Transurethral resection of the prostate
A transurethral resection of the prostate (TURP) is a surgical procedure that involves cutting away a section of the prostate gland.
It is often used to treat prostate enlargement (benign prostate hyperplasia).
A TURP may be necessary if:
the first treatments for prostate enlargement, such as medication, fail to control symptoms - this occurs in around one in 10 men
an enlarged prostate leads to complications - such as bladder stones or a bladder infection, because the man is unable to empty his bladder properly
How it is performed
A TURP is performed under general or spinal anaesthesia, so you will not feel any pain during the procedure.
The surgeon will insert a thin metal wire with a loop at the end into your urethra and up against your prostate. An electrical current is then used to heat the loop, which cuts away a section of your prostate.
Most men can leave hospital two to three days after surgery and resume most normal activities within one week.
However, it can take up to six weeks before you are fit enough to return to work if your job is physically strenuous.
Most men who have a TURP find it improves both their symptoms and quality of life.
You should notice the symptoms that bothered you before are no longer there, or are present to a much lesser extent. For example:
you should no longer need to strain to urinate
you should be able to go about your normal activities without having to worry about being near a toilet
you should be more in control of holding your urine in
you may not need to get up in the night to urinate as much as you used to
you should also notice you have a stronger stream of urine
you may no longer need to wear incontinence pads if you do so already
In most cases, a TURP is a safe procedure and the risk of serious complications occurring during surgery is very small.
However, many men who have had a TURP lose the ability to ejaculate semen during sex or masturbation, although they still have the physical pleasure associated with ejaculation (the climax). This is known as retrograde ejaculation, and can occur in as many as 9 out of 10 cases.
Also, many men temporarily lose the ability to control their bladder (they develop urinary incontinence), although this usually passes a few weeks after surgery. In rare cases, urinary incontinence may be persistent and need further treatment. As with all surgery there is a risk of infection and bleeding afterwards, which may need additional treatment.
There are a number of alternatives to a TURP. Some are not suitable for all men with prostate enlargement and may not be as effective in the long term.
They include the following.
Holmium laser enucleation of the prostate (HOLEP) - a laser is used to separate excess tissue from the prostate into the bladder and the tissue is then removed. HOLEP causes less blood loss, involves a shorter stay in hospital and is suitable for moderate to large prostates. Access to this type of treatment is currently limited in England.
Potassium-titanyl-phosphate (KTP) laser vaporisation of the prostate - this involves placing a small fibre optic cable into the urethra (the opening through which you pass urine) and up towards the prostate. Lasers can then be directed out of the fibre optic cable and used to burn away excess prostate tissue.
Both HOLEP and KTP laser vaporisation of the prostate may be more suitable for very large prostates, older men who are not fit, or for those using blood thinning medication such as warfarin
Illustration of TURP
Bladder containing urine
Enlarged prostate, blocking flow of urine through the urethra
Opening of urethra
The prostate is a small gland in the pelvis only found in men. It is located between the penis and bladder, and surrounds the urethra (the tube that carries urine from the bladder to the penis).
If the prostate becomes enlarged, it can place pressure on the bladder and urethra. This can cause symptoms that affect urination (passing urine when going to the toilet).
Having an operation
If your GP has suggested you may need surgery, this guide is for you
When it's necessary
A transurethral resection of the prostate (TURP) is usually recommended for prostate enlargement that is causing problematic urinary symptoms and fails to respond to treatment with medication.
The severity of urinary symptoms from prostate enlargement is assessed based on problems with your normal pattern of urination.
You may experience some or all of the following problems at least half the time you try to urinate:
problems starting to urinate
a weak urine flow or stopping and starting
having to push or strain to pass urine
a frequent need to urinate
waking up frequently during the night to urinate (nocturia)
a sudden urge to urinate, which can result in incontinence if you are unable to find a toilet quickly enough (urge incontinence)
being unable to empty your bladder fully
The first treatment option for problematic urinary symptoms from prostate enlargement is medication, such as:
finasteride or dutasteride – which help to reduce the size of the prostate
alpha blockers – which help relax the muscles of your bladder, making urination easier
These medications do not work for everyone because the degree of prostate enlargement is often too large to be controlled using medication. If this is the case, a transurethral resection of the prostate is usually recommended.
The procedure may also be recommended if you develop a complication from not being able to empty your bladder fully. Examples are:
repeated urinary tract infections
repeatedly passing large amount of blood in your urine
kidney failure (loss of normal kidney function)
difficulty with fully emptying the bladder
Who can use it
Most men can have a transurethral resection of the prostate (TURP) even if they are not in particularly good health.
However, there are reasons why a TURP would not be considered suitable, or where the risks of complications would be too high. These circumstances are explained below.
If you have recently had a heart attack and/or heart surgery. It would usually be recommended you wait between three and six months before having the operation.
If you have a neurological condition, such as Parkinson’s disease or multiple sclerosis, you may have problems controlling your bladder. A TURP would make this problem much worse, resulting in incurable urinary incontinence.
If you have been diagnosed with prostate cancer and are intending to have a total removal of the prostate (radical prostatectomy) as a treatment.
If you have recently had radiotherapy to treat prostate cancer. Again, having a TURP soon after radiotherapy would result in urinary incontinence. After having radiotherapy, a wait of at least six months is usually recommended before having the procedure.
If you have an active infection of your bladder, urethra or kidneys. If this is the case, the TURP would need to be delayed until after the infection has been treated with antibiotics.
How it is performed
A transurethral resection of the prostate (TURP) is carried out in hospital under anaesthetic. You will usually need to stay in hospital for two to four days.
Preparing for surgery
There are some preparations you can make before surgery, to help reduce the risks of complications. These are explained below.
You should try to ensure you are as fit as possible before the procedure. If you do not usually exercise regularly, you should aim to exercise for at least half an hour every day. Walking, swimming or even activities such as gardening are all good forms of exercise
If you smoke, you should try to cut down or give up completely - this will help reduce your risk of developing heart and chest complications following the operation
If you are currently taking anticoagulant medication, such as warfarin or clopidogrel, you will usually be asked to stop taking it at some point before the procedure - this is because this type of medication thins the blood, which could lead to excessive bleeding during surgery. Low-dose aspirin is normally fine but you should also check with your surgeon.
You may be sent an appointment for a pre-assessment of your health a few days before the operation. This may involve having blood tests and a general health check to make sure you are fit for surgery.
If you have a pre-assessment appointment, you can use it as an opportunity to discuss any concerns you have with your surgeon.
Before the procedure
You will usually be asked to stop eating and drinking around six hours before surgery. Depending on the results of your pre-assessment, you may be given compression stockings or blood-thinning medication to help prevent blood clots.
A TURP is performed using anaesthetic, so you will not feel any pain during the procedure. The type of anaesthetic used may be either:
a general anaesthetic - where you will be unconscious throughout the procedure
a spinal or epidural anaesthetic - where you will be awake during the procedure, but not able to feel anything below your waist
A TURP is usually carried out using a device called a resectoscope. A resectoscope is a thin metal tube that contains:
a loop of wire
The surgeon will insert the resectoscope into your urethra (the tube that carries urine from your bladder to your penis) before guiding it to the site of your prostate with the help of the light and the camera.
An electric current is used to heat the loop of wire, and the heated wire is used to cut away the section of your prostate that is causing your symptoms. After the procedure, a catheter (a thin, flexible tube) is used to pump saline water into the bladder and flush away pieces of prostate that have been removed.
A TURP can take up to an hour to perform, depending on how much of your prostate needs to be removed.
Once the procedure has been completed, you will be moved back to your hospital ward so you can recover.
Unless it is being used to treat a serious complication such as kidney failure, a transurethral resection of the prostate is not regarded as urgent surgery. This means you may have to wait several months for surgery.
Ask your surgeon or GP about estimated waiting times when the operation is discussed with you.
Recovering from surgery
Following a transurethral resection of the prostate (TURP), you should not feel any severe pain.
However, there may be some discomfort from the catheter and your urethra (the tube through which urine passes) will be swollen and sore.
You will be unable to urinate normally at first, due to the swollen urethra. A thin tube called a catheter will be inserted into your urethra and up into your bladder so urine can drain away.
Immediately after the operation, water may be pumped through the catheter to clean your bladder and get rid of any blood clots and other debris. This is not usually painful, but may make your bladder feel uncomfortably full.
After your urethra has healed and you are able to pass urine normally, the catheter will be removed and you can go home. This normally happens about 24-48 hours after surgery.
It's not uncommon to still experience problems passing urine and a catheter may need to be reinserted temporarily. A future date for its removal may then be arranged for you and you can go home with the catheter until then.
After having a TURP, most men are up and about around a week after surgery. However, you will be advised to take things easy for about a month to six weeks afterwards.
For the first four weeks, you should not lift or move any heavy objects (including shopping) or do any housework or digging. If possible, ask friends or family members if they can help around the house.
Once you feel able, some gentle exercise such as walking will help keep your blood circulating, and lower your risk of getting a blood clot in your legs.
Any symptoms of pain can usually be treated by taking over-the-counter painkillers, such as paracetamol or ibuprofen.
Blood in urine
After having a TURP, you may occasionally notice some blood in your urine. Around a week or two after the operation the amount of blood may increase as the scab on your prostate falls off. If the increased blood in your urine continues for longer than 48 hours, you should contact the hospital.
Drinking plenty of fluids, such as water, fruit juice and tea, will help flush any blood or small blood clots out of your bladder.
If you have constant bleeding or difficulty passing urine, you should contact your surgeon. It is normal to frequently feel the need to urinate for the first few weeks after the operation. This is because your urethra and bladder will have been irritated during the operation.
Sometimes, the irritation might feel like a stinging sensation when you urinate. Despite the stinging and a need to urinate more frequently, you should still drink plenty of fluid because it will also help prevent an infection from developing.
Returning to work
It may take between four and eight weeks to fully recover from a TURP. Your GP or surgeon will advise about when it is safe to return to work. This will depend on your occupation - for example, if you work in an office, you may be able to return to work sooner than someone who does heavy manual work.
You will be advised not to drive for six weeks after having a TURP. You will usually be able to drive again when you can comfortably carry out an emergency stop. Your GP will be able to advise you about this.
It will probably be several weeks after your operation before you feel comfortable enough to have sex.
Most men need to wait for six to eight weeks before having sex, after which time any bruising and tenderness should have healed.
Before you leave hospital after having a TURP, you should be given an appointment for a check-up at the outpatient clinic. This appointment will normally be about six weeks after the operation.
Risks of surgery
Transurethral resection of the prostate (TURP) is generally a safe procedure. However, as with all surgery, TURP is associated with potential risks.
The most common risks are described below.
Retrograde ejaculation is the most common long-term complication of a TURP and can occur in as many as 9 out of 10 cases.
Retrograde ejaculation means semen you ejaculate during sexual intercourse or masturbation does not come out of your penis, but flows into your bladder instead.
It is caused by damage to the nerves or muscles surrounding the neck of the bladder, which is the point where the urethra connects to the bladder.
You will still experience the physical pleasure associated with ejaculation (the climax) in the normal way. However, retrograde ejaculation can affect your fertility, so speak to your surgeon to discuss alternative procedures if this is a concern.
It may be possible to have a transurethral incision of the prostate (TUIP) instead, which carries a lower risk of causing retrograde ejaculation.
It is also sometimes possible to lower this risk when performing a TURP by leaving prostate tissue located near the urethra intact.
Urinary incontinence affects around 10% of men after a TURP. It usually gets better over time, but can be a long-term problem.
It usually takes the form of urge incontinence – when you have a sudden urge to pass urine and lose control of your bladder if you do not find a toilet quickly enough. Taking medication to help relax the muscles of the bladder may reduce the urge to urinate.
Around 2% of men will develop long-term stress incontinence, where small amounts of urine leak out during physical activities, such as coughing, sneezing, laughing and heavy lifting.
Narrowing of the urethra (urethra strictures) is estimated to develop in up to 4% of cases. It is thought some of the electric current used during the procedure may move back into the urethra, causing scarring and narrowing of the urethra.
Symptoms of a urethra stricture include:
straining to pass urine
spraying of urine or a ‘split-stream’ of urine
dribbling drops of urine once you have finished going to toilet
mild pain when passing urine
If the narrowing of the urethra is mild, it can usually be treated by inserting a rod to widen the urethra.
More extensive narrowing may require surgery to correct.
Less common risks
The less common risks of a transurethral resection of the prostate are described below.
Bleeding - In around 3-5% of cases there may be persistent bleeding after the operation and further treatment may be needed. A blood transfusion may be necessary in some cases, if there is significant bleeding.
Urinary tract infection (UTI) - In around 5-10% of cases, a UTI could develop after surgery.
Urinary retention - In around 2% of cases, the muscles that control the bladder may be temporarily damaged. This can lead to problems fully emptying the bladder. It is normally recommended to wait four to six weeks to see if the bladder muscles regain their normal functions.
Erectile dysfunction (impotence) - Around 5-10% of men may find it difficult getting and maintaining an erection after the procedure. However, this is usually temporary while your body recovers from surgery. Your surgeon may be able to provide more information on your individual risk (although this can only ever be an informed ‘guess’ rather than a completely accurate prediction).
A rare but potentially serious risk associated with a transurethral resection of the prostate is known as TURP syndrome.
During the procedure, it is necessary to pump a fluid called glycine through the urethra to clear away blood and debris. In cases of TURP syndrome, the glycine becomes absorbed into the bloodstream, leading to a potentially dangerous build-up of fluid in the blood.
Initial symptoms of TURP syndrome include:
feeling or being sick
swelling of your abdomen
slow heartbeat (bradycardia)
Left untreated, additional and more serious symptoms can develop such as:
shortness of breath
blue skin (cyanosis)
If you start to experience the symptoms of TURP syndrome during your procedure, the surgeon will stop the surgery, remove the resectoscope and inject you with a diuretic, which is a type of medication used to remove fluid from the body.
Nowadays, the risk of TURP syndrome is estimated to be less than one in 100. It is likely to become even lower if a new method, known as bipolar TURP, is used, which does not involve pumping water into the urethra.
A TURP carries a very small risk of causing death. The risk of dying during the procedure is now estimated to be less than one in 1,000.
The risk usually arises from complications involving the heart, or a serious post-operative infection.
Alternatives to surgery
There are several alternatives to a transurethral resection of the prostate (TURP). Your options will depend on how severe your symptoms are and which treatments are available.
If you have an enlarged prostate but do not find your symptoms particularly troublesome, you may decide to just wait and keep an eye on your symptoms.
This means you will not receive any immediate treatment, but will have the option of having a TURP in future, if your symptoms get worse.
If you do not have a TURP, lifestyle changes such as limiting your consumption of alcohol and taking regular exercise may be recommended to improve your symptoms.
There are a number of newer surgical techniques that may lead to fewer side effects, or a quicker recovery, than a TURP.
However, as these treatments are still fairly new they may not be available and their long-term effectiveness is not always clear.
These alternative techniques are explained below.
Bipolar transurethral resection of the prostate - different instruments are used to perform the procedure, which allow saline water to be pumped into the urethra rather than a fluid called glycine. This is thought to lead to a lower risk of TURP syndrome (see risks of a TURP).
Holmium laser enucleation of the prostate - a laser is used to remove excess prostate tissue using a similar route to a TURP. The procedure has shown good results in medium-term follow up (five to seven years) and is emerging as a promising alternative. It does not use glycine and hence there is no risk of TURP syndrome.
KTP laser vaporisation - a small tube known as a cystoscope is inserted into your urethra. The cystoscope fires pulses of laser energy to burn away prostate tissue.
This procedure may be more effective than a TURP if you have severe prostate enlargement.
However, open prostatectomy is now very rarely used, even for larger prostates, due to the development of other techniques such as holmium laser enucleation of the prostate (see above).
The procedure carries a higher risk of complications, such as erectile dysfunction and urinary incontinence. There is also a greater chance these complications will become permanent than if they occur following a TURP.
Transurethral resection of the prostate
During an open prostatectomy, an incision is made in your abdomen and the outer portion of your prostate is removed.