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BPH Surgery - Procedure, Grading, Risks & Treatment Types

BPH surgery entails the resection of the prostate gland to relieve the patient’s urinary problems caused due to prostate enlargement. Though there are many different surgical techniques that are performed for BPH treatment, TURP and HoLEP are the most commonly performed and effective procedures among them.

BPH, or benign prostatic hyperplasia, is a noncancerous prostate gland enlargement that occurs in most men as they age due to hormonal and other age-related changes. As the prostate enlarges, it restricts the urethra and the flow of urine through it, which leads to LUTS (lower urinary tract symptoms) like painful and uncomfortable urination, poor/intermittent urine stream, etc. 

Why is BPH Surgery Required?

BPH is a naturally progressive condition and is incredibly common among men. About 40-50% of men over the age of 50 have symptomatic BPH, and the number continues to rise, with over 80% of men above the age of 70 having BPH. 

Since BPH can’t be prevented, its management is necessary. Though patients can try different medications, generally, medicines are not effective for BPH, and patients need surgical management for long-term relief.

Most patients can delay surgery till their BPH symptoms are manageable, but once their quality of life starts decreasing significantly due to urinary problems, it is an indication that they should seek surgical treatment for BPH. 

A person can assess if they need treatment for BPH disease by evaluating their LUTS symptoms over the past month to calculate their IPSS (International Prostate Symptom Score):

IPSS

Not at all

Less than 1 in 5

Less than half the time

About half the time

More than half the time

Almost always

Incomplete Emptying

How often have you had the sensation of not emptying your bladder?

0

1

2

3

4

5

Frequency       

How often have you had to urinate, less than every two hours?

0

1

2

3

4

5

Intermittency      

How often have you found you stopped and started several times again when you urinated?

0

1

2

3

4

5

Urgency   

How often have you found it difficult to postpone urination?

0

1

2

3

4

5

Weak Stream        

How often have you had a weak urinary stream?

0

1

2

3

4

5

Straining        

How often have you had to strain to start urination?

0

1

2

3

4

5

Nocturia  

How many times did you typically get up at night to urinate?

0

1

2

3

4

5

With your IPSS score, you can evaluate the severity of your symptoms and their effect on your quality of life and determine whether you need surgical intervention. You can follow the given table for your assessment:

Score

Severity

1-7

Mild

8-19

Moderate

20-35

Severe

BPH grading is performed on the basis of the above table. Grade I BPH, i.e., mild BPH, signifies minor urinary symptoms and discomfort, while Grade II (moderate) and Grade III (severe) BPH may require treatment based on patient preference.

Preoperative Preparation

Since BPH is a progressive disorder, a thorough analysis is needed before surgery. Once a patient has evaluated their IPSS score and decided to get the surgery, they will need to undergo the following diagnostic tests and preparations for complete BPH diagnosis:

  • PSA and other blood tests: Prostate-Specific Antigen is a protein produced by the prostate gland. The level of PSA in the blood helps evaluate the status of prostate disease. Other blood tests like CBC, HbA1c, etc. help assess the patient's condition and determine whether they are ready for the surgery.
  • Digital rectal exam (DRE): During a digital rectal exam, the doctor inserts a finger into the patient’s anal region to palpate the prostate gland’s size and check for prostate enlargement.
  • Urine test: The lab will analyze your urine sample to rule out the presence of any infections or other conditions that may complicate the surgery or recovery.
  • Urinary flow test: A urine flow test is performed using a special machine that measures the strength and volume of the urine flow to determine the effectiveness of a given treatment.
  • Postvoid residual volume test: Postvoid test checks for bladder fullness after urination to check the patient’s ability to void their bladder completely. It is done using ultrasound or by inserting a catheter into the bladder after urination to measure the contents left in the bladder.
  • 24-hour voiding diary: The patient’s records of their frequency and amount of urination help assess the progress of the condition.
  • Transrectal ultrasound: The doctor inserts an ultrasound probe in the rectum to measure and evaluate the prostate. 
  • Prostate biopsy: If the doctor suspects that a patient may have prostate malignancy, they would advise a prostate biopsy. A biopsy is performed using transrectal ultrasound to guide the needle to collect prostate tissue samples.
  • Urodynamic and pressure flow studies: The doctor guides a catheter through the urethra and injects either water or air into the urethra to measure the bladder pressure and evaluate bladder muscle performance. 
  • Cystoscopy: The patient is anesthetized and a cystoscope is inserted into the urethra to visualize the area inside the urethra and bladder to look for any signs of damage, lumps, etc.

Once the results from all the diagnostic tests are obtained, the surgeon will recommend a particular treatment option/surgery and finalize the treatment plan. Preoperative preparation before the surgery entails:

  • The patient cannot take any blood thinners for up to 10 days before the surgery to prevent hemorrhage during or after the surgery.
  • The patient should have a urine culture within 2-4 weeks of the surgery to ensure they have no urinary infections.

Day Before Surgery

On the day before the surgery, the doctor will perform pre-operative tests such as urine culture, blood tests, etc., to make sure the patient is in optimum condition for the surgery. 

Since the surgery could be performed under local or general anesthesia, the patient has to follow the specific dietary restrictions to avoid complications. If the surgery is to be performed under general anesthesia, the patient can’t eat anything after midnight on the day before the surgery. 

If the patient has difficulty voiding their bowels completely, they may need an enema to clear their bowels. 

Procedure Day

On the day of the surgery, the patient will be admitted to the hospital and their pre-surgery vitals will be noted. The patient should also avoid wearing any  jewelry, eyeglasses, contact lenses, or dentures during the surgery, so they should come to the hospital accordingly. Once the patient is confirmed to be healthy, they will be moved to the operation theatre and anesthetized. The patient should also bring an overnight bag to the hospital as most patients are hospitalized overnight.

Types of BPH surgery

  • HoLEP: HoLEP surgery (Holmium Laser Enucleation of the Prostate) is performed using a modified resectoscope. The modified resectoscope for a HoLEP procedure has an attached camera lens, a light, and a laser device. The surgeon inserts the resectoscope through the urethra and chips away the excess part of the prostate, pressuring the urethra using a high-powered laser beam. 

    Since the procedure is performed using a laser beam, it is bloodless and provides much better recovery. It is preferred for patients with severe bleeding/clotting disorders and severe cardiopulmonary diseases. The potential risk of heavy bleeding after the surgery is very low, which decreases the chances of the patient needing blood transfusions. HoLEP also necessitates a very short hospital stay and recovery period after the surgery. The recurrence rate of BPH after HoLEP surgery is also very low.
     
  • TURP: Transurethral Resection of the Prostate or TURP is a minimally invasive surgical procedure that is performed for the treatment of abnormal growth in the prostate gland. The procedure is performed using a resectoscope. A resectoscope is a thin tube-like instrument that is used to remove tissue from the body. It has a light and camera lens to help view the inside of the body, along with an electric instrument that can be used to cut, remove, or destroy the tissue and cauterize the wound to limit bleeding. It is widely considered the gold standard among prostate treatments as it is the most effective and affordable treatment for BPH.

Post Procedure Tips to Follow After BPH surgery

After the surgery, you will be moved to a recovery ward. You may need a catheter for at least 1-2 weeks after the surgery, or at least until the swelling in the urethra has gone down. There may be mild to moderate pain in the surgical site for 7-10 days after the procedure. However, it is easily manageable via over-the-counter pain medication. Your normal urinary flow usually resumes as soon as the catheter is removed.

Recovery is usually fast after TURP surgery as it is a minimally invasive procedure. You can also improve the recovery time by following a few easy tips:

  • Stay well hydrated during the first couple of weeks after the surgery. Drink plenty of water and avoid alcohol, caffeine, and other diuretic foods.
  • Make sure to complete your antibiotic course to prevent infection.
  • Avoid lifting, gardening, and other physically taxing activities for at least two weeks after the surgery. Avoid sex for at least 3-4 weeks to ensure the urethra is completely healed.
  • Include extra fiber in your diet to make bowel movements easier.
  • Most patients are admitted to the hospital for overnight observation and catheter care. The patient may have a little bleeding after the surgery, but it usually resolves within 12 hours after the surgery.
  • You will be able to eat and drink without any complications on the same day as the surgery.
  • If the amount of bleeding is normal and manageable, the catheter will be removed and you will be discharged within 24 hours after the surgery. 

Sometimes patients may need to be catheterized for up to 7 days after the surgery if there is too much swelling or if the patient is unable to urinate without the catheter. There may be a little pain and discomfort while urinating right after the surgery, but it can be easily managed through pain medications and anti-inflammatories. 

  • You should drink more fluids during this period to help clear the blood more efficiently and quickly.
  • Perform kegel exercises and other pelvic floor strengthening exercises to improve urinary control after the surgery

The urinary symptoms that were caused due to BPH may take a little while to resolve as the bladder and urethra readjust themselves to the reduced amount of prostate tissue.

Risks and Complications

Common after-effects/side effects of BPH surgery are:

  • Temporary bleeding and burning sensation during urination: They are not indicative of any serious problems and resolve on their own within a few days.
  • Temporary urinary incontinence: It takes a little time for the urinary bladder muscles and strictures to get used to the reduced amount of prostate tissues, which makes it a little harder to control urination in the days following the surgery. You can also improve urinary control by performing pelvic floor strengthening exercises such as Kegel exercises.
  • Retrograde/Backward ejaculation: In over 75% of the cases, the patient may experience dry orgasms for a few days after the surgery, i.e., there is no semen after ejaculation.
  • Erectile dysfunction: Generally, erectile function is not affected. In very rare cases, the patient may have erectile dysfunction for a little while.

These side effects usually only last for a for days and do not need any medical attention. However, in some cases, if the patient has a surgical complication, they may need medical treatment immediately. 

Potential complications of BPH surgery are:

  • Injury to the surrounding structures such as the urinary bladder, prostate capsule, and urethra accompanied by extensive scarring
  • Infection
  • Recurrence of the condition
  • Hemorrhage
  • Prolonged catheterization due to extensive swelling in the urethra
  • Complications associated with anesthesia
  • Electrolyte abnormalities
  • Erectile dysfunction
  • Retrograde ejaculation 
  • TURP syndrome, etc.

If you notice any bleeding or pus discharge from the surgical site, then it is a sign that you may have an infection. Get in touch with your urologist immediately if you notice any complications. 

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