What is transurethral resection of the prostate?
Transurethral resection of the prostate (TURP) is a surgical procedure that involves cutting away a section of the prostate glan
TURP is often used to treat prostate enlargement (the medical term for prostate enlargement is benign prostate hyperplasia).
The prostate is a small gland in the pelvis only found in men. It is located between the penis and the bladder, and surrounds the urethra (the tube that carries urine from the bladder to the penis).
The main function of the prostate is to help the production of semen. The prostate produces a thick, white fluid that is liquefied by a special protein known as prostate-specific antigen (PSA). The fluid is then mixed with sperm, produced by the testicles, to create semen.
If the prostate becomes enlarged, it can place pressure on the bladder and urethra. This can cause symptoms that affect urination (passing urine when going to the toilet). These symptoms include:
- difficulties starting urination
- a frequent need to urinate
- difficulty emptying the bladder fully
Read more about the symptoms of prostate enlargement.
The first treatments to try for prostate enlargement are lifestyle changes, medications that help relax the bladder and make it easier to pass urine, and medications designed to prevent the prostate from getting larger.
However, in around one in 10 men, these treatments fail to control symptoms.
In such circumstances, a TURP is often needed.
Read more about why a TURP may be necessary.
How it is performed
A TURP is usually performed using a spinal anaesthetic (epidural), so you will be awake but you will lose all feeling below your waist and will feel no pain.
During the procedure the surgeon will insert a thin metal wire with a loop at the end into your urethra and up against your prostate. An electrical current is then used to heat the loop, which cuts away a section of your prostate.
Read more about how a TURP is performed.
Most men can leave hospital two to three days after surgery and resume most normal activities within one week.
However, it can take up to six weeks before you are fit enough to return to work if your job is physically strenuous.
Read more about recovering from a TURP.
In most cases, TURP is a safe procedure and the risk of serious complications occurring during surgery is now very small.
The most common problem during surgery is that a blood vessel could be accidentally damaged, leading to bleeding that requires a blood transfusion to correct. This occurs in around one in 35 cases.
Read more about the risks of TURP.
Pros and cons
The main advantage of having a TURP is that it is effective in relieving the symptoms of prostate enlargement and improving quality of life.
In one survey, around nine out of 10 men said they were happy they had chosen to have the surgery.
A common disadvantage is that men lose the ability to ejaculate semen out of their penis during sex or masturbation, although they still have the physical pleasure associated with ejaculation (the climax). This is known as retrograde ejaculation and can occur in as many as nine out of 10 cases.
Another common disadvantage is that men lose their ability to control their bladder (urinary incontinence), although this usually passes a few weeks after surgery.
Read more about the advantages and disadvantages of TURP.
There are a number of alternatives to TURP. Some are not always suitable for all men with prostate enlargement and may not be as effective in the long term.
- holmium laser enucleation of the prostate (HOLEP), where a laser is used to separate excess tissue from the prostate into the bladder; the tissue is then removed. HOLEP has the advantage of causing less blood loss, involves a shorter stay in hospital and is suitable for moderate to large size prostates.
- potassium-titanyl-phosphate (KTP) laser vaporisation of the prostate involves placing a small fibre optic cable into the urethra (the opening through which you pass urine) and then up towards the prostate. Lasers can then be directed out of the fibre optic cable and used to burn away excess prostate tissue
Both HOLEP and KTP laser vaporisation of the prostate may be more suitable for older men who are not fit or those who using blood thinning medication such as warfarin.
Read more about the alternatives to TURP.
How common is TURP
Due to the nature of prostate enlargement, most TURPs are carried out in men aged 60 or over, with the average age being 69 years.
The procedure is relatively straightforward and can usually be performed at your local hospital.
Transurethral resection of the prostate risks
Transurethral resection of the prostate (TURP) is generally a very safe procedure. However, as with all surgery, TURP is associated with a number of potential risks.
A relatively common risk that can occur during surgery is that a blood vessel could be accidentally damaged, leading to bleeding that requires a blood transfusion to correct. This occurs in around one in 35 cases.
Urinary tract infection
Another relatively common risk is that you develop a urinary tract infection (UTI) after surgery.
A UTI is a general term used to describe an infection in any part of your urinary tract such as your bladder or kidneys.
It is estimated that around one in 25 men will develop a UTI after surgery.
Symptoms of a UTI include:
- cloudy urine
- a need to urinate more frequently
- pain or discomfort when passing urine
- abdominal pain
- a high temperature (fever) of 38ºC (100.4ºF) or above
UTIs can usually be successfully treated with antibiotics.
Read more about the treatment of UTIs.
In around one in 20 cases, a man finds he still has problems fully emptying his bladder after surgery (urinary retention).
This is usually due to the muscles that control the bladder being temporarily damaged, rather than the TURP being unsuccessful.
It is normally recommended to wait four to six weeks to see if the bladder muscles regain their normal functions.
Bladder clot retention
In around one in 100 cases, persistent or recurring bleeding causes blood clots to form. The clots can then block the flow of urine out of the bladder.
This is known as bladder clot retention and requires further surgery to remove the clots and repair the source of the bleeding.
An uncommon and potentially serious risk associated with TURP is known as TURP syndrome.
During a TURP, it is necessary to pump a fluid called glycine through the urethra to clear away blood and debris. In cases of TURP syndrome, the glycine becomes absorbed into the bloodstream, leading to a potentially dangerous build-up of fluid in the blood.
Initial symptoms of TURP syndrome include:
- feeling or being sick
- swelling of your abdomen
- slow heartbeat (bradycardia)
Left untreated, additional and more serious symptoms can develop such as:
- seizures (fits)
- shortness of breath
- blue skin (cyanosis)
- heart pain
If you start to experience the symptoms of TURP syndrome during your TURP procedure, the surgeon will stop the surgery, remove the resectoscope and inject you with a diuretic, which is a type of medication used to remove fluid from the body.
Nowadays, the risk of TURP syndrome is estimated to be less than one in 100. It is likely to become even lower if a new method, known as bipolar TURP, is used, this does not involve pumping water into the urethra.
A TURP carries a very small risk of causing death. The risk of dying during a TURP procedure is now estimated to be less than one in 1,000.
The risk usually arises from complications involving the heart, or a serious post-operative infection.
Advantages and disadvantages
Most men who have a transurethral resection of the prostate (TURP) find it improves both their symptoms and quality of life.
For example, in a study that interviewed 280 men 12 years after they had a TURP, only 13% said they were unsatisfied with the results of the surgery.
You should notice the symptoms that bothered you before are no longer there, or are present to a much lesser extent. For example:
- you should no longer need to strain to urinate
- you should be able to go about your normal activities without having to worry as much about being near a toilet
- you should be more in control of holding your urine in
- you may not need to get up in the night to urinate as much as you used to
- you should also notice you have a stronger stream of urine
- you may no longer need to wear incontinence pads if you do so already
Retrograde ejaculation is the most common long-term complication of a TURP and can occur in as many as nine out of 10 cases.
Retrograde ejaculation occurs when the semen you ejaculate during sexual intercourse or masturbation does not come out of your penis, but flows into your bladder instead.
It is caused by damage to the nerves or muscles surrounding the neck of the bladder, which is the point where the urethra connects to the bladder.
Normally, semen is pushed out of your testicles and up through your urethra when you ejaculate. It is prevented from moving into your bladder by the muscles around the neck of the bladder, which close tightly at the moment of orgasm.
However, if the muscles or nerves surrounding the neck of your bladder are damaged, preventing them from closing, semen will flow into the bladder rather than up and out of the urethra.
You will still experience the physical pleasure associated with ejaculation (the climax) in the normal way. However, you may not be able to father children if you have retrograde ejaculation, although it may be possible to take a sample of sperm from your urine for use in fertility treatments such as artificial insemination or IVF.
If infertility is of concern, then you should mention this to your surgeon as it may be possible to treat you with an alternative procedure known as a transurethral incision of the prostate (TUIP). A TUIP carries a lower risk of causing retrograde ejaculation.
It is also sometimes possible to lower the risk when performing a TURP by leaving prostate tissue located near the urethra intact.
Urinary incontinence is very common in the first few weeks after surgery, affecting 30-40% of men. It can be caused by a number of factors, such as unstable bladder muscles.
This usually takes the form of urge incontinence – when you have a sudden urge to pass urine and lose control of your bladder if you do not find a toilet quickly enough. Taking medication to help relax the muscles of the bladder may reduce the urge to urinate.
Around one in 200 men will develop long-term stress incontinence, where small amounts of urine leak out during physical activities, such as coughing, sneezing, laughing and heavy lifting.
Pelvic floor muscle exercises can help treat stress incontinence. Your pelvic floor muscles are the muscles you use to control the flow of urine as you urinate.
They surround the bladder and urethra (the tube that carries urine from the bladder to outside the body). Weak or damaged pelvic floor muscles can cause urinary incontinence, so exercising these muscles can improve symptoms.
Your doctor should be able to refer you to an instructor who can teach you how to perform these exercises.
The Bladder & Bowel Foundation has pelvic floor exercise factsheets for both men and women which explain how to complete these exercises, although your specialist should teach you how to do them.
There are also medications that can treat stress incontinence. They work by contracting the muscles surrounding the urethra, which should keep the urethra closed and stop urine leaking out.
Read more about the treatment of urinary incontinence.
After having a TURP, narrowing of the urethra (urethra strictures) develops in an estimated one in 25 men. It is thought some of the electric current used during the TURP procedure may move back into the urethra, causing scarring and narrowing of the urethra.
Symptoms of a urethra stricture include:
- straining to pass urine
- spraying of urine or a ‘split-stream’ of urine
- dribbling drops of urine once you have finished going to toilet
- mild pain when passing urine
If the narrowing of the urethra is mild, it can usually be treated by inserting a rod to widen the urethra.
More extensive narrowing may require surgery to correct.
Around one in five men may find it difficult getting and maintaining an erection after having a TURP.
This is known as erectile dysfunction or impotence.
However, it is usually a short-term problem and should resolve once the body recovers from the effects of the procedure.
Exactly how many men will experience permanent erectile dysfunction is difficult to estimate because the results of various studies have been contradictory.
Also, as erectile dysfunction is often associated with ageing, it is not easy to estimate exactly how many cases are directly related to the TURP procedure.
Your surgeon should be able to provide more information on your individual risk (although this can only ever be an informed ‘guess’ rather than a completely accurate prediction).
If you have an enlarged prostate but do not find your symptoms particularly troublesome, you may decide to just wait and keep an eye on your symptoms.
This means you will not receive any immediate treatment, but will have the option of having a transurethral resection of the prostate (TURP) in future, if your symptoms get worse.
If you do not have a TURP, lifestyle changes such as limiting your consumption of alcohol and taking regular exercise may be recommended to improve your symptoms.
Read more about the treatment of prostate enlargement.
An open prostatectomy is a type of surgery where an incision is made in your abdomen and the outer portion of your prostate is removed.
While an open prostatectomy may be effective in treating your symptoms, it carries a high risk of complications. Therefore, it is usually only recommended for men with severely enlarged prostates.
Complications of an open prostatectomy include:
If these complications develop following an open prostatectomy, there is a greater chance they will become permanent than if they occur following TURP.
However, it may be possible to treat the symptoms of erectile dysfunction with medication, such as sildenafil (Viagra). Read more about the treatment of erectile dysfunction.
There are a number of new surgical techniques that are broadly based on the same principle as a TURP, but use new ways of removing the prostate tissue. Most of the newer types of surgery have fewer side effects and cause less bleeding, and the recovery time is usually quicker.
However, as these treatments are still fairly new, their long-term effectiveness is unknown. They are also usually only suitable for men who have a moderately enlarged prostate. Men with a severely enlarged prostate will usually require a TURP.
The new techniques are explained below.
KTP laser vaporisation
KTP (potassium-titanyl-phosphate) laser vaporisation involves inserting a small tube known as a cystoscope into your urethra. The cystoscope fires pulses of laser energy to remove the affected section of your prostate.
Complications of KTP laser vaporisation include:
- pain while passing urine
- urge incontinence (a sudden urge to pass urine)
- blood in your urine – this complication usually passes within a few weeks
Transurethral radiofrequency needle ablation of the prostate
Transurethral radiofrequency needle ablation of the prostate (TUNA) involves inserting two electrodes into your urethra and attaching them to your prostate.
Radiofrequency energy heats the electrodes so they can burn away the excess prostate tissue.
Complications of TUNA include:
- retrograde ejaculation
- narrowing of the urethra
Transurethral electrovaporisation of the prostate
Transurethral electrovaporisation of the prostate is similar to a TURP, but the resectoscope is attached to a small roller ball rather than a coil of wire. High voltage electricity is passed into the ball, which vaporises the excess tissue of the prostate before sealing any bleeding.
Transurethral electrovaporisation of the prostate has a similar complication rate to TURP, but is associated with less bleeding afterwards.
Holmium laser enucleation of the prostate
Here a laser is used to remove excess prostate tissue using an approach much like the TURP. The procedure has shown good results in medium-term follow up (three to five years) and is emerging as a promising alternative to TURP. It does not use glycine and hence there is no risk of TURP syndrome.
Following a transurethral resection of the prostate (TURP), you will be unable to urinate normally initially.
This is because your urethra (the tube that carries urine from your bladder to your penis) will be swollen and painful. Instead, a thin tube called a catheter will be inserted into your urethra and up into your bladder so urine can drain away.
Immediately after the operation, water may be pumped through the catheter to clean your bladder and get rid of any blood clots and other debris. This is not usually painful, but may make your bladder feel uncomfortably full.
After your urethra has healed and you are able to pass urine normally, the catheter will be removed and you can go home. This normally occurs about 36-48 hours after surgery.
It is not uncommon that you may still experience problems passing urine and a catheter may need to be reinserted temporarily.
A future date for its removal may then be arranged for you and you can go home with the catheter until then.
After having a TURP, most men are up and about around a week after surgery. However, you will be advised to take things easy for about a month to six weeks afterwards.
For the first four weeks, you should not lift or move any heavy objects (including shopping) or do any housework or digging. If possible, ask friends or family members if they can help around the house.
Once you feel able, some gentle exercise such as walking will help keep your blood circulating, and lower your risk of getting a blood clot in your legs.
Any symptoms of pain can usually be treated by taking over-the-counter painkillers, such as paracetamol or ibuprofen.
After having a TURP, you may occasionally notice some blood in your urine for a few weeks.
Drinking plenty of fluids, such as water, fruit juice and tea, will help flush any blood or small blood clots out of your bladder.
If you have constant bleeding or difficulty passing urine, you should contact your surgeon. It is normal to frequently feel the need to urinate for the first few weeks after the operation. This is because your urethra and bladder will have been irritated during the operation.
Sometimes, the irritation might feel like a stinging sensation when you urinate. Despite the stinging and a need to urinate more frequently, you should still drink plenty of fluid because it will also help prevent an infection from developing.
Returning to work
Most men take about six weeks to fully recover from having a TURP. Your doctor or surgeon will advise you about when it is safe to return to work – it will depend on your occupation. For example, if you work in an office, you may be able to return to work sooner than someone who does heavy manual work.
You will be advised not to drive for six weeks after having a TURP. You will usually be able to drive again when you can comfortably carry out an emergency stop. Your doctor will be able to advise you about this.
It will probably be several weeks after your operation before you feel comfortable enough to have sex. Most men need to wait for six to eight weeks before having sex, after which time any bruising and tenderness should have healed.
Before you leave hospital after having a TURP, you should be given an appointment for a check-up at the outpatient clinic. This appointment will normally be about six weeks after the operation.
Preparing for surgery
If you need a transurethral resection of the prostate (TURP), you should try to ensure you are as fit as possible before the procedure.
If you do not usually exercise regularly, you should aim to exercise for at least half an hour every day. Walking, swimming or even activities such as gardening are all good forms of exercise.
If you smoke, cutting down or giving up completely will help reduce your risk of developing heart and chest complications following the operation.
You may be sent an appointment for a pre-assessment of your health a few days before the operation. This may involve having blood tests and a general health check-up to make sure you are fit for surgery. If you have a pre-assessment appointment, you can use it as an opportunity to discuss any concerns you have with your surgeon.
If you are currently taking medication to prevent blood clots, you may be asked to stop taking it at a certain time before having a TURP. This is because this type of medication thins the blood, which could lead to excessive bleeding during surgery.
If you are taking warfarin, you will usually be asked to stop taking it four to five days before having surgery. If you are taking clopidogrel and/or aspirin, you will usually be asked to stop taking them 10-14 days before surgery.
A transurethral resection of the prostate (TURP) is usually performed using an epidural. An epidural is an injection of anaesthetic into your spinal column.
Once you have been given an epidural, you will temporarily lose all feeling below your waist, which means you will not feel any pain during the procedure.
If you would prefer the TURP to be performed under a general anaesthetic (where you will be unconscious throughout the procedure) you should let your surgical team know as it may be possible in certain circumstances.
A TURP is usually carried out using a device called a resectoscope. A resectoscope is a thin metal tube that contains:
- a light
- a camera
- a loop of wire
The surgeon will insert the resectoscope into your urethra (the tube that carries urine from your bladder to your penis) before guiding it to the site of your prostate with the help of the light and the camera.
An electric current is used to heat the loop of wire, and the heated wire is used to cut away the section of your prostate that is causing your symptoms. During the procedure, water is pumped through the resectoscope to flush away pieces of prostate that have been removed.
A TURP usually takes about 60 minutes to perform, depending on how much of your prostate needs to be removed.
Once the TURP has been completed, you will be moved back to your hospital ward so you can recover from the procedure.
Who can use it
Most men can have a transurethral resection of the prostate (TURP) even if they are not in particularly good health.
However, there are a number of reasons why a TURP would not be considered a safe procedure, or where the risks of complications would be too high. These circumstances are explained below.
- If you have recently had a heart attack and/or heart surgery. It would usually be recommended you wait between three and six months before having a TURP.
- If you have a neurological condition, such as Parkinson’s disease or multiple sclerosis, you may have problems controlling your bladder. A TURP would make this problem much worse, resulting in incurable urinary incontinence.
- If you have recently had radiotherapy to treat prostate cancer. Again, having a TURP soon after radiotherapy would result in urinary incontinence. After having radiotherapy, a wait of at least six months is usually recommended before having a TURP.
- If you are due to have cryotherapy treatment for prostate cancer (where intense cold is used to kill cancer cells) or brachytherapy (where radioactive ‘plugs’ are used to kill cancer cells). Removing a section of prostate before either treatment is completed carries the risk of making the treatment less effective.
- If you have an active infection of your bladder, urethra or kidneys. If this is the case, the TURP would need to be delayed until after the infection has been treated with antibiotics.
Why it is necessary
A transurethral resection of the prostate (TURP) is usually recommended for moderate to severe prostate enlargement that fails to respond to treatment with medication.
The severity of prostate enlargement is assessed based on how often your enlarged prostate is causing problems with your normal pattern of urination.
Moderate to severe prostate enlargement would usually mean you experience some or all of the following problems at least half the time you try to urinate:
- problems starting to urinate
- a weak urine flow or stopping and starting
- having to push or strain to pass urine
- a frequent need to urinate
- waking up frequently during the night to urinate (nocturia)
- a sudden urge to urinate, which can result in incontinence if you are unable to find a toilet quickly enough (urge incontinence)
- being unable to empty your bladder fully
The first treatment option for moderate to severe prostate enlargement is medication, such as:
- finasteride – which helps to reduce the size of the prostate
- alpha blockers – which help relax the muscles of your bladder, making urination easier
These medications do not work for everyone because the degree of prostate enlargement is often too large to be controlled using medication. If this is the case, a TURP is usually recommended.
A TURP may also be recommended if you develop a complication because you are unable to empty your bladder fully. Examples are: