Tissue removal
surgeries
Tissue removal
surgeries
There are effective treatments available for prostate gland enlargement, including medications, minimally invasive therapies and surgery.
To choose the best option, you and your doctor will consider your symptoms, the size of your prostate, other health conditions you might have, and your preferences.
The primary categories of treatment options are:
Please see below for more information on surgical options for BPH.
If the patient has attempted other treatments without success, is unable to urinate or has bladder stones, surgery may be required. This information is not intended to be an exhaustive list of all possible surgical treatments for an enlarged prostate, but presents some common options for your information:
TURP is generally considered an option for men with moderate to severe urinary problems that haven’t responded to medication. Traditionally, TURP has been considered the most effective treatment for an enlarged prostate.
However, a number of other, minimally invasive procedures are becoming more effective, due to improved techniques and surgical tools. These minimally invasive procedures generally cause fewer complications and have a quicker recovery period than TURP. The risk of bleeding is generally higher with TURP, so it might not be the best option for certain men who take blood-thinning medications.
In a transurethral resection of the prostate (TURP), which is performed under general or spinal anesthesia, the surgeon inserts a thin tube known as a resectoscope into the urethra and threads it up into the enlarged prostate.
The resectoscope contains a tiny camera, enabling the surgeon to view the prostate as the operation proceeds, and an electric loop. Using one type of electrical current, the surgeon uses the loop to remove some of the overgrown prostate tissue. The surgeon then applies a different electrical current to cauterize the tissue and reduce bleeding.
The area is then flushed with a sterile solution to remove bits of tissue, and a catheter is inserted temporarily into the urethra and bladder until the area recovers. After surgery, the newly enlarged passageway enables urine to flow more easily.
The CUA describes TURP as a standard option in the 2018 guideline on male lower urinary tract symptoms/benign prostatic hyperplasia, which states:
Monopolar TURP (M-TURP): M-TURP remains the primary, standard-reference surgical treatment option for moderate to severe LUTS due to BPH in patients with prostate volume 30–80 cc.42 Perioperative mortality has decreased over time (0.1%), while morbidity is related to prostate volume (particularly >60 cc).
Contemporary series have reported the following complications: bleeding (2–9%), capsule perforation with significant extravasation (2%), TUR syndrome (0.8%), urinary retention (4.5–13%), infection (3–4%; sepsis 1.5%), incontinence (<1%), bladder neck contracture (3–5%), retrograde ejaculation (65%), erectile dysfunction (6.5%), and surgical retreatment (2%/year).
We recommend M-TURP as a standard first-line surgical therapy for men with moderate to severe MLUTS/BPH with prostate volume of 30–80 cc (strong recommendation based on high- to moderate-quality evidence).
The most commonly occurring risks of TURP include post-surgical urinary tract infection and sexual dysfunction. Any surgery carries risks related to general anaesthesia and infection of the intervention.
Specific risks include:
Open prostatectomy is the surgical removal of all or part of the prostate gland. It is done under a general or spinal anesthetic. Usually, an incision is made through the lower abdomen, although sometimes the incision is made between the rectum and the base of the penis.
A catheter may be placed in the bladder through the lower abdominal skin to help flush the bladder (postoperative bladder irrigation) and another catheter comes out of the penis to drain the urine. The procedure requires a longer hospital stay and recovery period than transurethral resection of the prostate (TURP).
Open prostatectomy is a relatively invasive and less common treatment for benign enlargement of the prostate. It may be recommended if:
The CUA describes open simple prostatectomy (OSP) as a treatment alternative in the 2018 guideline on male lower urinary tract symptoms/benign prostatic hyperplasia, which states:
Open simple prostatectomy (OSP) OSP is an appropriate and effective treatment alternative for men with moderate to severe LUTS with substantially enlarged prostates >80–100 cc and who are significantly bothered by symptoms.
Other indications for OSP include plans for concurrent bladder procedure, such as diverticulectomy or cystolithotomy, and in men who are unable to be placed in dorsal lithotomy position due to severe hip disease.
OSP is the most invasive surgical method requiring longer hospitalization and catheterization. The estimated transfusion rate has been reported from 7–14%.
Long-term complications include transient urinary incontinence (8–10%), bladder neck contracture, and urethral stricture (5–6%).
Less invasive techniques, including laparoscopic and robotic approaches have demonstrated equivalent efficacy and potentially fewer complications compared to OSP, but require specialized equipment and relevant skills.
We recommend OSP as a first-line surgical therapy for men with moderate to severe MLUTS/BPS and enlarged prostate volume >80 cc (strong recommendation based on moderate- to high-quality evidence).
Although prostatectomy can work well in relieving BPH symptoms, it has a higher risk of complications and a longer recovery time than other enlarged prostate surgical procedures such as transurethral resection of the prostate (TURP) or holmium laser prostate surgery (HoLEP).
In addition to the risks associated with any surgery, risks of prostatectomy include:
Less invasive techniques have demonstrated equivalent efficacy and potentially fewer complications compared to open prostatectomy, so it is generally considered only for very large prostates or when there reasons why other surgical or MIST options are not appropriate for the patient.
When prostate enlargement obstructs the flow of urine a relatively new laser technique may be used instead of TURP. In a photoselective vaporization of the prostate (PVP), or GreenLight, procedure, the surgeon threads a thin tube known as a cystoscope into the urethra and up into the enlarged prostate.
The surgeon then threads a fiber-optic device through the cystoscope to generate high-intensity pulses of light, which simultaneously vaporize the obstructing tissue and cauterize it to reduce bleeding. After surgery, a catheter may be inserted temporarily to allow urine to flow while the area is healing. This technique creates an enlarged, uniform channel for urine to flow through. Removing the excess tissue rapidly restores natural urine flow in most patients.
The GreenLight laser procedure is typically performed on an outpatient basis under general anesthesia. Most patients experience rapid relief of BPH symptoms and improvement in urine flow after the procedure.
The CUA describes Greenlight-PVP (photoselective vaporization of the prostate) as a safe and effective treatment alternative in the 2018 guideline on male lower urinary tract symptoms/benign prostatic hyperplasia, which states:
Photoselective vaporization of the prostate (PVP): Greenlight-PVP (180W XPS and 120W HPS systems) provides comparable outcomes to TURP in terms of durable improvements in IPSS and Qmax with similar overall complication rate.
Five-year mid-term durability of XPS reported a 1.6% retreatment rate. PVP has been shown to be a cost-effective alternative to TURP in the Canadian setting. The data suggests superior safety in men on anticoagulation and/or high cardiovascular risk.
We recommend PVP as an alternative to TURP in men with moderate to severe LUTS (strong recommendation based on high-quality evidence).
We suggest Greenlight PVP therapy as an alternate surgical approach in men on anticoagulation or with a high cardiovascular risk (conditional recommendation based on moderate quality evidence).
All surgical treatments have inherent and associated risks. The most common risks associated with Photoselective Vaporization of the Prostate (PVP) are: hematuria; short term dysuria; and urinary tract infections.
Specific potential side effects include:
Holmium laser enucleation of the prostate (HoLEP) is a type of laser surgery used to treat the obstruction of urine flow as a result of benign prostatic hyperplasia. The holmium laser is a surgical laser that has been found particularly effective in performing several types of urological surgeries. In the case of HoLEP, the laser is used to cut and remove the bulky prostate tissue that is blocking the flow of urine.
Patients who are appropriate for HoLEP are typically symptomatic due to very large prostates. Patients may not be candidates for HoLEP if they have bleeding problems or have had certain types of prior prostate treatments.
HoLEP requires the patient to be under general anesthesia. If a patient cannot have general anesthesia for some reason, a spinal anesthetic can be used—this allows him to remain awake but blocks all feeling from the waist down.
A surgical instrument called a resectoscope is inserted through the urethra. The resectoscope includes a camera that allows the surgeon to view the internal structure of the prostate gland, and to see where incisions are being made during surgery.
The laser is inserted into the resectoscope and is used to enucleate the enlarged prostate tissue from the outer shell of the prostate, and then to seal up any blood vessels. The tissue that has been removed is deposited in the bladder. When tissue removal is complete, the resectoscope is withdrawn and a urinary catheter is put in place.
The CUA describes HoLEP as a safe and effective treatment alternative in the 2018 guideline on male lower urinary tract symptoms/benign prostatic hyperplasia, which states:
Holmium laser enucleation of the prostate (HoLEP) provides significant and durable improvements in Qmax, PVR volume, quality of life, IPSS, and PSA reduction and can be used to treat men on anticoagulation and those with bleeding dyscrasia.
There is a low reoperation rate (approximately 4% for recurrent LUTS) within series with long followup (up to 7–8 years). The procedure requires a steep learning curve (estimated >20–50 cases) often requiring fellowship training.
We recommend HoLEP as an alternative to TURP or OSP in men with moderate to severe LUTS if performed by a HoLEP-trained surgeon (strong recommendation based on high-quality evidence).
One key differentiation of this treatment is that it can be performed on men taking blood thinners or who have a bleeding disorder.
Also – the CUA highlights that the surgeon’s training and experience is an important factor.
The side effects of holmium laser enucleation of the prostate (HoLEP) immediately after the procedure can include:
General and longer term risks of the surgery include:
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