Transurethral prostatectomy

Description

Prostatectomy is the removal of part or all of an enlarged prostate gland, an organ located at the base of the bladder in men. A TUR is a particular kind of prostatectomy.

Why is it done?

The start of the urethra, at the base of the bladder, is encircled by the prostate gland. This gland produces fluid which is added to the ejaculate. With normal ageing, the prostate gland enlarges, and this is called benign prostatic hypertrophy or BPH. As the gland slowly enlarges, it constricts the urethra, causing symptoms which gradually increase over several years:

• increased frequency of urination
• nocturia - frequent urination at night
• weak urinary stream
• hesitancy -difficulty starting urination
• urgency - the sudden need to urinate

While none of the symptoms are life-threatening, they can cause a significant decrease in the quality of life, and surgery is thus often recommended. Several surgical techniques exist for prostatectomy, but TUR is still the most frequently done for BPH, with excellent results.

How is it done?

Under general anaesthesia, a cystoscope is passed into the urethra. This is a rigid tube having several inbuilt channels, and a light source. The scope is advanced until it reaches the prostate.

A special cutter is then introduced through the scope, to shave off slivers of prostate tissue from inside the gland until the passage is opened back to its normal size. The bits of tissue fall back into bladder, are flushed out at the end of the procedure, and sent for histological analysis. Bleeding caused by the shaving of tissue is controlled by electrocautery done via the scope.

Variations on the standard TUR are

• laser prostatectomy, in which a laser is used instead of a shaver, to remove tissue
• transurethral needle ablation (TUNA) - here needles are placed into the prostate, and heated with ultrasound, causing the tissue to shrink over the next few days. This type of TUR may be done under local anaesthetic.
• cryosurgery uses the same transurethral approach, but freezes the tissue to destroy it. Not many surgeons favor this method.

After the operation, the cystoscope is withdrawn, and a standard catheter is inserted and left in place for a few days. This allows urine, and any blood, to drain, and permits flushing of the bladder to remove small clots which may have formed.

Complications

All surgery carries risks of bleeding and infection. TUR specifically, has few complications, but these may include

• urinary incontinence in up to 50% of patients. This may be mild or severe, but usually improves with time
• impotence - not a common problem with TUR, though the patient's age and previous erectile function may affect this. More than 75% of men under the age of 60 recover full potency after TUR
• retrograde ejaculation - sperm is ejaculated backwards into the bladder
• bladder infection
• bladder neck stricture (narrowing due to scarring) is rare.
• recurrence of obstruction after many years

Outcome

TUR is a highly successful procedure, with a good safety record.