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Transurethral resection of the prostate

Transurethral resection of the prostate (TURP) is a minimally invasive surgical procedure that removes excess prostate tissue obstructing urine flow, primarily to treat symptoms of benign prostatic hyperplasia (BPH) in men. Performed endoscopically through the urethra using a resectoscope equipped with a light, camera, and wire loop, the surgery trims away the inner prostate tissue while preserving the prostate capsule, typically lasting 60 to 90 minutes under general or spinal anesthesia.^[1]^[2] Introduced in the 1940s, TURP remains the gold standard for managing moderate to severe BPH symptoms, such as urinary frequency, urgency, weak stream, and incomplete bladder emptying, when medical therapies fail or complications like recurrent infections, bladder stones, or acute urinary retention arise.^[2]^[3] The procedure effectively improves urinary flow rates by an average of 10 mL/second and increases bladder capacity, with approximately 90% of patients experiencing significant symptom relief that can last 10 to 15 years or more.^[2]^[1] Despite its efficacy, TURP carries potential risks, including retrograde ejaculation in most cases, urinary tract infections, temporary incontinence, erectile dysfunction, and rare complications like TUR syndrome (hyponatremia from irrigation fluid absorption) or urethral strictures.^[3]^[2] Patients typically require a 1- to 3-day hospital stay and catheter use for 1 to 3 days postoperatively, with full recovery often achieved within weeks, though re-treatment may be needed in 10-15% of cases over time.^[1]^[3]

Background

Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is a nonmalignant condition characterized by the unregulated growth of prostate tissue, leading to enlargement of the gland without cancerous involvement.^[4] This histological diagnosis involves proliferation of smooth muscle, epithelial cells, and connective tissue within the prostate.^[5] BPH becomes increasingly prevalent with age, affecting approximately 50% to 60% of men in their 60s and rising to 80% to 90% in those over 85 years, based on autopsy studies and clinical observations.^[4]^[6] The pathophysiology of BPH centers on hormonal influences and cellular imbalances that disrupt normal prostate homeostasis. Androgens, particularly dihydrotestosterone (DHT) derived from testosterone via the enzyme 5-alpha-reductase, play a key role in promoting prostatic growth.^[7] This leads to an imbalance favoring cellular proliferation over apoptosis, primarily in the transitional zone of the prostate surrounding the urethra.^[4] The resulting enlargement compresses the urethra, contributing to obstructive effects, while associated inflammation and stromal remodeling further exacerbate the condition.^[8] BPH commonly manifests through lower urinary tract symptoms (LUTS), which are categorized into storage and voiding subtypes. Storage symptoms include urinary frequency, nocturia (waking at night to urinate), and urgency, while voiding symptoms encompass a weak or intermittent stream, hesitancy, and straining.^[4] These symptoms arise from urethral obstruction and detrusor muscle dysfunction. Complications such as acute urinary retention (AUR)—the sudden inability to pass urine—occur in about 1% to 2% of men with BPH annually, with cumulative risks reaching up to 10% over several years in older populations.^[9]^[10] Diagnosis of BPH typically begins with a digital rectal examination (DRE) to assess prostate size and consistency, often revealing an enlarged, smooth gland.^[11] Prostate-specific antigen (PSA) levels are measured to evaluate for potential malignancy, as elevated PSA can occur in BPH but helps differentiate it from prostate cancer.^[4] Uroflowmetry quantifies urine flow, with a peak flow rate below 15 mL/s suggesting obstruction in approximately 70% of cases, particularly when voided volume exceeds 150 mL.^[12] Post-void residual (PVR) urine measurement, ideally performed immediately after uroflowmetry, identifies incomplete emptying, with volumes over 100 mL indicating significant retention.^[4] For severe symptomatic BPH, procedures like transurethral resection of the prostate (TURP) may be considered as an intervention.^[4]

Overview of TURP

Transurethral resection of the prostate (TURP) is a minimally invasive endoscopic surgical procedure used to remove obstructing prostate tissue through the urethra, without requiring external incisions. It addresses urinary symptoms caused by benign prostatic hyperplasia (BPH), the most common condition necessitating this intervention. The procedure employs a resectoscope to access and resect excess prostate tissue that compresses the urethra, thereby alleviating bladder outlet obstruction.^[1]^[2] The primary goals of TURP are to relieve urethral obstruction and improve urinary function, typically resulting in a significant enhancement of peak urinary flow rates by an average of 10 mL/s and a reduction in lower urinary tract symptoms (LUTS) by approximately 85%. This leads to better urine flow and decreased frequency of symptoms such as hesitancy and incomplete emptying. On average, the procedure involves resecting 20-40 grams of prostate tissue, with durations ranging from 30 to 90 minutes depending on prostate size and complexity.^[2]^[13] In TURP, an electrosurgical wire loop on the resectoscope cuts and coagulates prostate tissue under continuous irrigation to maintain visibility and flush debris. Non-conductive irrigants, such as 1.5% glycine, are used in monopolar setups to prevent electrical conduction through the body. The resectoscope, often a continuous-flow model like the Iglesias type, facilitates precise tissue removal while minimizing bleeding.^[2]^[1]

Indications and Patient Selection

Primary Indications

Transurethral resection of the prostate (TURP) is primarily indicated for men with benign prostatic hyperplasia (BPH) experiencing complications or persistent symptoms that impair quality of life. Absolute indications include conditions where conservative or medical management fails to prevent serious sequelae, such as refractory acute urinary retention (AUR) secondary to BPH, where TURP relieves obstruction to restore voiding.^[14] Recurrent urinary tract infections (UTIs) attributable to BPH also warrant TURP, as unresolved obstruction promotes bacterial stasis and repeated episodes.^[14] Similarly, persistent gross hematuria due to BPH, recurrent bladder stones from incomplete emptying, and renal insufficiency (such as hydronephrosis) caused by bladder outlet obstruction are absolute triggers for intervention to avert further renal damage or hemorrhage.^[14] Relative indications encompass moderate-to-severe lower urinary tract symptoms (LUTS) refractory to pharmacological therapy, typically defined by an International Prostate Symptom Score (IPSS) of 8 or greater, indicating significant bother from storage and voiding dysfunction.^[15] TURP is commonly pursued when multiple factors, including symptom severity and patient preference, converge after unsuccessful trials of alpha-blockers or 5-alpha reductase inhibitors.^[2] These scenarios often arise in the context of bothersome LUTS leading to clinical evaluation for BPH. TURP is most commonly performed in men aged 60 to 80 years with prostate volumes of 30 to 80 grams, where the procedure effectively targets transitional zone hyperplasia causing obstruction.^[16] In selected patients meeting these criteria, TURP achieves success in improving quality of life in 80-90% of cases by alleviating symptoms and restoring normal voiding patterns.^[2]

Contraindications and Considerations

Transurethral resection of the prostate (TURP) has specific absolute contraindications that preclude its performance due to high risk of complications. These include an active, untreated urinary tract infection (UTI), which must be resolved with antibiotics prior to surgery to prevent systemic spread or exacerbation during the procedure.^[2] Untreated urethral stricture represents another absolute contraindication, as it can lead to instrumentation failure or further trauma, necessitating prior management such as dilation or urethrotomy.^[17] Prostate cancer is generally contraindicated unless performed palliatively for severe lower urinary tract symptoms (LUTS), as TURP is not curative and may complicate subsequent therapies like radiation or brachytherapy.^[2] Severe coagulopathy, such as an international normalized ratio (INR) greater than 1.5, is also absolute until corrected, given the procedure's reliance on normal hemostasis to control bleeding.^[18] Relative contraindications require careful assessment and may favor alternative approaches like laser enucleation or open prostatectomy. A prostate volume exceeding 80-100 grams is relative, as prolonged resection times increase risks of fluid absorption and complications, though skilled surgeons may extend to 150 grams with bipolar techniques.^[2] High post-void residual volume (>150 mL) or poor detrusor function (assessed via urodynamics) poses a relative risk due to potential incomplete emptying and higher incontinence rates post-procedure, warranting further evaluation.^[17] Neurological disorders affecting bladder control, such as Parkinson's disease, multiple sclerosis, or myasthenia gravis, are relative contraindications owing to elevated risks of urinary incontinence and detrusor instability.^[2] Preoperative considerations emphasize thorough evaluation to mitigate risks and ensure suitability. Cardiac assessment is essential for anesthesia tolerance in elderly patients, including electrocardiogram (ECG) and review of cardiovascular history to address fluid overload or hyponatremia risks.^[17] Preoperative use of alpha-blockers may be continued or initiated for symptom optimization in patients with moderate LUTS severity, aiding bladder decompression without directly impacting bleeding, though 5-alpha reductase inhibitors like dutasteride are preferred for vascular reduction if time allows.^[2] The American Urological Association (AUA) guidelines (2021, amended 2023 and finalized 2024) stress shared decision-making, incorporating patient preferences, prostate size via transrectal ultrasound, and post-void residual volume to weigh TURP against alternatives, particularly when bothersome moderate-to-severe LUTS (e.g., IPSS ≥8) guides initial assessment but barriers like comorbidities arise.^[15]

Surgical Procedure

Preoperative Preparation

Preoperative preparation for transurethral resection of the prostate (TURP) begins with a comprehensive diagnostic evaluation to confirm the appropriateness of the procedure and assess prostate characteristics. Cystoscopy is routinely performed to visualize the urethra, prostate, and bladder, allowing identification of any anatomical abnormalities or stones that could impact surgery.^[19] If a neurogenic bladder is suspected, urodynamic studies are recommended to evaluate bladder function, detrusor pressure, and voiding dynamics, helping to predict postoperative outcomes.^[2] Transrectal ultrasound (TRUS) is often used to measure prostate volume, guiding surgical planning as glands larger than 80 mL may require alternative approaches.^[17] Medication management is critical to minimize bleeding risks. Anticoagulants and antiplatelet agents, such as warfarin or clopidogrel, should be discontinued 5-7 days prior to surgery, with bridging low-molecular-weight heparin considered for patients at high thrombotic risk to maintain anticoagulation balance.^[20] For patients on 5-alpha-reductase inhibitors like finasteride, continuation for 2-6 weeks preoperatively can reduce prostate vascularity and intraoperative blood loss by decreasing microvessel density, though longer-term use (up to 3 months) further shrinks prostate size.^[21] Alpha-blockers may be continued or adjusted based on symptom control, while routine screening for urinary tract infections with culture and treatment if positive is essential. Additionally, perioperative antibiotic prophylaxis is administered in accordance with current guidelines, typically as a single dose of an appropriate antibiotic such as cefazolin, to prevent postoperative infections.^[22]^[23] Anesthesia selection favors spinal over general in most cases due to lower cardiovascular stress and better hemodynamic stability during the procedure.^[24] Informed consent is obtained after discussing procedure benefits and risks, including a 70-90% incidence of retrograde ejaculation as a common outcome from bladder neck disruption.^[25] Patients undergo standard preoperative fasting, remaining nil per os (NPO) for 6-8 hours to reduce aspiration risk under anesthesia. A bowel enema may be administered if rectal emptying is needed to facilitate access, though it is not universally required.^[1]

Intraoperative Technique

The patient is positioned in the lithotomy stance with the buttocks placed at the edge of the cystoscopy table to facilitate straight-line access for the resectoscope, and the table is adjusted to an appropriate height for the surgeon's ergonomics.^[2] After initial cystoscopic examination to confirm urethral patency and identify key anatomical landmarks such as the verumontanum and ureteral orifices, the resectoscope sheath (typically 24-28 Fr) is lubricated and gently inserted through the urethra under direct vision using a visual obturator to avoid trauma.^[17] Continuous irrigation with an appropriate solution—nonconductive like glycine for monopolar TURP or isotonic saline for bipolar—is initiated, warmed to body temperature and maintained at a height of 60 cm above the table to provide an inflow of approximately 300 mL per minute for optimal visualization while minimizing intravesical pressure.^[2] The standard intraoperative technique follows the Nesbit method, originally described in 1943, which systematically resects prostatic tissue in defined stages to minimize bleeding and ensure complete adenoma removal while preserving continence.^[17] Resection begins with the intravesical stage, targeting the bladder neck and prostatic roof: starting at the 12-o'clock position, the cutting loop is withdrawn in long, smooth strokes to remove tissue in 1 cm chips clockwise around the bladder neck, creating a circumferential opening while avoiding the ureteral orifices.^[26] This is followed by the extravesical stage for the lateral lobes: the scope is repositioned just proximal to the verumontanum, and tissue is resected from the 5-7 o'clock (posterior) and 3-9 o'clock (lateral) positions, devascularizing and mobilizing the lobes toward the surgical capsule—a white, fibrous plane serving as the lateral resection margin—using curving strokes to drop the lobes posteriorly.^[2] The procedure concludes with the apical stage, approached with particular caution near the verumontanum to preserve the external urethral sphincter: a rectal finger may be used to elevate the prostate apex for better exposure, and tissue is resected in small increments, stopping approximately 5 mm proximal to the verumontanum to avoid incontinence.^[26] Throughout, hemostasis is achieved by coagulating visible vessels with the resectoscope loop in a blended cutting-coagulation mode, and resected chips are evacuated periodically using an Ellik evacuator to maintain clear visualization.^[17] The entire resection is typically completed in under 90 minutes to reduce fluid absorption risks, with complete removal of obstructing adenoma prioritized over exhaustive resection of non-obstructive tissue.^[2] Intraoperative monitoring focuses on fluid balance, with irrigation input and output volumes tracked to ensure absorption remains below 1 L—calculated as the difference between inflow and outflow—through frequent bladder irrigation checks and hematocrit assessments.^[17] Vital signs, including blood pressure and mental status under spinal anesthesia, are observed continuously for early signs of TUR syndrome, such as bradycardia or confusion, prompting immediate intervention if serum sodium falls below 125 mEq/L.^[2]

Variations of TURP

Monopolar TURP

Monopolar transurethral resection of the prostate (TURP) represents the traditional endoscopic approach to treating benign prostatic hyperplasia, building on the general TURP technique of resecting obstructing prostate tissue via a resectoscope inserted through the urethra.^[2] In this method, electrical energy is delivered through a monopolar circuit, where the active electrode on the resectoscope loop vaporizes and coagulates tissue, while the return path completes via a grounding pad attached to the patient's skin.^[27] The electrical setup employs monopolar high-frequency current, typically set at 200-300 watts for cutting to enable precise tissue resection and 80-120 watts for coagulation to achieve hemostasis.^[28] This configuration necessitates non-conductive irrigants, such as glycine or sorbitol solutions, to maintain visibility in the surgical field without short-circuiting the current; these fluids are hypotonic and non-electrolytic, allowing the monopolar energy to function effectively.^[29] Monopolar TURP offers established efficacy as the historical gold standard for managing bladder outlet obstruction due to benign prostatic hyperplasia, particularly for prostate volumes between 30 and 80 grams, where it provides reliable symptom relief and durable outcomes.^[30]^[31] However, its use of non-conductive irrigants carries a notable risk of electrolyte imbalance, including transurethral resection (TUR) syndrome from systemic absorption, which can lead to hyponatremia and associated complications.^[32] Additionally, the monopolar energy produces deeper tissue coagulation compared to alternatives, contributing to a higher incidence of urethral strictures, reported in 2-7% of cases.^[33]^[34] Since the introduction of bipolar TURP, monopolar TURP utilization has declined significantly, from nearly 100% of TURP procedures in the early 2000s to around 78% by 2013, reflecting a shift toward methods with potentially lower complication profiles.^[35]

Bipolar TURP

Bipolar transurethral resection of the prostate (TURP) represents a significant advancement in the surgical management of benign prostatic hyperplasia, utilizing bipolar radiofrequency energy to resect prostate tissue. In this technique, the electrical circuit is completed between the active resection loop electrode and the return electrode integrated into the resectoscope sheath, without requiring a separate grounding pad on the patient's skin. This configuration confines the current to the immediate vicinity of the resection site, enabling the use of isotonic saline (0.9% NaCl) as the irrigation medium, which is both conductive and physiologically compatible, thereby eliminating the risk of fluid absorption leading to transurethral resection (TUR) syndrome.^[36] The primary safety advantages of bipolar TURP stem from its irrigation compatibility and localized energy delivery. It virtually eliminates the incidence of dilutional hyponatremia, reporting 0% rates in multiple studies compared to 0.8-1.4% in monopolar TURP due to the avoidance of non-conductive, hypotonic irrigants like glycine. Patients typically experience a shorter hospital stay, averaging around 1-1.5 days, facilitating faster recovery and reduced healthcare resource utilization. Furthermore, the technique is particularly advantageous for patients with cardiac comorbidities, as the absence of a dispersive current path minimizes risks of arrhythmias or electrolyte disturbances that could exacerbate underlying heart conditions.^[37]^[38]^[30]^[39] Despite these improvements, bipolar TURP is not without limitations. The more superficial coagulation effect may provide less deep hemostasis in highly vascular tissues, occasionally necessitating supplementary coagulation during surgery. The procedure also incurs higher costs attributable to specialized bipolar generators and resectoscopes. Long-term durability is comparable to other TURP variants, with reoperation rates of approximately 1-2% per year for recurrent symptoms or complications.^[17]^[40] Adoption of bipolar TURP has grown substantially since its introduction in the early 2000s, surpassing monopolar TURP in many institutions by the mid-2010s due to its superior safety profile, with guidelines from organizations like the American Urological Association endorsing its use alongside traditional methods.^[35]^[41]

Risks and Complications

Intraoperative Risks

During transurethral resection of the prostate (TURP), bleeding is a primary intraoperative concern, originating from capsular vessels and exacerbated in highly vascular prostates. Surgeons manage this by applying pressure to bleeding sites and using electrocoagulation to achieve hemostasis. The risk of significant hemorrhage necessitating blood transfusion is approximately 2-3% in standard cases, though rates can range from 0-9% and approach 5-10% in patients with larger or more vascular glands.^[16]^[2] TUR syndrome represents another critical intraoperative hazard, caused by systemic absorption of hypotonic irrigation fluid (typically glycine solution) exceeding 1 L, resulting in dilutional hyponatremia and fluid overload. Early symptoms include confusion, nausea, visual disturbances, and bradycardia, progressing to severe manifestations such as seizures or coma if untreated. The incidence is approximately 0.8-2% with monopolar TURP, significantly reduced by intraoperative monitoring of fluid input/output and serum sodium levels, as well as limiting procedure duration to under 90 minutes; bipolar TURP virtually eliminates this risk by using isotonic saline irrigation.^[2]^[16]^[42] Bladder or prostatic capsular perforation occurs rarely during TURP, with an incidence of less than 1%, typically resulting from excessive or blind resection in thin-walled areas such as the bladder roof or capsule. This complication can lead to extravasation of irrigation fluid and sudden hemodynamic instability, managed by immediate cessation of resection, bladder drainage via Foley catheter, and assessment for repair if needed.^[2]^[43] Anesthesia-related risks during TURP include hypotension, particularly under spinal anesthesia, which is a common complication due to sympathetic blockade; this is mitigated with vasopressor support and fluid management. Additionally, unrecognized capsular perforation can open venous sinuses, causing acute bradycardia and hypotension from rapid fluid absorption or vagal stimulation, emphasizing the need for vigilant monitoring of vital signs throughout the procedure.^[44]^[2]

Postoperative Complications

Postoperative complications following transurethral resection of the prostate (TURP) are categorized into early and late onset, with rates influenced by surgical technique, patient factors, and perioperative care. Early complications typically occur within the first few weeks and are often related to the immediate healing process, while late complications may manifest months to years after surgery due to tissue remodeling or regrowth. Early postoperative complications include urinary tract infections (UTIs), which affect 2-10% of patients and are mitigated by routine antibiotic prophylaxis to reduce bacteriuria and sepsis risk.^[45]^[46] Clot retention, occurring in approximately 2-5% of cases, often requires bladder irrigation and can stem from intraoperative bleeding that leads to postoperative clot formation.^[45] Retrograde ejaculation, resulting from incision of the bladder neck, is a common side effect affecting 70-90% of patients and typically leads to dry orgasm, which is permanent in most cases.^[25] Late postoperative complications encompass urethral stricture, seen in 2-5% of patients due to trauma from the resectoscope, and bladder neck contracture, occurring in 1-3% and more frequently with smaller prostates.^[45] Urinary incontinence, particularly if the external sphincter is damaged, affects 1-2% of patients long-term, though transient urge incontinence is more common early on (up to 30-40%) and usually resolves.^[45]^[47] Sexual complications beyond retrograde ejaculation are infrequent; erectile dysfunction is rare, with new-onset rates below 5% and erectile function preserved in over 90% of cases.^[2] Reoperation for prostatic regrowth is required in 1-2% of patients per year, accumulating to 10-15% at 10 years.^[48]

Recovery and Follow-up

Immediate Postoperative Care

Following transurethral resection of the prostate (TURP), patients are typically admitted to the hospital for 1 to 3 days to facilitate close monitoring and initial recovery.^[49]^[50] A three-way Foley catheter is inserted during surgery and used for continuous bladder irrigation (CBI) with normal saline to flush the bladder and prevent blood clot formation, which could obstruct urine flow.^[2]^[17] The irrigation is maintained for 24 to 48 hours postoperatively, with the flow rate adjusted to achieve light pink or "pink lemonade" colored effluent, and it is discontinued once the urine remains clear or only slightly pink for at least 24 hours.^[2]^[51] Prolonged CBI may be required if significant postoperative bleeding persists, extending the duration based on ongoing hematuria assessment.^[17] Key monitoring parameters in the immediate postoperative period include serial hemoglobin levels, serum electrolytes, and vital signs to detect complications such as hemorrhage or transurethral resection (TUR) syndrome. A hemoglobin drop of less than 2 g/dL is generally considered normal, reflecting typical blood loss of 200 to 400 mL during the procedure, with levels checked within 48 hours to confirm stability.^[52]^[53] Electrolytes, particularly sodium, are evaluated especially if the surgery exceeded 60 minutes or involved excessive irrigation fluid absorption, to identify and resolve hyponatremia associated with TUR syndrome.^[2] Vital signs are routinely assessed for signs of hemodynamic instability or infection, ensuring prompt intervention if needed.^[17] Pain management focuses on alleviating dysuria and irritative symptoms common in the early recovery phase, with alpha-blockers such as tamsulosin (0.4 mg daily) recommended to relax the prostate and bladder neck, reducing discomfort without increasing bleeding risk.^[54] Nonsteroidal anti-inflammatory drugs (NSAIDs) are typically avoided initially due to their potential to exacerbate postoperative bleeding.^[17] Mild analgesics may be used as needed for general discomfort. Discharge occurs once hematuria has cleared, CBI is discontinued, and urinary output exceeds fluid input by at least 1 L over 24 hours, confirming adequate voiding without retention.^[2]^[17] Patients receive education on catheter care if an indwelling catheter is required beyond discharge, including signs of infection or obstruction to report, along with instructions for gradual resumption of activities.^[2]

Long-term Management

Following transurethral resection of the prostate (TURP), patients typically undergo follow-up clinic visits at 1 to 3 months postoperatively to assess symptom resolution and detect any early complications. These evaluations include administration of the International Prostate Symptom Score (IPSS) to quantify lower urinary tract symptoms and uroflowmetry to measure peak urinary flow rate, with a target improvement to greater than 15 mL/s indicating successful outcomes.^[15] Subsequent visits may occur annually or as needed based on persistent symptoms or quality-of-life concerns.^[15] The durability of TURP is well-established, with 80-90% of patients experiencing sustained symptom relief at 5 years post-procedure, as measured by IPSS reductions and improved flow rates. Reoperation rates remain low in the long term, approximately 5% at 5 years and rising to about 15% at 10 years, often due to recurrent hyperplasia or stricture formation.^[55]^[17]^[56] Lifestyle modifications play a supportive role in long-term management, including pelvic floor exercises to potentially aid continence recovery, though evidence for their efficacy beyond the immediate postoperative period is limited. Patients are advised to avoid heavy lifting for 4-6 weeks to prevent strain on the surgical site, transitioning to general prostate health practices thereafter. Ongoing prostate-specific antigen (PSA) monitoring is recommended as part of routine cancer screening, adjusted for the expected postoperative PSA decline.^[57]^[15]^[4] Quality-of-life improvements are a key benefit of TURP, particularly in reducing nocturia episodes by an average of 1 to 2 per night, though individual responses vary and some patients may experience persistent symptoms. Sexual function counseling is essential, as retrograde ejaculation occurs in up to 70% of cases, though erectile function is generally preserved; patients should be informed of these changes to manage expectations and psychological impact.^[58]^[59]^[60]

Alternatives to TURP

Minimally Invasive Options

Minimally invasive options for benign prostatic hyperplasia (BPH) offer effective symptom relief with reduced recovery times and lower risks compared to more invasive procedures like TURP, particularly for patients seeking to preserve sexual function or those with comorbidities. These treatments target prostate tissue reduction or retraction through endoscopic, thermal, embolic, or ablative methods, often performed outpatient under local or general anesthesia. They are generally preferred for smaller prostates or high-surgical-risk individuals, providing durable improvements in lower urinary tract symptoms (LUTS) while minimizing complications such as bleeding or retrograde ejaculation.^[61] The UroLift system employs permanent nitinol implants to mechanically retract and compress lateral prostate lobes, widening the urethral lumen without tissue ablation, cutting, or removal. This approach is indicated for prostates measuring 20–100 cm³ (typically <80 cm³) and is performed as an outpatient procedure lasting 10–15 minutes. Clinical studies demonstrate significant LUTS relief, with 86% of patients achieving substantial symptom improvement within one month and sustained benefits up to five years, including reduced International Prostate Symptom Score (IPSS) and increased maximum urinary flow rate (Qmax). Ejaculatory function is preserved in nearly all cases, with no significant decline in antegrade ejaculation reported, making it suitable for sexually active patients prioritizing fertility or sexual satisfaction.^[61] Rezum therapy utilizes transurethral water vapor thermal ablation, delivering steam injections to denature prostate tissue via convective heat, leading to necrosis and volume reduction over weeks. Indicated for prostates measuring 30–80 cm³, it typically involves 4–10 injections per session in an outpatient setting, targeting central prostate zones while sparing the urethra and ejaculatory ducts. Five-year outcomes show durable symptom improvement, with mean IPSS reductions of about 50% (e.g., -10.3 points from baseline) and enhanced quality of life, alongside low retreatment rates. Sexual side effects are minimal, with no clinically meaningful impact on erectile function (International Index of Erectile Function change: -2.4 points) or ejaculatory preservation, positioning Rezum as a favorable option for patients with moderate BPH and concerns over sexual dysfunction.^[62]^[63] Prostatic artery embolization (PAE) reduces prostate blood supply by injecting embolic particles into feeding arteries, inducing ischemia, glandular atrophy, and smooth muscle relaxation to alleviate obstruction. This endovascular procedure, done under local anesthesia, is particularly suited for high-risk patients with comorbidities or anticoagulant use, as it avoids general anesthesia and surgical trauma. IPSS reductions of approximately 50-80% are reported, with some studies showing up to 81%, and 2024 systematic reviews confirming comparable efficacy to TURP at two years in symptom relief and quality of life, though with fewer complications (35.5% vs. 60.6%) and shorter hospital stays. PAE's non-invasive profile makes it ideal for frail individuals unfit for endoscopic surgery.^[64]^[65] Aquablation employs a robotically controlled, high-velocity waterjet guided by real-time ultrasound to precisely enucleate excess prostate tissue, sparing structures like the verumontanum to maintain ejaculatory pathways. Performed endoscopically in an operating room, it accommodates larger glands and ensures hemostasis via post-ablation cautery. The procedure preserves antegrade ejaculation in 90% of patients, markedly better than TURP's 64% rate, with similar LUTS improvements (e.g., IPSS reductions). Emerging 2025 data affirm its durability, with five-year follow-up showing sustained IPSS and Qmax gains without increased reintervention, highlighting its role for patients desiring long-term efficacy and sexual function preservation.^[66]^[67]

Open Surgical Alternatives

Open surgical alternatives to transurethral resection of the prostate (TURP) primarily involve procedures that directly excise the prostatic adenoma through an abdominal incision, reserved for cases where endoscopic approaches are less feasible. Simple open prostatectomy, the traditional method, employs either a suprapubic (transvesical) or retropubic (extravesical) approach to remove the hyperplastic tissue while preserving the prostate capsule and neurovascular structures. The suprapubic approach involves an incision into the bladder to access the adenoma from above, offering enhanced visualization of the bladder neck and adenoma base, whereas the retropubic approach accesses the prostate directly through the space anterior to the bladder, minimizing bladder manipulation but potentially complicating hemostasis. This procedure is indicated for prostates exceeding 80-100 grams, where TURP's operative time and irrigation fluid absorption risks become prohibitive for large volumes.^[68]^[69] Simple open prostatectomy achieves high success rates, with approximately 90% of patients experiencing sustained symptom relief and improved urinary flow rates at long-term follow-up, attributed to the complete removal of the adenoma. However, it carries a risk of urinary incontinence in 5-10% of cases, typically transient but occasionally requiring intervention, alongside other morbidities such as bleeding necessitating transfusion in 5-15% of patients. These outcomes reflect the procedure's durability for severe benign prostatic hyperplasia (BPH), though its invasiveness contributes to longer hospital stays and recovery periods compared to endoscopic options.^[15]^[70] Robotic-assisted simple prostatectomy represents a modern evolution, utilizing laparoscopic techniques with the da Vinci robotic system to perform adenoma enucleation through small ports, often via a transperitoneal retropubic or suprapubic route. This approach yields functional outcomes comparable to open surgery, including equivalent improvements in voiding symptoms and quality of life, but with reduced blood loss and shorter hospital stays. A 2023 meta-analysis confirmed similar efficacy to traditional open methods, highlighting robotic assistance's role in minimizing complications while accelerating recovery to 2-4 weeks versus 6 weeks for open procedures.^[70]^[71] Indications for open surgical alternatives over TURP include very large glands (>80-100 grams) and concomitant conditions such as bladder stones or diverticula, where complete adenoma removal addresses multiple pathologies in a single operation. Despite these benefits, the procedures entail higher overall morbidity, including transfusion rates of 5-15%, due to the abdominal access and potential for significant hemorrhage.^[15]^[70] Historically, open prostatectomy constituted about 20% of BPH surgeries in the 1980s, serving as a mainstay before endoscopic advancements. By 2024, its utilization has declined to less than 5%, supplanted by less invasive techniques amid evolving guidelines favoring TURP and minimally invasive options for most patients.^[72]^[73]

History and Current Research

Historical Development

The development of transurethral resection of the prostate (TURP) built upon foundational advancements in endoscopic technology for treating benign prostatic hyperplasia (BPH), a condition causing urinary obstruction that has been recognized since ancient times. In 1877, Max Nitze invented the cystoscope, an illuminated endoscope that allowed visualization of the urethra and bladder, laying the groundwork for minimally invasive urological procedures.^[74] Early attempts at transurethral prostatectomy emerged in the 1920s, with American urologist Hugh Hampton Young performing initial resections using a punch instrument equipped with an electric cautery blade to remove obstructing tissue.^[75] This approach was refined in 1926 when Maximilian Stern introduced the first resectoscope, a device incorporating a cystoscope with a cutting loop to resect prostatic tissue under direct vision, marking the birth of modern TURP.^[76] Further refinements in the 1930s solidified TURP as a viable alternative to open surgery. Joseph F. McCarthy, collaborating with instrument maker Frederick Wappler, developed the Stern-McCarthy resectoscope in 1931, featuring improved visualization through a fore-oblique lens and enhanced electrical coagulation to control bleeding, which significantly reduced operative risks.^[77] By 1943, Reed M. Nesbit standardized the technique in his seminal textbook, describing a systematic method for complete prostate resection that emphasized en bloc removal of adenoma chips and meticulous hemostasis, promoting widespread adoption among urologists. Technological progress continued post-World War II, amid a temporary resurgence of open prostatectomy due to wartime shortages of electrical equipment and catheters. In 1945, Terence Millin introduced the retropubic open prostatectomy, but TURP regained prominence by the 1950s because of its lower morbidity, shorter hospital stays, and reduced blood loss compared to open approaches.^[78] A major innovation came in 1975 with José M. Iglesias's resectoscope, which incorporated continuous irrigation and suction to maintain clear visualization and low intravesical pressure, minimizing complications like fluid absorption.^[79] TURP reached its zenith in the United States during the mid- to late 20th century, with approximately 350,000 procedures performed annually among Medicare beneficiaries by the 1980s, accounting for over 95% of BPH surgeries.^[80] However, the introduction of medical therapies in the 1990s, particularly alpha-blockers like terazosin and doxazosin, offered non-surgical symptom relief and contributed to a sharp decline in TURP volume, with procedure rates dropping by about 40% by 2000 as pharmacological options became first-line treatments.^[81]

Ongoing Research and Advances

Recent studies have focused on techniques to preserve ejaculatory function during TURP, particularly ejaculation-preserving TURP (EP-TURP), which involves colliculus-preserving resection to minimize disruption to the ejaculatory ducts. A 2025 review highlights EP-TURP as a refinement of conventional TURP, achieving antegrade ejaculation rates of 50-70% in selected patients, compared to approximately 10% with standard TURP.^[82] Another randomized controlled trial reported an 83% success rate for antegrade ejaculation using a similar sparing technique around the verumontanum and prostatic apex.^[83] Meta-analyses from 2024 and 2025 demonstrate that TURP provides comparable symptom relief to holmium laser enucleation of the prostate (HoLEP) and photoselective vaporization of the prostate (PVP), with International Prostate Symptom Score (IPSS) reductions of approximately 15 points across procedures for small-to-moderate prostate volumes.^[84] TURP is associated with comparable costs to HoLEP, averaging around $6,500 per procedure in US analyses, with variations due to equipment and operative time expenses.^[85] For Aquablation, 2025 trials confirm equal durability to TURP at 5 years, with reoperation rates below 5% and sustained IPSS improvements in both large and small prostates.^[86] Advancements include enhancements in bipolar TURP for larger prostates (>80 mL), which reduce irrigation needs and transfusion risks compared to monopolar resection, enabling safer treatment of glands up to 100 g or more.^[87] Emerging AI applications, such as machine learning algorithms for predicting post-TURP urethral strictures, aid in resection planning and risk stratification to optimize outcomes.^[88] The 2024 AUA guideline (amended from 2023) and EAU guidelines endorse TURP as a first-line option for intermediate-risk benign prostatic hyperplasia (prostate volume 30-80 mL), emphasizing its efficacy and safety profile.^[41] Future directions emphasize transitioning TURP to outpatient settings, with 2023-2025 feasibility studies showing reduced hospital stays to under 24 hours without increased complications in low-risk patients. Adjunct therapies like preoperative dutasteride aim to lower reoperation rates by minimizing bleeding and capsular perforation, potentially decreasing retreatment needs by 20-30% over 5 years.^[89]

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