What are the indications for Transurethral Resection of the Prostate (TURP)?

Indications for Transurethral Resection of the Prostate (TURP)

TURP is indicated for patients with absolute indications (renal insufficiency, refractory urinary retention, recurrent UTIs, recurrent bladder stones, or gross hematuria due to BPH) and for those with moderate-to-severe lower urinary tract symptoms who have failed or are unwilling to use medical therapy. 1

Absolute Indications (Surgery Recommended as Initial Intervention)

The following conditions warrant surgical intervention regardless of symptom severity:

• Renal insufficiency secondary to BPH - bladder outlet obstruction causing kidney damage requires urgent surgical decompression 1
• Refractory urinary retention secondary to BPH - inability to void despite catheter trials and medical management 1, 2
• Recurrent urinary tract infections - persistent infections attributable to prostatic obstruction and incomplete bladder emptying 1, 2
• Recurrent bladder stones - stone formation due to chronic urinary stasis from obstruction 1, 2
• Gross hematuria due to BPH - significant bleeding from prostatic vasculature that is refractory to medical management 1, 2

Relative Indications (After Failed Conservative Management)

• Moderate-to-severe LUTS attributed to BPH that have not responded adequately to medical therapy (alpha-blockers and/or 5-alpha-reductase inhibitors) 1, 3, 2
• Patients unwilling to use medical therapies who have bothersome symptoms affecting quality of life 1
• Acute urinary retention - particularly in patients who fail trial without catheter or have recurrent episodes 3, 4

Technical Considerations for TURP Selection

TURP should be offered specifically for prostates ≤80 grams, as larger glands are better managed with simple prostatectomy (open, laparoscopic, or robotic) or alternative techniques like HoLEP 1. The AUA guideline notes that while some experienced surgeons successfully perform bipolar TURP on larger glands, not all providers have this expertise or technology access 1.

For prostates ≤30 grams, transurethral incision of the prostate (TUIP) may be preferred over TURP, offering lower rates of retrograde ejaculation (18.2% versus 65.4%) and reduced transfusion requirements 1, 2.

Important Caveats

• Do not perform surgery solely for asymptomatic bladder diverticulum - however, evaluate for bladder outlet obstruction and treat if clinically indicated 1
• Preoperative evaluation must include AUA-Symptom Index scoring, urinalysis, and consideration of post-void residual measurement 1
• Anticoagulation management is critical - discontinue anticoagulants before TURP to reduce significant bleeding complications 3
• Consider urodynamic studies in patients with acute urinary retention to rule out concomitant bladder dysfunction before proceeding with surgery 4

Monopolar versus Bipolar TURP

Both approaches are acceptable depending on surgeon expertise 1. The key difference is that bipolar TURP has reduced risk of TUR syndrome and hyponatremia, allowing for longer resection times and safer treatment of larger prostates 1, 2. Monopolar TURP requires limiting resection time to under 90 minutes to prevent TUR syndrome 3.