Prostate Surgery — How It Works, Benefits & Recovery — Procedure Guide, Recovery & Risks | MyMedicPlus

Prostate surgery encompasses a spectrum of transurethral and open procedures performed to relieve lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) — non-cancerous enlargement of the prostate gland. BPH is an age-related condition affecting over 50% of men in their 60s and 80% of men in their 80s, causing bladder outlet obstruction that produces symptoms of urinary hesitancy, weak stream, incomplete bladder emptying, nocturia, urgency, and in severe cases, urinary retention.

The most commonly performed surgical treatment for BPH remains transurethral resection of the prostate (TURP) — widely considered the urological gold standard against which all other BPH interventions are compared. TURP uses a resectoscope introduced through the urethra to remove obstructing prostatic tissue using electrocautery loops under direct vision. Modern bipolar TURP systems use saline rather than glycine irrigation medium, eliminating the risk of TUR syndrome (dilutional hyponatraemia) that was a significant complication with older monopolar systems.

Holmium laser enucleation of the prostate (HoLEP) has emerged as the procedure of choice for all prostate sizes — particularly large glands over 80 g where TURP has technical limitations — due to its superior haemostasis, shorter catheterisation time, and lower retreatment rates. GreenLight laser photoselective vaporisation of the prostate (PVP) and prostatic urethral lift (UroLift) are additional minimally invasive options for selected patients. Open simple prostatectomy is reserved for very large glands (over 100-150 g) unsuitable for endoscopic techniques. This guide focuses specifically on BPH surgery; radical prostatectomy for prostate cancer is a separate, fundamentally different procedure.

Prostate surgery for BPH is indicated when pharmacological therapy has failed, is poorly tolerated, or when specific clinical complications make urgent intervention necessary.

Medical therapy prerequisites: Before surgery is considered, patients should have been assessed with the International Prostate Symptom Score (IPSS), uroflowmetry, post-void residual measurement, and renal function testing. Medical therapy with alpha-1 adrenoceptor blockers (tamsulosin, alfuzosin, silodosin) and/or 5-alpha reductase inhibitors (finasteride, dutasteride) is first-line treatment for moderate-to-severe LUTS. Surgery is appropriate when these fail to provide adequate symptom relief.

Absolute indications for surgery (complications of BPH): - Acute urinary retention requiring catheterisation that fails a trial without catheter - Recurrent urinary tract infections (two or more per year) secondary to incomplete bladder emptying - Bladder stones secondary to chronic urinary stasis - Upper urinary tract obstruction with renal impairment or bilateral hydronephrosis - Recurrent haematuria refractory to 5-alpha reductase inhibitor therapy

Relative indications: - Moderate-to-severe IPSS (score 8 or above) despite maximum tolerated pharmacological therapy - Patient preference for surgical cure rather than ongoing medication - Large prostate glands (over 30-40 mL) less likely to respond adequately to medical therapy alone - Retention of urine without definitive obstruction relief on urodynamics

Procedure selection: - Prostate up to 80 g: TURP (bipolar preferred), GreenLight PVP, prostatic urethral lift - Prostate over 80 g: HoLEP (size-independent), open simple prostatectomy - High anaesthetic risk: GreenLight PVP or prostatic urethral lift under sedation - Patients on anticoagulation: HoLEP or GreenLight PVP preferred (superior haemostasis) - Desire to preserve ejaculation: Prostatic urethral lift (UroLift), Rezum steam therapy

The specific technique varies by the chosen procedure. TURP and HoLEP, the two most common surgical approaches, are described in detail.

TURP (Transurethral Resection of the Prostate): Patients receive spinal or general anaesthesia. A cystoscopy is performed to inspect the urethra and bladder. A resectoscope — a rigid instrument 22-26 French in diameter — is introduced transurethrally without any skin incision. The obstructing prostatic tissue (adenoma) is visualised and systematically removed in sequential chips using an electrocautery loop under continuous irrigation. The resection proceeds from the bladder neck to the verumontanum (the landmark protecting the external urinary sphincter beyond which resection is unsafe). Bipolar energy systems use saline irrigation, minimising systemic absorption. Resected tissue chips are evacuated by bladder washout. Haemostasis is achieved with coagulation. A three-way urinary catheter is placed at the end of the procedure to allow continuous bladder irrigation until the effluent clears.

HoLEP (Holmium Laser Enucleation of the Prostate): A holmium laser fibre is introduced through a continuous-flow resectoscope. The holmium:YAG laser (2140 nm wavelength) creates precise tissue cuts that follow the natural anatomical plane between the adenoma and the surgical capsule. The entire adenomatous tissue is enucleated in two or three large anatomical lobes rather than in chips. The lobes are pushed into the bladder, then a morcellator instrument is introduced to macerate the adenoma into small pieces for evacuation via suction. HoLEP achieves more complete adenoma removal than TURP, has superior haemostasis due to the laser's excellent coagulation properties, requires a shorter catheter time (24 hours vs 2-3 days), and has equivalent or lower retreatment rates regardless of prostate size.

Post-operative catheter management: After TURP, continuous bladder irrigation is maintained until the drainage clears (typically 24-48 hours). The catheter is removed on day 1-3. After HoLEP, the catheter is typically removed at 24 hours. Patients are observed for successful voiding before discharge.

Prostate surgery for BPH provides superior, durable symptom relief compared with medical therapy and is guideline-recommended when medical therapy fails or complications occur.

TURP outcomes: TURP improves International Prostate Symptom Score (IPSS) by 70-80% from baseline and increases maximum urinary flow rate (Qmax) by 100-150% (typically from under 10 mL/second to 20-30 mL/second). Patient satisfaction at 1 year exceeds 85%. Symptom durability is strong: 80-90% of patients remain free of retreatment at 5 years, 70-75% at 10 years. Retreatment is most commonly required for urethral stricture or bladder neck stenosis rather than BPH recurrence.

HoLEP outcomes: HoLEP achieves symptom improvement equivalent or superior to TURP across all prostate sizes, with lower blood loss (mean 100-200 mL vs 300-500 mL for TURP), lower transfusion rates (under 1% vs 2-5% for TURP), and shorter catheterisation time. A 2021 Cochrane systematic review confirmed HoLEP superiority for large glands over 80 g and equivalent efficacy for smaller glands. Retreatment rates for HoLEP are lower than TURP at long-term follow-up, reflecting more complete adenoma removal.

Long-term prostate cancer prevention: Routine BPH surgery does not prevent prostate cancer, as BPH (arising from the central/transition zone) and prostate cancer (predominantly peripheral zone) are anatomically distinct. However, tissue removed during TURP or HoLEP is routinely sent for histopathology — incidental prostate cancer is found in 5-10% of TURP specimens.

Prostate surgery for BPH carries a well-characterised complication profile that patients should understand before consenting to the procedure.

Retrograde ejaculation: The most common and expected functional change, affecting 65-90% of patients after TURP and 70-90% after HoLEP. Resection or enucleation disrupts the bladder neck mechanism that normally directs ejaculate antegrade into the urethra during orgasm. Retrograde ejaculation causes semen to travel backward into the bladder rather than forward, resulting in a dry orgasm. Sensation and ability to orgasm remain intact. Fertility implications must be discussed with men who wish to father children — sperm retrieval from urine or other assisted reproduction techniques remain possible. UroLift and Rezum preserve ejaculatory function.

Urinary incontinence: Mild post-operative stress urinary incontinence is common immediately after catheter removal and resolves within 4-8 weeks in over 95% of patients with pelvic floor exercises. Persistent urinary incontinence beyond 3 months occurs in 1-2% of TURP patients due to inadvertent sphincter trauma and is managed with pelvic floor physiotherapy; severe cases may require an artificial urinary sphincter.

Erectile dysfunction: Erectile dysfunction attributable to TURP occurs in 5-10% of cases, from vascular or neurological changes during surgery. This risk is substantially lower with HoLEP and GreenLight PVP.

Urethral or bladder neck stricture: Urethral stricture from resectoscope trauma or bladder neck contracture from scar formation occurs in 3-5% and is managed with urethrotomy or dilatation.

TUR syndrome (monopolar TURP only): Dilutional hyponatraemia from systemic absorption of glycine irrigation fluid causes confusion, nausea, hypertension, and bradycardia. Eliminated by bipolar TURP using normal saline.

Haematuria: Post-operative haematuria is expected and resolves within 2-4 weeks in almost all cases. Delayed secondary haemorrhage at 7-14 days (from sloughing of coagulated tissue) occurs in 1-2% and may require brief re-hospitalisation.

Recovery from prostate surgery is typically straightforward, with most patients returning to near-normal activity within 2-4 weeks.

Hospital phase (Days 0-3): A urinary catheter drains the bladder continuously for 1-3 days (24 hours for HoLEP, 48-72 hours for TURP). Continuous bladder irrigation with normal saline prevents clot formation during the first 24-48 hours. Patients are mobilised on the day of surgery. Diet is resumed as tolerated. Pain is usually mild and managed with paracetamol and NSAIDs.

Post-catheter removal: After catheter removal, patients typically experience urinary urgency, frequency, and mild burning for 2-4 weeks as the healing urothelium recovers. Haematuria — pink to red-tinged urine — is expected and resolves over 2-4 weeks. Adequate hydration (2-3 litres of water daily) dilutes urine and flushes clots.

Activity restrictions: Strenuous activity, heavy lifting (over 10 kg), and vigorous sports are avoided for 2-4 weeks. Constipation and straining at stool increase risk of delayed haemorrhage — a fibre-rich diet and laxatives prevent this. Sexual activity and masturbation are avoided for 4 weeks. Driving is usually permitted after catheter removal and once comfortable.

Pelvic floor exercises: Pelvic floor muscle exercises (Kegel exercises) commenced before surgery and continued throughout recovery significantly reduce the duration and severity of post-operative urinary incontinence. A specialist continence physiotherapist can guide proper technique.

Follow-up: Urine flow rate and post-void residual are measured at the 6-week post-operative review to confirm adequate bladder outlet decompression. IPSS is repeated to document symptom improvement. Prostate-specific antigen (PSA) will fall significantly after TURP or HoLEP due to reduction in prostate volume, and a new PSA baseline is established at 3-6 months for future cancer surveillance comparison.