and takes part in many metabolic functions, for example, the conversion of sugars into glycogen. The liver is reddish-brown, multilobed, and in humans is located in the upper right part of the abdominal cavity.

  • local anesthesia: Loss of sensation only in one part of the body induced by application of an anesthetic agent.

  • microwave thermotherapy: Use of controlled heat for treatment.

  • necrosis: Death of one more more cells, or a portion of a tissue or organ.

  • nocturia: Excessive urination at night.

  • obstruction: something that obstructs, blocks, or closes up with an obstacle

  • open prostatectomy: A procedure whereby an incision is made through the skin above the bladder to remove the central part of the prostate that causes the blockage.

  • orgasm: The climax of sexual excitement, consisting of intense muscle tightening around the genital area experienced as a pleasurable wave of tingling sensations through parts of the body.

  • pathologist: A physician who interprets and diagnoses the changes caused by disease in tissues and body fluids.

  • penis: The male organ used for urination and sex.

  • perineal: Related to the area between the anus and the scrotum in males and the area between the anus and the vagina in females.

  • postoperative: Occurring after a surgical operation.

  • prostate: A walnut-shaped gland in men that surrounds the urethra at the neck of the bladder. The prostate supplies fluid that goes into semen.

  • prostatectomy: Surgical procedure for the partial or complete removal of the prostate.

  • prostatic: Pertaining to the prostate.

  • prostatism: A disorder of the prostate gland, especially enlargement that block or inhibits urine flow.

  • PSA: Also referred to as prostate-specific antigen. A protein made only by the prostate gland. High levels of PSA in the blood may be a sign of prostate cancer.

  • PSA test: Also referred to as prostate-specific antigen test. A blood test used to help detect prostate cancer.

  • pubic bone: Also referred to as the pubis. Lower front of the hip bone.

  • radio waves: Electromagnetic waves.

  • rectal: Relating to, involving or in the rectum.

  • rectal ultrasound: A diagnostic test that uses very high frequency sound waves to produce an image of the rectum.

  • rectum: The lower part of the large intestine, ending in the anal opening.

  • resection: The surgical removal of a portion of a body part.

  • resectoscope: A tube-shaped instrument used by the urologist to scoop a tumor from the bladder lining.

  • retrograde: Backwards.

  • retrograde ejaculation: Cuased by the failure of the bladder neck to close during ejaculation allowing the ejaculate to be propelled into the bladder instead of out the penis.

  • retrograde ejaculation: Caused by the failure of the bladder neck to close during ejaculation allowing the ejaculate to be propelled into the bladder instead of out the penis.

  • sedation: State of calm relaxation induced in one or more body systems by administration of medical agents (sedatives).

  • spinal anesthesia: Anesthesia injected into the lower back which results in a loss of sensation in that part of the body.

  • stage: Classification of the progress of a disease.

  • stone: Small hard mass of mineral material formed in an organ.

  • suprapubic: An area of the central lower abdomen above the bony pelvis and overlying the bladder.

  • suprapubic prostatectomy: This involves the removal of obstructing prostate tissue through a surgical incision below the belly button.

  • tissue: Group of cells in an organism that are similar in form and function.

  • transfusion: Transfer of whole blood, blood components or bone marrow from a healthy donor into the bloodstream of somebody who has lost blood or who has a blood disorder.

  • transurethral: Through the urethra. Several transurethral procedures are used for treatment of BPH. (See TUIP, TUMT, TUNA or TURP.)

  • TUIP: Also referred to as transurethral incision of the prostate. A procedure that widens the urethra by making a few small cuts in the bladder neck where the urethra joins the bladder and in the prostate itself. Treatment for BPH.

  • TUMT: Also referred to as transurethral microwave thermotherapy. Destroys excess prostate tissue interfering with the exit of urine from the body by using a probe in the urethra to deliver microwaves. Treatment for BPH.

  • TUNA: Also referred to as transurethral needle ablation. Destroys excess prostate tissue with electromagnetically generated heat by using a needle-like device in the urethra. Treatment for BPH.

  • TURP: Also referred to as transurethral resection of the prostate. Surgical procedure where a lighted tube with an attached electrical loop is inserted through the urethra into the prostate. Serves as a diagnostic and therapeutic role in the treatment of bladder cancer.

  • ultrasound: Also referred to as a sonogram. A technique that bounces painless sound waves off organs to create an image of their structure to detect abnormalities.

  • urethra: A tube that carries urine from the bladder to the outside of the body. In males, the urethra serves as the channel through which semen is ejaculated and it extends from the bladder to the tip of the penis. In females, the urethra is much shorter than in males.

  • urethral: Relating to the urethra, the tube tha carries urine from the bladder to outside the body.

  • urge: Strong desire to urinate.

  • urinary: Relating to urine.

  • urinary tract: The system that takes wastes from the blood and carries them out of the body in the form of urine. Passageway from the kidneys to the ureters, bladder and urethra.

  • urinary tract infection: Also referred to as UTI. An illness caused by harmful bacteria, viruses or yeast growing in the urinary tract.

  • urinate: To release urine from the bladder to the outside. Also referred to as void.

  • urination: The passing of urine.

  • urine: Liquid waste product filtered from the blood by the kidneys, stored in the bladder and expelled from the body through the urethra by the act of urinating (voiding). About 96 percent of which is water and the rest waste products.

  • urine flow study: A test in which the patient urinates into a special device that measures how quickly the urine is flowing.

  • urologist: A doctor who specializes in diseases of the male and female urinary systems and the male reproductive system. Click here to learn more about urologists. (Download the free Acrobat reader.)

  • urology: Branch of medicine concerned with the urinary tract in males and females and with the genital tract and reproductive system of males.

  • vas: Also referred to as vas deferens. The cordlike structure that carries sperm from the testicle to the urethra.

  • void: To urinate, empty the bladder.

BPH: Surgical Management (Benign Prostatic Hyperplasia/Enlarged Prostate) Anatomical Drawings

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