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BPH Surgery

Believed to be triggered by hormonal changes, prostate tissue continues growing as most men age, and benign prostatic hyperplasia, or BPH, usually results. The prostate is typically the size and shape of a walnut, but when prostatic hyperplasia exerts its influence and the enlarged prostate begins encroaching on the urethra, the duct which carries urine out of the body from the bladder, moderate to severe BPH symptoms can occur. When watchful waiting or medication is no longer effective, BPH surgery may be necessary. Transurethral resection (TURP) has been considered the “gold standard” of BPH surgery for decades, but newer surgeries utilizing heat-free waterjet resection, laser therapy, prostatic implants, electrical loops, artery embolization, water vapor, microwaves, radio waves, and robotics have made inroads toward helping men relieve their urinary symptoms more easily and with fewer complications.

Many tests can be performed to diagnose and evaluate BPH. A urologist can provide the appropriate assessments after an examination and consultation. There are three methods by which benign prostatic hyperplasia is typically treated: Watchful waiting, medication, and surgery. Any size prostate could require surgery since men with both small and large prostates can experience severe enough lower urinary tract symptoms (LUTS) to necessitate BPH surgery.

It is time to consider surgery for BPH when watchful waiting and medication no longer help with BPH symptoms and lifestyle and behavioral changes become necessary. BPH surgery can be performed in a doctor’s office, a clinic, or in a hospital. BPH surgery can also be outpatient or inpatient. Most BPH procedures are outpatient surgeries, meaning one goes home the same day or spends one night in the hospital, BPH surgeries that require abdominal incisions typically require a longer hospital stay.

The best BPH surgery is the surgery that matches the greatest number of personal objectives. Some surgical procedures are more invasive, some require more recovery time, and others have more side effects and complications. When considering BPH surgery, numerous questions should be asked and clear goals should be established. BPH surgical procedures are becoming more successful as scientific advances continue, and BPH surgery is now at a point where a man with any size prostate or nearly any other considerations, can have a successful outcome if they choose the right surgery that matches their objectives.

Depending on the BPH surgery selected, there can be some side effects or virtually none at all. Common, long-lasting, side effects of some of the BPH procedures include retrograde ejaculation (semen enters the bladder instead of being ejaculated during orgasm) and the need to have a procedure re-done. With a few surgical procedures, erectile dysfunction and/or incontinence are remote possibilities, but these are typically uncommon side effects. The recovery time for BPH surgery depends on the procedure performed, the size of the prostate and an individual’s body, and how it responds to surgery. Considering even the largest prostate or more aggressive surgeries, full recovery typically falls within an 8-week window and is often much less.

10 Questions to Ask Before BPH Surgery

BPH surgery has come a long way in addressing benign prostatic hyperplasia over the past decade. Numerous surgical procedures have been developed to address moderate to severe BPH symptoms. These therapies vary greatly in their invasiveness, technology, ability or inability to handle all prostate sizes, and their side effects, but all can address BPH and its symptoms.

When considering BPH surgery for unresolved benign prostatic hyperplasia symptoms and or complications, the following questions are good to ask your doctor.

  • How is BPH diagnosed and evaluated?
  • How is benign prostatic hyperplasia treated?
  • Do I have BPH and do you think I might need BPH surgery?
  • What size prostate requires surgery?
  • When is it time to consider surgery for BPH?
  • How is BPH surgery done?
  • What is the best surgery for BPH?
  • Is surgery for an enlarged prostate successful?
  • What are the side effects of BPH surgery?
  • How long does it take to recover from BPH surgery?
 

8 of the Most Common BPH Surgeries

  • Aquablation therapy – A FDA and Medicare-approved BPH surgery that can be performed on prostates of all shapes and sizes; large, medium, and small. This advanced, minimally invasive, highly effective, durable, and one-of-a-kind procedure utilizes heat-free water ablation to remove excess prostate tissue. This revolutionary therapy is controlled by a robotic device that follows a unique surgical map customized by the surgeon. Guided from multiple angles by both a cystoscope-mounted camera and strategically placed ultrasound, which gives the surgeon the ability to see the entire prostate in real-time, the precision waterjet resection of prostate tissue without damaging heat is the only procedure of its kind. Because of its unique map-guided robotic precision, Aquablation therapy is becoming very popular for its versatility, effectiveness, and safety profile, specifically very low rates of urinary and sexual complications.
 
  • Laser Enucleation – Is a minimally invasive laser therapy that removes problematic prostate tissue using laser energy via a telescope inserted into the urethra and up to the bladder. The laser cores out the troubling portion of the prostate, leaving the outer layer intact – much like coring out an apple and leaving the skin behind. No incisions are needed since the laser does the cutting. A device called a morcellator is used to grind up the excess prostate tissue which is then removed back through the urethra. Laser enucleation is one option for men with large prostates and for those who take blood thinners and can’t risk higher impact surgery. Some men will experience temporary urinary incontinence after surgery, but it typically resolves with pelvic floor exercises within a few months. However, most men will experience retrograde ejaculation with this treatment option.1
 
  • Prostatectomy (Simple) – The simple prostatectomy is an open, traditional, and more invasive surgical procedure for men suffering from benign prostatic hyperplasia with large prostates over 100 grams, damaged bladders, or those who might suffer other limitations. A large incision is made that allows for the removal of the inside of the prostate leaving the shell or outside of the prostate intact after it is stitched back up. An incision is made either vertically or horizontally below the navel and above the pubic bone for the surgeon to gain access to the prostate through the bladder. As robotic-assisted simple prostatectomies have grown in popularity, simple prostatectomy isn’t being used as often as it once was since it has a higher risk of complications and a longer recovery time. Risks from this BPH surgery include retrograde ejaculation, incontinence, and higher transfusion rates.2
 
  • Robotic Assisted Simple Prostatectomy (RASP) – A robot-assisted simple prostatectomy (RASP) produces smaller incisions and scars, less bleeding, quicker recovery time, and fewer complications than a simple prostatectomy. The da Vinci robotic surgical system is utilized and any size prostate is eligible. Typically, six small incisions are made in the abdomen through which miniaturized robotic instruments are placed under the guidance and control of a surgeon. The abdomen is inflated with CO2 to give the surgeon more space in which to work. A small incision is made into the bladder to gain access to the prostate where the inside of the prostate is cored out and removed while the capsule or outside of the prostate is left in situ. It is similar to removing the inside of an orange and leaving the rind. Men who have non-urethral sparing RASP should expect retrograde ejaculation as a result.2 Other risks from this BPH surgery include incontinence and higher transfusion rates.2
 
  • Prostatic Urethral Lift – This minimally invasive benign prostatic hyperplasia or BPH procedure is unique because it utilizes small, permanent prostate implants to lift and hold the prostate back from the urethra so urine can more freely flow again. The prostatic urethral lift delivery device is like a telescope and is inserted into the obstructed urethra and positioned between the prostate lobes. Since it simply lifts and holds the prostate away from the urethra, nothing is removed. There is also no cutting, heating, or destroying of prostate tissue. The prostatic urethral lift implants can provide fast, in-office relief for patients with prostates of 100 grams or less in size and who don’t want to undergo a surgical procedure and longer downtime. However, men with larger prostates will need to find another BPH procedure.
 
  • PVP GreenLight Laser – A minimally invasive outpatient surgical procedure, laser-initiated photo-vaporization of the prostate (PVP) utilizes high-powered GreenLight Laser therapy to remove excess, problematic prostate tissue through laser vaporization with very little blood loss. This procedure is beneficial for those on blood thinners or anticoagulants. Once anesthetized, a cystoscope containing a thin laser fiber is inserted into the urethra and up to the prostate and bladder. The laser focuses a patented high-energy GreenLight Laser light onto the excess prostate tissue and vaporizes it, removing the problematic tissue. Risks include irritative symptoms and retrograde ejaculation.3
   
  • Transurethral Incision of the Prostate (TUIP) – Another minimally invasive BPH surgery to address benign prostatic hyperplasia, TUIP can be an additional option for men desiring a lower risk of bleeding if they are on blood thinning medication or who have a blood disorder and their blood doesn’t clot well. It is often a procedure used on younger men with small prostates and who want to father children naturally since TUIP has a lower incidence of retrograde ejaculation than some of the other BPH procedures.3 A resectoscope surgical device, containing a camera, is inserted into the urethra and up to the bladder neck where the bladder and prostate meet. The surgeon then cuts one or two grooves into the bladder neck to expand the urinary channel which will in turn allow for a better urine flow. Recovery time is minimized due to low blood loss and the side effects are minimal.
 
  • Transurethral Resection of the Prostate (TURP) – Considered the “gold standard” of prostate surgeries for nearly 100 years since being first introduced in the U.S. in 1926, it has helped an untold number of men with their enlarged prostate-related urinary symptoms. A surgical instrument called a resectoscope is inserted into the urethra where a doctor can view the prostate and determine how much prostate tissue to remove so urine can flow freely from the bladder again. Transurethral resection is one option for men who haven’t responded to watchful waiting or medication and are not candidates for other less invasive procedures. Even though TURP has been the go-to surgery for many decades, other BPH procedures have surpassed TURP in their effectiveness by producing less blood loss, offering a quicker recovery time, and having fewer side effects and complications. Risks from this BPH surgery include retrograde ejaculation, incontinence, and higher transfusion rates.2
 
  • Water Vapor Thermal Therapy – One of the newer minimally invasive procedures to address benign prostatic hyperplasia, water vapor thermal therapy harnesses the thermal energy from water vapor to remove or ablate excess prostate tissue that is causing BPH symptoms. It is a procedure developed for use in small to medium size prostates up to 80 grams. Men with larger prostates will need to consider a different procedure. A telescope is inserted into the urethra and up to the prostate where a needle is inserted into the prostate tissue multiple times and radiofrequency energy is utilized to create water vapor that travels into the prostate and kills prostate cells. Within weeks and up to a few months, the body reabsorbs the dead cells, causing the prostate to shrink. After the water vapor thermal therapy, the body goes through an inflammatory response which will make urinary symptoms worse for the first few weeks. Urinary and sexual side effects after the procedure are reported as minimal.
For most men, their prostate tissue continues growing throughout their life. What was once a positive development while young, can produce troublesome urinary symptoms later in life. Prostatic hyperplasia is an unwanted condition, but thankfully there are good solutions to this affliction that affects nearly every man if they live long enough. Watchful waiting and prostate medication may be enough to resolve mild to moderate benign prostatic hyperplasia symptoms. However, when BPH symptoms become severe enough to prompt lifestyle or behavioral changes, it is time to consider prostate surgery. Not only can an enlarged prostate become bothersome and life-altering, but it can become a health threat if there is bladder or kidney damage or severe urinary retention occurs without access to immediate medical care. In cases like this, BPH surgery can be a literal lifesaver.

References:

1. Kim SH, Yang HK, Lee HE, Paick JS, Oh SJ. HoLEP does not affect the overall sexual function of BPH patients: a prospective study.  Asian J Androl 2014: 16:873-7

2. Couteau N, Duquesne I, Frédéric P, Thiounn N, Timsit M-O, Mejean A, Pinar U, Audenet F. Ejaculations and Benign Prostatic Hyperplasia: An Impossible Compromise? A Comprehensive Review. Journal of Clinical Medicine. 2021; 10(24):5788

3. Massimiliano Spaliviero, Kurt H. Strom, Xiao Gu, Motoo Araki, Daniel J. Culkin, and Carson Wong. Does Greenlight HPSTM Laser Photoselective Vaporization Prostatectomy Affect Sexual Function? Journal of Endourology. Dec 2010.2051-2057

All surgical treatments have inherent and associated side effects. Individual’s outcomes may depend on a number of factors, including but not limited to patient characteristics, disease characteristics and/or surgeon experience. The most common side effects are mild and transient and may include mild pain or difficulty when urinating, discomfort in the pelvis, blood in the urine, inability to empty the bladder or a frequent and/or urgent need to urinate, and bladder or urinary tract infection. Other risks include ejaculatory dysfunction and a low risk of injury to the urethra or rectum where the devices gain access to the body for treatment. Further, there may be other risks as in other urological surgery, such as anesthesia risk or the risk of infection, including the potential transmission of blood borne pathogens. For more information about potential side effects and risks associated with Aquablation therapy for Benign Prostatic Hyperplasia (BPH) treatment, speak with your urologist or surgeon. Prior to using our products, please review the Instructions for Use, Operator’s Manual or User Manual, as applicable, and any accompanying documentation for a complete listing of indications, contraindications, warnings, precautions and potential adverse events. No claim is made that the AquaBeam Robotic System will cure any medical condition, or entirely eliminate the diseased entity. Repeated treatment or alternative therapies may sometimes be required.

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