TURP prostate surgery: how long it takes, the catheter and recovery

Prostate surgery through the urethra is the name patients most often use for transurethral resection of the prostate, or TURP for short. The urologist passes a thin instrument with a camera (a resectoscope) and an electrical loop through the urethra and removes, piece by piece from the inside, the prostate tissue that narrows the passage for urine. There is no cut in the skin and no stitches.

The procedure is most often recommended for benign enlargement of the prostate (benign prostatic hyperplasia), when urinary symptoms do not settle with medication or when complications develop, for example repeated episodes of urinary retention. Whether this method is suitable in a particular case is decided by the urologist, based on the examination, the size of the prostate and test results. The removed tissue is sent for histopathology.

In the Maja Hospital price list, this procedure is listed as bipolar transurethral resection of the prostate. In bipolar TURP, the current passes between two electrodes at the tip of the instrument rather than through the patient's body, so the bladder is irrigated with saline during the procedure. Laser methods are also carried out through the urethra, but they are not listed in the Maja Hospital price list.

TURP does not remove the whole prostate, only the part that narrows the urethra. This is why follow-up appointments with the urologist are still needed after the operation, and the urologist also decides on further PSA checks.

Before the procedure, the urologist usually asks for examinations and tests that show how enlarged the prostate is and how the bladder is working. Most often these are:

• a urological examination and an ultrasound scan of the prostate and bladder
• measurement of the strength of the urine flow (uroflowmetry) and a check of how much urine is left in the bladder after passing urine
• blood and urine tests with a urine culture, as a urinary tract infection is usually treated before the operation
• a PSA blood test, when the urologist considers it necessary
• an anaesthetic assessment and an ECG, and if needed a check of heart function and of any long-term conditions

It is important to tell the doctor in advance which medicines you take, especially blood thinners. Whether a medicine is paused or changed, and how many days beforehand, is decided by the doctor who prescribed it, the urologist and the anaesthetist. Do not stop taking medicines on your own.

On the day of the operation you arrive having fasted, exactly as instructed. You must not drive after an anaesthetic, so it is a good idea to arrange for someone to take you home. For the hospital stay, patients usually bring an identity document, previous test results, a list of medicines, comfortable clothes and toiletries.

The operation itself usually takes about an hour, and longer if the prostate is larger. The duration depends mainly on the size of the prostate and the amount of tissue that needs to be removed. With preparation and recovery from the anaesthetic, the patient is away from the ward for longer than the procedure itself.

It is most often done under spinal anaesthetic, when the body is numb from the waist down and the patient is awake or lightly sedated. In that case the patient usually feels no pain during the procedure, only possibly touch or pressure. The other option is general anaesthetic. The type of anaesthetic is decided by the anaesthetist, together with the urologist, according to the patient's health.

At the end of the operation a catheter is placed in the bladder, and bladder irrigation is usually started.

After prostate surgery through the urethra a catheter is placed, usually a three-way catheter. Irrigation fluid flows into the bladder through one channel, fluid and urine drain into a bag through another, and the third is used for a small balloon that holds the catheter in the bladder. Irrigation usually continues for the first few hours, and sometimes days, to prevent clots from forming. In the first hours and days the urine in the bag is often pink or reddish.

The catheter is usually removed after one to three days, once the urine has cleared. It sometimes stays in longer, for example if the prostate was larger or if bleeding settles more slowly, and sometimes the patient goes home with the catheter, with instructions on how to care for it. The exact day is decided by the urologist. While the catheter is in the bladder, there may be occasional bladder spasms and a feeling of needing to pass urine, even though urine is draining through the catheter.

After the catheter is removed, staff check whether the patient can pass urine on his own and whether the bladder is emptying well. If passing urine does not start, the catheter is sometimes put back for a short time to let the bladder recover. This happens in a small number of patients and is usually temporary.

In the first days after the catheter is removed, the following are common:

• stinging when passing urine
• passing urine more often and a sudden urge to go, including at night
• occasionally a little blood or small clots in the urine
• in some men, reduced bladder control

These symptoms usually ease gradually over several weeks. In some men, frequency and urgency last longer, up to three months. For dribbling or reduced bladder control, pelvic floor exercises may help, as advised by the urologist. Permanent urinary incontinence after this operation is rare. The operation may not relieve all symptoms, especially if the bladder has been weakened by long-term difficulty emptying.

Blood in the urine may reappear around the tenth to fourteenth day after the operation, when the scab comes away from the operated area. This is part of healing. It usually helps to drink more fluids, unless the doctor has advised otherwise, and to avoid straining and constipation. If the bleeding is heavy, larger clots appear or passing urine becomes difficult, contact the urologist or the emergency service without delay.

Questions about erections and ejaculation are among the most common before the procedure. In most men, prostate surgery through the urethra leads to what is called retrograde ejaculation: at climax, semen is not released outwards but goes into the bladder and leaves with the urine, which may then look cloudy. This change is not harmful to health and the sensation of orgasm is usually preserved, but it is usually permanent.

For this reason, the chance of natural conception after the operation is usually greatly reduced. Even so, it must not be relied on as contraception. Men who are planning to have children should discuss this with the urologist before the procedure.

As for erections, in most men they remain as they were before the procedure, while in a small number they may become weaker. This is why it is a good idea to tell the urologist openly before the operation what your erections are like now. Sexual intercourse can usually be resumed after three to four weeks, when the patient feels ready, and the exact timing is decided by the urologist.

Many men feel tired for one to two weeks after discharge. They usually return to light activities after two to four weeks, and full healing takes about six weeks. Returning to work depends on the type of work: physically demanding work usually needs longer time off.

In the first four to six weeks the usual advice is to:

• drink enough fluids, spread throughout the day, unless the doctor has advised otherwise
• avoid lifting heavy objects and strenuous exercise
• avoid cycling and sitting for long periods without getting up
• prevent constipation with a diet rich in fibre and avoid straining when opening your bowels
• ask the doctor about driving and about painkillers

Contact the urologist or the emergency service without delay if:

• you cannot pass urine or it is becoming increasingly difficult
• your urine turns dark red, bleeding gets heavier or larger clots appear
• your temperature rises to 38 °C or higher, or you start shivering
• pain becomes severe and does not go away
• the catheter, if it is still in place, stops draining urine
• your calf becomes swollen or painful, or you have difficulty breathing or chest pain

Maja Hospital is located in Niš, at Vizantijski bulevar 39. The first step is a consultation with a urologist, who assesses whether surgery is needed and which method is suitable. Prices for the consultation, the operation and histopathology of the tissue are listed in the urology price list, and prices for blood and urine tests in the laboratory price list.

Like any operation, this one carries certain risks. Possible risks include, among others, heavier bleeding, which sometimes requires a blood transfusion or a further procedure, urinary tract infection and later narrowing of the urethra (urethral stricture). The urologist discusses the risks of the procedure with the patient before the operation, and the anaesthetist discusses the risks of the anaesthetic.

It is useful to bring previous test results and a list of the medicines you take to the consultation, and to ask:

• which method is proposed and why
• what the possible risks are in your case and how they are monitored
• how many days the catheter is likely to stay in and how long a hospital stay to expect
• what is included in the price of the operation, for example the anaesthetic, the stay and histopathology of the tissue
• when the follow-up appointments are and when the histopathology result will be available
• how the operation may affect ejaculation and erections in your case