Transurethral Resection of the Prostate (TURP) Transurethral Incision of the Prostate (TUIP)

Definition

Transurethral = Through or across the urethra (tube through which urine exits bladder)

Resection = cutting away or removal. Some people refer to it as a “scraping.”Incision = making a cut in

In short, a special scope termed a “cystoscope” is placed in the penis and guided up into the part of the urethra that is the center portion of the prostate. This prostate tissue is systematically resected until all of the obstructing tissue is removed.

In cases where the prostate is small and perhaps the problem is the increased tone (see below),we can do a more limited procedure. This would be an “incision” rather than a full” resection.” In this regard, the procedure is termed TUIP instead of a TURP.

Most TURPs are performed to treat a condition termed “benign prostatic hyperplasia” (BPH).With progressive BPH, the prostate enlarges and obstructs the proper flow of urine from the bladder. Most often, the reduced flow represents a combination of prostate enlargement and tone (the prostate constricting down on the urethra as the urethra courses through the center of the prostate). Some patients with this condition may already have been on one or a combination of medications at increasing doses prior to needing a procedure. If the medications are no longer effective in alleviating symptoms, then a surgical procedure may be warranted. Sometimes, the medications are effective at high doses, but side-effects prohibit their use in a particular patient. In other instances, the symptoms are tolerable, but we have determined that the degree of obstruction is progressively damaging your bladder and even your kidneys. The characteristic symptoms are those of an obstructive urination pattern and are most commonly recognized as:

• straining (need to push to begin urination)
• hesitancy (delayed onset of urination following the urge to urinate)
• slow or diminished force of stream
• intermittence (urine stream that starts and stops)
• a sensation of incomplete emptying of your bladder

Other symptoms that may be associated are what we call irritative symptoms and include: frequency of urination, urgency to urinate and nocturia (getting up at night to urinate).

There are other types of procedures that are available for this condition, and these have been explained to you in your surgical consultation. The pros and cons of each with respect to your health and your particular prostate condition will have already been discussed. In the urologic literature, the TURP is still considered the “gold-standard” operation to which the results of all other procedures need be compared.

Preparation

There is no particular preparation for this procedure. It is necessary, as with any procedure or operation requiring anesthesia, that you have not eaten for at least eight hours prior to the scheduled time.

*It is definitely to your advantage not to be constipated in the week after the procedure as straining may cause bleeding in the urine. We therefore recommend that for the entire week before the procedure, you avoid constipating foods such as rice, bananas and red meat. You should be eating lots of fruits and vegetables as well as oatmeal and cereals. If you have a known problem of constipation, you should consider administering an enema one hour before bed the night before your procedure. enemas should not be used for a few weeks after this operation, however.

As with any procedure in which anesthesia is administered, you will be asked not to eat or drink anything after midnight on the evening prior to your surgery. You may brush your teeth in the morning but not swallow the water. If you are on medications that must be taken, you will have discussed this with us and /or the anesthesiologist and instructions will have been given to you. The procedure will not be performed if you are currently taking, or have recently taken any medication that may interfere with your ability to clot your blood (“blood thinners, aspirin, anti-inflammatory medicines, etc.”). The most common of these medications are aspirin and all related pain relievers or anti-inflammatory compounds (whether prescription or over-the-counter). Please refer to the attached list and tell us if you took any of these within the past ten days. If your new medication is not on the list, alert us immediately so that we may ensure optimal procedure safety. We will have reviewed all of your current medications with you during the pre-operative/pre-procedure consultation. You are obligated to inform us if anything has changed (medication or otherwise) since your previous visit.

Procedure

To review the basics of what we discussed in the office: The actual procedure can take anywhere from 20 to 90 minutes depending on the particulars of the case and the size of your prostate. You will be placed in lithotomy position (lying down on your back with your legs gently elevated in holsters call stirrups). The scope (which has continuous fluid running through it) is carefully inserted into the urethra and advanced into the bladder. We carefully examine the bladder to ensure that everything is within normal limits. The scope is then pulled back into the first part of the urethra termed the “prostatic urethra.” Next, a special electric knife or similar technology is used to scrape away the inner core of the prostate. Think of it like coring an apple. In the TUIP, incisions are made with a slightly different type of electric knife to allow the prostate to open its center channel. In some occasions, we can use a specific type of laser to do the same procedures. Other than being a different type of technology, it does not change the procedure. We will have already discussed the advantages and disadvantages of each technology with you prior to scheduling. Once the resection is complete, all of the prostate pieces (chips) are irrigated out of the bladder. They will be sent to the pathologist for examination under a microscope. A the end of the procedure, a catheter is placed in the bladder to allow proper healing of the prostate channel.

Post Procedure

After the procedure, you will be in the recovery room until you are ready to be admitted to a room. If you are having a TUIP as opposed to a TURP, there is a chance that you will be discharged home with or without a catheter.

It is normal for you to feel a strong sense of urgency to urinate. This is from the procedure and the presence of the catheter. In most patients, this dissipates within a couple of hours. Some patients require medications to help relax the bladder while the catheter is in. Your catheter may be attached to a large bag that runs fluid into your bladder (irrigation) to keep it washed out. Through a separate channel in the catheter, the fluid runs out into a drainage bag. This continuous bladder irrigation (CBI) is done to prevent blood clots from obstructing the catheter. Patients may have clear urine, mild blood, or even what appears to be a significant amount of blood or small clots. It is rare for the blood to not disappear within a day or two. The rate of the irrigation will be adjusted by the doctor or the nurses to a rate that keeps your urine on the clear side. Other patients may not require continuous irrigation and so there will not be any fluid running in. The urine will simply be draining out of the catheter and into a bag. In many patients, the catheter is removed the following morning and you are discharged home after you urinate on your own. In patients with larger prostates or in patients that still have moderate or significant blood in the urine, we may keep you in the hospital with the catheter for an extra day or so.

Plan to be out of work and avoid driving a car for a few weeks.

Expectations of Outcome

Most patients are very satisfied after the procedure. We typically hear phrases such as “I can urinate like a teenager again.” The improvements that are typically noted immediately after the operation are:

• Stronger force of stream
• Decreased standing around waiting for the urination to commence
• Decreased need to push
• Loss of intermittence (i.e. where the flow used to start and stop and start, etc.)
• Loss of the sensation that you are “not really emptying your bladder”

In some patients, it may be difficult to control the urine for a couple of weeks. You may notice that you are still voiding frequently and with some urgency (sensation that forces you to get to the bathroom quickly). These symptoms can take a long time to disappear. In patients that were significantly obstructed for a prolonged period, these symptoms may never fully resolve. Nocturia (getting up at night to urinate) is typically the last symptom to resolve. In many instances, it may become less frequent, but never fully disappear. The reason is that nocturia can be due to several other physiological issues and also because the night-time ritual becomes somewhat habitual.
Retrograde ejaculation is when the semen (during ejaculation) goes backward into the bladder instead of forward and out of the penis. This is expected to some degree in almost all patients. It may be that your semen volume is less, or absent altogether. *You will still have the sensation of orgasm, but you may not seen the semen. In this regard, you may be considered sterile.

Possible Complications of the Procedure

All surgical procedures, regardless of complexity or time, can be associated with unforeseen problems. They may be immediate or even quite delayed in presentation. While we have discussed these and possibly others in your consultation, we would like you to have a list so that you may ask questions if you are still concerned. It is important that every patient be made aware of all possible outcomes which may include, but are not limited to:

• Hematuria: As we scrape the prostate tissue, small blood vessels (arteries and veins)may be cut and bleed. Throughout the entire procedure, we cauterize (burn) the vessels shut. At the end of the procedure, we carefully inspect the area to ensure that there is no significant bleeding. Rarely, a scab of a vessel we cauterized can fall off and cause delayed hematuria (blood in the urine). In most cases, we can observe and it will spontaneously stop. Sometimes we will manipulate the catheter to compress the vessel. In patients with continuous irrigation, we can increase the rate of irrigation dripping into the catheter to clear the urine. If clots form, it can block the catheter and we consequently will need to hand-irrigate the clots out. Very rarely, we have to return to the operating room to put the scope back inside the bladder and recauterize. If bleeding is prolonged during or after the operation, we would check your blood count. It is rare to need a a blood transfusion following a TURP.
• Urinary Tract Infection or Urosepsis: Although we may give you antibiotics, it is still possible for you to get an infection. It may be a simple bladder infection that presents with symptoms of burning urination, urinary frequency and a strong urge to urinate. This will usually resolve with a few days of antibiotics. If the infection enters the bloodstream, you may feel very ill. This type of infection often presents with the urinary symptoms and any combination of the following: fevers, shaking chills, weakness or dizziness, nausea and vomiting. You may need a short hospitalization for intravenous antibiotics, fluids, and observation. This problem is more common in diabetics, patients on long-term steroids, or patients with any disorder of the immune system. If you have symptoms suggesting any of the above after your discharge from the hospital, you must contact us immediately or go to the nearest emergency room.
• Urethral Stricture/Bladder Neck Contracture: A stricture is scar tissue that can form anywhere in the urethra following prolonged instrumentation. It typically occurs weeks to months (or even longer) after the procedure. Scar tissue can also form at the exit(neck) of the bladder, and this is termed a contracture. For either condition, it may be necessary to schedule another scope procedure to open the scar. These procedures can be done with a small blade, electric knife, or with a laser and they are quick and almost always an outpatient procedure. A scar at the tip of the urethra can sometimes be dilated (spread open) in the office. Sometimes, a stricture or contracture can recur in the future.
• Urinary Incontinence: Bladders that are obstructed for years learn to over-compensate by squeezing with more force. The bladder, like any other muscle, thickens and gets stronger over those years of hard work. Now that the obstruction is gone, it can take weeks or longer for the bladder to readjust. In this period, you might occasionally lose some urine when the bladder suddenly squeezes forcefully against a now-open channel. In extremely rare instances, this may never resolve completely. In other very rare instances, the sphincter that allows you to voluntarily hold urine back can be damaged from the energy course. With severe injury to the sphincter, you can have total incontinence (inability to hold back urine). Again, this is very rare.
• Urinary Retention: Sometimes, a bladder that has been severely obstructed for many years can lose its ability to contract (squeeze) properly. If urodynamics testing (special computerized testing of your bladder) demonstrates adequate ability of the bladder to squeeze, we may offer a procedure as a last resort to get you to empty your bladder.

It is possible, however, that even with a wide-open channel, the bladder is still un able to fully empty or empty at all. Sometimes it improves over time, and occasionally never. Patients at greatest risk are those who presented originally with severe blockage and huge volumes in the bladder, as well as diabetics in which the bladder may have already lost some ability to contract. Again, in cases that we are suspicious of this outcome, we probably will have performed a special test on your bladder (urodynamics) to help predict the outcome.

• TUR Syndrome: If there is excessive absorption of irrigating fluid during the procedure, the blood can become somewhat diluted. The changes in the blood could affect the blood pressure, the heart, and in severe instances, the brain. With the newer fluid, more advanced equipment, and more efficient ways to treat even the suspicion of “too much absorbed fluid,” TUR syndrome is quite rare.
• Perforation: The prostate capsule or even the bladder can be perforated. In most cases, all we need to do is leave the catheter in for an extra few days to allow self-healing. Other procedures are rarely necessary. Injuries to the ureteral orifices(holes where the kidney tubes come into the bladder) are also very rare. Sometimes ,we may need to place a temporary stent in place (a plastic tube that goes from the kidney to the bladder). If a stent cannot be placed, it may be necessary to put a temporary tube into the kidney through a hole in your back. It would be quite unusual to need an open operation to repair any of these problems.
• Erectile Dysfunction: According to the literature, anywhere from 5-25% of patients complain of some degree of erectile dysfunction (ED or impotence) after a TURP. For the majority of these patients, the patient notes a change but does not complain of complete impotence. Most studies report ED numbers on the lower end of the spectrum. This problem has always been quite puzzling to urologists in that a sound “cause and effect relationship” has not been established. The most plausible explanation may be the transmission of the energy source through the entire thickness of the prostate and subsequently to the nerves controlling erections. Psychological and other pre-existing factors may play a role as well.
• Deep Vein Thrombosis (DVT)/Pulmonary Embolus (PE): This is uncommon in a short procedure such as TURP. However, in any operation (especially longer operations or those in which your legs are in stirrups), you can develop a clot in a vein of your leg (DVT). Typically, this presents 2-7 days (or longer) after the procedure as pain, swelling, and tenderness to touch in the lower leg (calf). Your ankle and foot can become swollen. If you notice these signs, you should go directly to an emergency room and also call our office. Although less likely, this blood clot can move through the veins and block off part of the lung (PE). This would present as shortness of breath and possibly chest pain. We may sometimes ask the medical doctors to be involvedwith the management of either of these problems.

We provide this literature for patients and family members. It is intended to be an educational supplement that highlights some of the important points of what we have previously discussed in the office. Alternative treatments, the purpose of the procedure/surgery, and the points in this handout have been covered in our face-to-face consultation(s).

The information contained in this document is intended solely to inform and educate and should not be used as a substitute for medical evaluation, advice, diagnosis or treatment by a physician or other healthcare professional. While UUANJ endeavors to ensure the reliability of information, such information is subject to change as new health information becomes available. UUANJ cannot and does not guaranty the accuracy or completeness of the information contained in this document, and assumes no liability for its content or for any errors or omissions. Please call your doctor if you have any questions.

UUANJ, P.C.