The prostate gland is a fibrous organ that surrounds the urethra at the base of the bladder in men. An enlarged prostate gland can compress the urethra, thus causing problems with urination. Prostate enlargement may be caused by prostate gland overgrowth (benign prostatic hypertrophy or hyperplasia) or prostate cancer.

Removal of the prostate gland can be performed in a number of different ways, depending on the size of the prostate and the cause of the prostate enlargement (such as prostate cancer).

The three most common procedures for surgically removing the prostate for benign disease include: transurethral resection of the prostate (TURP), suprapubic prostatectomy, and transurethral incision of the prostate (TUIP).

The decision regarding the type of prostatectomy to perform depends on the size of your prostate gland. Generally, for prostates less than 30 grams, TUIP is recommended.

For glands bigger than 30 grams and less than 80 grams (this number depends on the experience of the surgeon), TURP is performed. If the prostate is bigger than 80 grams, open prostatectomy is recommended.

TURP
Transurethral resection of the prostate is the gold standard treatment and most common surgical procedure for benign prostatic hyperplasia (BPH). TURP is performed using spinal or general anesthesia. A special kind of cystoscope (tubelike instrument) is inserted into the penis through the urethra to reach the prostate gland.

A special cutting instrument is inserted through the cystoscope to remove the prostate gland piece by piece. Blood vessels are cauterized (using heat to stop the bleeding) with electric current during the surgery.

A Foley catheter (artificial tube to remove urine from the body) is placed to help drain the bladder after surgery. The urine will initially appear very bloody, but will clear with time.

A bladder irrigation solution may be attached to the catheter to continuously flush the catheter, thus keeping it from becoming clogged with blood or tissue. The bleeding will gradually decrease, and the catheter will be removed within 1-3 days. You will remain in the hospital for 1 to 5 days.

OPEN PROSTATECTOMY
Although the transurethral approach is more commonly used, other surgical approaches to removal of the prostate gland (such as the transvesical, retropubic, and suprapubic approach) are sometimes used. The primary advantage of the transurethral approach is that it does not create an external incision. However, it is difficult to remove a large prostate using TURP.

To perform an open prostatectomy (sometimes called suprapubic or retropubic prostatectomy), an incision is made in the lower abdomen between the umbilicus (belly-button) and the penis through which the prostate gland is removed. This is a much more involved procedure and usually requires a longer hospitalization and recovery period.

Open prostatectomy is performed using general or spinal anesthesia. You will return from surgery with a Foley catheter in place. Occasionally, a suprapubic catheter will be inserted in the abdominal wall to help drain the bladder.

A bladder irrigation solution may be attached to the catheter to continuously flush the catheter, thus keeping it from becoming clogged with blood. A drainage tube may also be placed in the abdominal cavity to drain excess blood and fluids from the area.

Your urine may initially appear very bloody, but this should resolve in a few days. The Foley catheter and suprapubic catheters will remain in place for 5 days to a few weeks until the bladder has sufficiently healed.

TUIP
Transurethral incision of the prostate (TUIP) is similar to TURP, but is usually performed in people who have a relatively small prostate. This procedure is usually performed on an outpatient basis and usually does not require a hospital stay.

A small incision is made in the prostatic tissue to enlarge the lumen (opening) of the urethra and bladder outlet, thus improving the urine flow rate and reducing the symptoms of BPH.

A Foley catheter may be placed to help drain the bladder after surgery. The catheter will usually remain in place for a few days after surgery. Another key advantage to the TUIP is the preservation of normal ejaculation.

Although orgasm is the same in both the TURP and TUIP, the TURP causes the ejaculate fluid to be projected into the bladder instead of out the penis. The TUIP usually continues to allow the ejaculate fluid to be expressed out the penis. Unfortunately, many patients are not candidates for this surgery due to configuration of their prostates.

NEWER TECHNIQUES
Transurethral laser incision of the prostate (TULIP) and visual laser ablation (VLAP) are two newer procedures that use lasers to cut out or destroy the prostate tissue. These procedures are similar to the transurethral incision of the prostate (TUIP). Laser is being evaluated for use in removal of prostatic tissue because of the ability to easily control bleeding and decrease the amount of time required for healing.

Other treatments being investigated for treating the symptoms of prostate enlargement include: microwave therapy of the prostate, balloon dilation of the prostatic urethra, and placement of prostate stents that stretch open the narrowed urethral passage through the prostate gland.

These procedures have demonstrated short term efficacy in select patients, but have not had adequate long-term testing.

Symptoms of prostate enlargement and blockage (obstruction) include:

• Frequent urination with small amounts of urine
• Recent need to urinate at night (nocturia)
• Difficulty starting a stream of urine
• Slow stream of urine
• Urine dripping out of urethra after urination (dribbling)
• Feeling that bladder is never empty
• Urinary tract infection

• inability to completely empty the bladder (urinary retention)
• recurrent bleeding from the prostate
• bladder stones (calculi) with prostate enlargement
• extremely slow urination
• stage A and B prostate cancer
• increased pressure on the ureters and kidneys (hydronephrosis) from urinary retention

• blood clotting disorders
• bladder disease (neurogenic bladder)

• reactions to medications
• problems breathing

• bleeding
• infection

• problems with urine control (incontinence)
• difficulty achieving and maintaining an erection (impotence)
• loss of sperm fertility (infertility)
• passing the semen into the bladder instead of out through the urethra (retrograde ejaculation)
• urethral stricture (tightening of the urinary outlet)