What you need to know about prostate surgery for an enlarged prostate

An enlarged prostate is a very common condition in men aged over 50. The prostate gland — a walnut-sized gland that sits at the base of the bladder in men and produces fluid to transport sperm — grows from around age 40 onwards. This growth becomes more rapid when a man is in his fifties and sixties then slows down in their seventies. 

As the prostate gland gets larger, it can press on the bladder and the tube that carries urine from the bladder out of the body (urethra). This can make it difficult to start urinating and completely empty the bladder. It can also make urination painful, more frequent, including at night, and take longer. 

Although, in most cases, an enlarged prostate is not life-threatening and is due to the natural ageing process — a condition called benign prostatic hyperplasia — around one in seven men will experience symptoms of an enlarged prostate caused by prostate cancer. 

Diagnosing an enlarged prostate

If you have symptoms of an enlarged prostate, it’s important to see your GP for treatment and to rule out prostate cancer. 

Your GP will ask about your medical history and symptoms and may perform a physical examination of your abdomen and genital areas. This may include feeling your prostate gland by inserting a gloved, lubricated finger into your back passage (rectum). This is called a digital rectal examination, where digital refers to the use of a finger, and will give your GP a rough idea of the size of your prostate gland. 

They may also refer you for a blood test to measure levels of prostate-specific antigen (PSA). The PSA blood test can be used as an indicator of whether you have prostate cancer; however, it is not a definitive test. Your PSA levels increase naturally with age, so what’s considered above normal for a man in his forties may not be considered above normal for a man in his seventies. 

Based on your age, symptoms and PSA test result, your GP may refer you to a doctor who specialises in treating the urinary system (a urologist). 

Your urologist may recommend that you have an MRI scan. This will help determine the safest course of treatment by getting a more accurate evaluation of the size of your prostate gland, and will also determine whether there are any suspicious areas within your prostate gland if your PSA level is raised, which may suggest prostate cancer.

Treating an enlarged prostate

You can ease symptoms of an enlarged prostate by making simple lifestyle changes, such as avoiding caffeine, reducing how much alcohol you drink and spreading out the drinks you consume throughout the day. 

However, even with these changes, you may eventually need medical treatment. This may include medication, which typically includes an alpha receptor blocker to relax the muscles in your prostate gland and bladder neck so it’s easier to urinate and a 5-alpha reductase inhibitor to shrink your prostate gland. After taking both medications together for one to three months, you will usually see improvements in your symptoms. 

If medication isn’t effective, you can’t tolerate the side effects of medication, you can’t pass urine or have needed a catheter to empty your bladder, then your urologist may recommend prostate surgery.

Types of surgery for an enlarged prostate

Transurethral resection of the prostate (TURP) 

The main surgical treatment for an enlarged prostate is TURP, which was developed in the early 1900s. It’s performed under general anaesthetic and involves removing a section of the prostate gland to relieve the pressure on your urethra and bladder.  

TURP uses a thin, telescope-like device with a camera, light and loop of wire on the end called a resectoscope. This is passed into your urethra and up into your prostate gland. Consequently, no cuts are made into your body. 

The loop of wire is heated up using electricity and this energy is passed into the tissue of your prostate gland to cut it away — this process is called monopolar diathermy. 

During this procedure, your bladder and prostate need to be irrigated. This refers to filling your bladder and prostate gland with fluid to help open up the space so your surgeon has a clearer view of the tissue. In the UK, the standard irrigating fluid used is glycine. 

However, this irrigating fluid is absorbed by the surrounding tissue, particularly by blood vessels that have been cut through. This presents a risk of TURP syndrome, where too much fluid is absorbed into your bloodstream, diluting levels of sodium in your blood and causing potentially life-threatening hyponatraemia. Consequently, monopolar diathermy TURP can only be carried out for a maximum of one hour. 

If you have a very large prostate gland, one hour may not be enough to remove the required amount of prostate tissue and you will, therefore, need an alternative procedure. 

In the past, this would usually involve Millin’s simple prostatectomy; however, today there are procedures which use lasers, including green light laser prostatectomy (GLLP), holmium laser enucleation of the prostate (HoLEP) and thulium fibre laser enucleation (ThuLEP).

Laser surgery for an enlarged prostate doesn’t need glycine to irrigate the bladder and prostate gland. Instead, an isotonic fluid is used, such as normal saline, which means there is no risk of hyponatraemia and the surgery can be performed for over an hour. 

Millin’s simple prostatectomy

Millin’s simple prostatectomy was developed in 1945 and is an open surgery, where a cut is made into your abdomen to access your prostate gland. The prostate gland is cut through and tissue from the inside is removed. A bladder catheter is usually inserted and left in place for a week while your prostate gland heals from the surgery. 

Holmium laser enucleation of the prostate (HoLEP)

HoLEP involves passing a resectoscope through your urethra and up into your prostate gland. Then, a holmium laser fibre is passed through the resectoscope to allow pulses of laser energy to peel away sections of the prostate gland. These sections are cut into smaller pieces using a special instrument called a morcellator, which is inserted through the resectoscope; the pieces of tissue are then removed. 

Thulium fibre laser enucleation of the prostate (ThuLEP)

ThuLEP is performed in a similar way to HoLEP, except a thulium laser fibre cuts through the prostate tissue and coagulates the blood, that is, encourages liquid blood to turn into semi-solid blood clots. Consequently, ThuLEP causes less bleeding than HoLEP. 

Green light laser prostatectomy (GLLP) 

GLLP involves passing a resectoscope through your urethra and up into your prostate gland. Then, a side-firing laser fibre is passed through the resectoscope, which allows high-power laser light to vaporise the prostate tissue. It is, therefore, less effective at cutting out prostate tissue than HoLEP but also involves less bleeding than HoLEP. 

Side effects and outcomes of prostate surgery 

Prostate surgery for an enlarged prostate gland is a highly successful procedure, whether you have TURP or a laser procedure. The ability to pass urine significantly improves in most men; however, surgery can’t improve bladder tone, which weakens over time due to the enlarged prostate. 

As with any surgical procedure, there are risks of side effects. For the first three months after surgery, you may notice blood in your urine intermittently. In rare cases, you may develop a blood infection, urosepsis, urinary stress incontinence, penile discomfort and/or inflammation of your urethra (urethritis). In most cases, these side effects improve with time. 

Prostate surgery also has a one in 10 risk of impotence and a one in two chance of retrograde ejaculation, where semen travels backwards into the bladder.

These risks occur with TURP and laser procedures; however, the risks tend to be lower when having a laser procedure. 

Recovering from prostate surgery for an enlarged prostate

Usually prostate surgery only needs a one to two night stay in hospital after your surgery. You will need to avoid strenuous activity such as long-distance walking, running, driving, heavy lifting and sex for the first two to three weeks of your recovery. However, it is nonetheless important to mobilise after your procedure with short, gentle stretches of walking. After this time, you can usually return to work.