When you hear the term ‘prostate surgery,’ it is easy to first think about ‘how large it is.’ However, the decision to have surgery is not determined by size alone. It also considers whether daily life is difficult even with medication, whether urination is repeatedly blocked, and whether there are complications such as infection, bladder stones, hematuria, or decreased kidney function.
Also, what is commonly referred to as prostate surgery often means surgery for benign prostatic hyperplasia, but it is completely different in purpose and scope from surgery for prostate cancer. This article focuses on surgery aimed at reducing obstruction caused by benign prostatic hyperplasia.
Check if the symptoms and test results are in the same direction
Before surgery, we evaluate the International Prostate Symptom Score (IPSS), urine flow test, post-void residual volume, urinalysis, and kidney function, as well as the size of the prostate and the condition of the bladder through ultrasound. If necessary, PSA, cystoscopy, or urodynamic study can be considered. Even if the prostate appears enlarged, if weak bladder contraction is the main cause, the urine stream may not improve as much as expected even after removing the obstruction.
Recurrent urinary retention, recurrent urinary tract infections, bladder stones, untreated prostatic bleeding, upper urinary tract dilation, or decreased kidney function are signals that prompt active discussion of surgery. Even without complications, if medication is ineffective or difficult to take due to side effects, and symptoms significantly reduce quality of life, surgery can be considered.
Minimally invasive treatment and surgery have different goals
Minimally invasive treatments, such as Rezūm steam therapy or prostatic urethral lift, are considered when tissue burden, anesthesia burden, and preservation of ejaculation function are important. However, the same effect cannot be expected for all sizes, shapes, and complications. If obstruction needs to be widely removed or there are issues such as recurrent urinary retention and stones, resection or removal surgery may be more appropriate.
The ‘step-by-step approach of trying small procedures first’ is not always the right answer. To reduce unnecessary retreatment, it is important to compare prostate volume and median lobe shape, bladder function, the use of anticoagulants and anesthesia risks, and the outcomes that the patient values all at once.
TURP and HoLEP have different tissue processing methods
Transurethral resection of the prostate (TURP) is a representative surgery in which a resectoscope is inserted through the urethra to shave off enlarged tissue little by little to widen the passage. Bipolar equipment is widely used and has long been the standard for medium-sized prostates. HoLEP is an enucleation procedure in which enlarged tissue is separated from the capsule using a holmium laser and then cut into pieces and removed in the bladder.
EAU guidelines recommend HoLEP as an alternative to TURP or open simple prostatectomy. Medium- to long-term improvements in urination have been reported similarly, and HoLEP can be applied to large prostates, with reported advantages in terms of bleeding and hospitalization. However, surgical time, learning curve, and equipment availability depend on the institution and the surgeon’s experience. Since there are other options, such as photoselective vaporization or bipolar enucleation, you should be explained the reasons suitable for your own condition rather than just by name.
Observe hematuria and changes in urination during recovery
After surgery, a catheter may be kept in place for a certain period, and after its removal, frequent urination, urgency, pain during urination, and slight blood in the urine may temporarily occur. Follow discharge instructions regarding fluid intake, lifting heavy objects, exercise, resuming driving, and sexual activity. Large amounts of blood or large clots, inability to urinate, high fever or chills, and worsening pain are signs that should be checked immediately.
After surgery for benign prostatic hyperplasia, retrograde ejaculation, where semen goes into the bladder instead of coming out, can commonly be an issue. Erectile function and ejaculation function are not the same concept. If you have plans for pregnancy in the future or if preservation of ejaculation function is important, be sure to inform the doctor before deciding on the surgical method. The EAU recommends follow-up care to assess treatment response and adverse reactions 4–6 weeks after catheter removal.
Ask questions based on test results rather than the name of the surgery
- Is the main cause of my symptoms a prostate obstruction, or is there also decreased bladder function?
- What is the method suitable for the prostate volume and the shape of the median lobe?
- What are the expected improvements in urinary flow and residual urine, and what is the likelihood of retreatment?
- How do you adjust bleeding risk and anticoagulants?
- How do you anticipate the duration of the catheter and hospital stay, and the timing of returning to work?
- What changes are possible for erectile function and ejaculatory function, respectively?
Prostate surgery is not a treatment that simply removes enlarged tissue; it is an option to improve urinary function and quality of life by reducing confirmed obstructions and complications. Based on the test results, place the expected benefits and the burdens you would have to bear on the same table and make your decision.
Referenced Medical Information
- European Association of Urology (EAU) Guidelines on the Treatment of Male Lower Urinary Tract Symptoms
- European Association of Urology (EAU) postoperative follow-up recommendations
This article is general health information about surgery for benign prostatic hyperplasia and does not replace diagnosis or treatment. Surgery for prostate cancer has different purposes and scope, so a separate consultation is required.
