What is the recommended treatment approach for patients undergoing a Transurethral Resection of the Prostate (Turp) procedure for symptomatic Benign Prostatic Hyperplasia (BPH)?

Transurethral Resection of the Prostate (TURP) for Benign Prostatic Hyperplasia

TURP remains the benchmark surgical treatment for symptomatic BPH due to its proven long-term efficacy and should be offered as a primary treatment option for men with moderate-to-severe lower urinary tract symptoms (LUTS) or BPH-related complications. 1

Indications for TURP

• TURP is indicated for patients with moderate-to-severe LUTS attributed to BPH who are bothered enough to request intervention 1
• Surgery is specifically recommended for patients with: 1
  • Renal insufficiency secondary to BPH
  • Refractory urinary retention secondary to BPH
  • Recurrent urinary tract infections
  • Recurrent bladder stones or gross hematuria due to BPH
  • LUTS/BPH refractory to or unwilling to use medical therapy

Patient Selection and Preoperative Evaluation

• Initial evaluation should include: 1

  • Medical history
  • AUA Symptom Index (AUA-SI) score
  • Urinalysis
  • Post-void residual (PVR) in select patients

• Prostate imaging (transrectal or transabdominal ultrasound) may be appropriate when surgical intervention is planned to determine prostate size and shape 1

• Urethrocystoscopy may be indicated in patients with: 1

  • History of hematuria
  • Urethral stricture or risk factors
  • Bladder cancer
  • Prior lower urinary tract surgery

Surgical Approach Options

• Monopolar vs. Bipolar TURP: 1

  • Both approaches have similar efficacy outcomes
  • Bipolar TURP has reduced risk of hyponatremia and TUR syndrome
  • Bipolar TURP allows for longer resection times and surgery on larger glands
  • Choice depends on surgeon expertise with these techniques

• Prostate Size Considerations: 1

  • For prostates ≤30g: Transurethral Incision of the Prostate (TUIP) should be offered 1
  • For very large prostates: Consider open, laparoscopic, or robotic-assisted prostatectomy 1
  • Some surgeons can effectively perform bipolar TURP on prostates >60g 1

TURP Procedure Details

• Involves surgical removal of the prostate's inner portion via an endoscopic approach through the urethra 1
• Uses an electrified loop to resect prostatic tissue and cauterize bleeders 1
• Usually performed under general or spinal anesthesia 1
• Typically requires hospital stay 1

Potential Complications

• Complications occurring in >5% of patients include: 1

  • Sexual dysfunction (may not be attributable to surgery in all cases)
  • Irritative voiding symptoms
  • Bladder neck contracture
  • Need for blood transfusion
  • Urinary tract infection
  • Hematuria

• TURP syndrome (dilutional hyponatremia) is a unique complication when irrigant solution is absorbed into bloodstream 1

  • More common with monopolar TURP
  • Bipolar TURP has significantly reduced this risk 1

• Risk of urinary incontinence is approximately 1% 1

Special Considerations

• Patients should be counseled about potential sexual side effects, including ejaculatory dysfunction and possible worsening of erectile dysfunction 1

• For high-risk surgical patients who cannot undergo TURP, alternative options like prostatic stents may be considered, though these are associated with significant complications (encrustation, infection, chronic pain) 1, 2

• Sedoanalgesia (local anesthesia with sedation) may be a safe alternative to general or regional anesthesia in high-risk patients 3

Medical Therapy Considerations

• While TURP is effective, medical therapy with alpha-blockers and 5-alpha-reductase inhibitors (like finasteride) is often tried before proceeding to surgery 1, 4

• However, medical therapy is not a requirement before surgery, especially if symptoms are particularly bothersome or if BPH-related complications are present 1

• Finasteride can reduce the risk of acute urinary retention and the need for surgery including TURP 4