Transurethral prostate resection (TURP) is an endoscopic surgical procedure used in the treatment of benign prostatic hyperplasia (BPH). It is a well-known method and yields highly successful results when performed by experienced hands. In this article, I will provide general and up-to-date information about TURP surgery.

What is TURP surgery?

TURP surgery is an endoscopic, non-invasive procedure performed to relieve urinary difficulties caused by prostate enlargement in men. For many years, it has been considered the “gold standard” in the surgical treatment of BPH. However, in recent years, the HOLEP technique has been recognized as the new gold standard for the surgical treatment of prostate enlargement, producing very successful outcomes. We have also been successfully applying the HOLEP method to our patients for many years. TURP remains a valid option today due to its lower cost and its use in many centers. We have performed TURP on countless patients for over 25 years and still successfully apply it to those who cannot undergo HOLEP.

How is TURP surgery performed?

The patient is positioned on their back in a gynecological position. A resectoscope is inserted through the urethra to view the enlarged parts of the prostate causing urinary difficulties, as well as the bladder and ureteral openings (the outlets of the urinary channels opening into the bladder). The bladder is examined for cancer or stones. The enlarged prostate tissues are then cut into small pieces and removed through the bladder without any external incisions. After the resection (TUR, TURP) is completed, bleeding in the prostate area is controlled (cauterization), and the removed prostate pieces are flushed out of the bladder with pressurized water. At the end of the procedure, a Foley catheter is placed in the urethra, and the operation is concluded by flushing the catheter with saline to prevent bleeding.

What techniques are used?

There are different techniques for TURP surgery, including:

• Plasma kinetic, bipolar TURP
• Classic, monopolar TURP

Both plasma kinetic and classic TURP surgeries are performed similarly. However, plasma kinetic TURP is a more advanced technique. Its main advantages over classic TURP are reduced bleeding during surgery, faster operation times, and fewer complications. Plasma kinetic TURP uses saline, which eliminates the risk of TUR syndrome. We prefer the bipolar plasma kinetic method for our TURP patients.

What are the alternative methods?

Alternative methods to TURP include:

• HOLEP surgery: In developed countries like the USA and Europe, HOLEP has replaced TURP as the gold standard. It has minimal bleeding, does not affect sexual function, has no recurrence, and can be applied to prostates of any size.
• Open prostate surgery: Rarely performed, only in cases of very large prostates or when other methods are not feasible.
• Green light laser: A laser technique, though rarely used now.
• Rezum surgery: A treatment where steam is applied endoscopically to shrink the prostate.
• Other laser methods

Who is eligible for TURP surgery?

TURP is recommended in the following situations:

• Symptoms do not improve despite medication
• Presence of bleeding
• Inability to urinate, requiring catheterization
• Formation of bladder stones
• Formation of bladder diverticula
• Recurrent urinary tract infections
• Incomplete bladder emptying
• Kidney function deterioration
• Frequent nighttime urination disrupting sleep
• Presence of a bladder diverticulum
• Presence of an inguinal hernia

Pre-operative preparation

Since patients with prostate enlargement are usually elderly, they may have other conditions such as heart disease, high blood pressure, or diabetes, which need to be evaluated before surgery.

• Patients with conditions like high blood pressure or diabetes should be evaluated by a cardiologist and endocrinologist.
• If patients are taking blood thinners, these should be stopped one week before surgery, or medications with a lower risk of bleeding should be prescribed.
• General blood tests (kidney, liver, etc.) are performed.
• A chest X-ray and EKG are taken.
• 1-2 units of blood may be prepared in case of bleeding.
• If a urinary tract infection is present, it should be treated with appropriate antibiotics before surgery.
• Patients are admitted to the hospital on the same day of surgery, and they should avoid eating or drinking for at least 4-5 hours before the operation.
• Patients are asked to read and sign an informed consent form.

What type of anesthesia is used?

Usually, spinal anesthesia (numbing from the waist down) is used for TURP surgery. In some cases, general anesthesia is applied. The type of anesthesia is decided by the anesthesiologist and the surgeon together.

How long does the surgery take, and how long is hospitalization?
The duration of TURP surgery depends on the size of the prostate. On average, it lasts 1 to 1.5 hours, but it can take longer if the prostate is large. The catheter usually remains in place for 1-2 days, and patients typically stay in the hospital for 1-2 days.

Post-operative care

Patients are advised to follow certain guidelines after catheter removal and discharge:

• Drink plenty of water to help clear the urine and prevent bleeding.
• High-fiber foods are recommended to avoid constipation. Gaseous foods and drinks should be avoided.
• Avoid blood thinners in the early post-operative period unless necessary.
• Avoid strenuous activities for the first 4-6 weeks.
• Sexual activity should be avoided for 4 weeks to prevent bleeding.
• Avoid sitting on hard surfaces for prolonged periods for 4-6 weeks to reduce the risk of bleeding.

Risks of the surgery

TURP surgery, when performed by experienced hands, generally yields highly successful results, and serious complications are rare. The infrequent risks associated with TURP surgery include:

• Difficulty urinating: In the early stages after catheter removal, temporary difficulty in urinating can occur due to swelling in the surgical area.
• Urinary tract infection: To prevent this, appropriate antibiotic treatment is given before and after the surgery.
• Absence of semen: In all prostate surgeries, semen may pass into the bladder instead of exiting during ejaculation (retrograde ejaculation). This may be a concern for men wishing to have children, though in vitro fertilization can still allow them to father a child. However, since most prostate patients are of advanced age, this is usually not a significant issue.
• Erectile dysfunction (impotence): This problem may occur in a very small percentage of patients. It is extremely rare or non-existent in HOLEP surgery.
• Bleeding: In patients with very large prostates, the surgery may take longer, leading to a risk of bleeding and the need for a blood transfusion.
• Urinary incontinence: This risk exists in all prostate surgeries. If TURP surgery is performed by highly experienced hands, it is very rare. Temporary mild leakage that may occur initially generally resolves over time. We have successfully performed TURP surgery for many years with minimal complications.
• TURP syndrome: This occurs when the fluid used during TURP enters the bloodstream. However, with the modern use of bipolar TURP techniques and advanced solutions, this issue is no longer encountered.
• Need for repeat TURP surgery: If the prostate is not fully removed during the first surgery, there may be a recurrence of symptoms and the need for a second surgery. This does not happen with HOLEP surgery.
• Urethral stricture: After TURP and all endoscopic surgeries, damage to the urinary tract can lead to future narrowing of the urethra.

What can happen after the surgery?

Patients usually stay in the hospital for 1-2 days after the surgery, and their catheters are removed before discharge. During this period, patients should be aware of the following:

• Blood in the urine: It is normal for urine to appear bloody in the early stages after catheter removal, but this typically improves over time.
• Inability to urinate: Especially in older patients or those with diabetes, the inability to urinate after catheter removal may occur due to blockage, which can sometimes result from bleeding or clot formation. In such cases, a temporary catheter may need to be reinserted.
• Burning during urination: Temporary burning and pain while urinating may occur after surgery. This is sometimes due to infection and can be treated with antibiotics. Painful urination can last for up to 4-6 weeks in some cases.
• Frequent urination and urgency: In the early stages, some patients may experience frequent urination or a sudden urge to urinate, along with occasional leakage. This is temporary and can be treated with appropriate medication in severe cases.
• Urinary incontinence: After catheter removal, some patients may experience stress incontinence, such as leakage during movement, coughing, or standing up. This is temporary and usually resolves over time.

When should patients contact their doctor?

Although rare, certain problems may arise after this surgery. Patients should contact their doctor in the following situations:

• Inability to urinate
• Severe bleeding with clots in the urine
• Urine remains red despite drinking plenty of fluids
• Prolonged fever of 38°C (100.4°F) or higher, accompanied by chills.

In summary

TURP has been a long-standing, successful method for the endoscopic treatment of benign prostate enlargement. However, the HOLEP technique has become the new gold standard in developed countries, offering advantages like minimal bleeding, no recurrence, and preservation of sexual function.

Prof. Dr. Emin ÖZBEK
Urology Specialist
Istanbul, TURKEY