For Patients

Prostate Surgery (excluding cancer)

As men get older the prostate gland increases in size, and for some men, this can result in obstruction to the flow of urine. If this causes bothersome symptoms, or even stops urine flow altogether (urinary retention), then surgery on the prostate gland may be required. There are several different operations available, all designed to relieve obstruction and improve symptoms. Many of these operations are available at Newcastle Urology. Your urologist will be happy to discuss them with you.

HoLEP (Laser Enucleation of Prostate)

What does the procedure involve?

This operation involves the telescopic removal of obstructing prostate tissue using a laser and temporary insertion of a catheter which is removed the day after surgery in the majority of men

What are the alternatives to this procedure?

Observation/no treatment depending on symptoms, modifying fluid intake (caffeine reduction), medications, use of a catheter, conventional transurethral resection of the prostate or an open operation (with a skin incision in the tummy).

What should I expect before the procedure?

If you are taking Clopidogrel or any other blood-thinning medication on a regular basis, you must stop this before your admission. These drugs can cause increased bleeding after prostate surgery. Treatment can be re-started safely about 10 days after you get home. You will be advised by the Urology team well in advance of your operation.

You will usually be admitted on the day of your surgery. You will normally receive an appointment for pre assessment before your admission, to assess your general fitness and to perform some baseline blood and urine tests.

After admission, you will be seen by members of the medical team who will include the Consultant, your anaesthetist and your nurse. You will be asked not to eat or drink for 6 hours before surgery.

What happens during the procedure?

Either a full general anaesthetic (where you will be asleep throughout the procedure) or a spinal anaesthetic (where you are awake but unable to feel anything from the waist down) will be used. All methods minimise pain; your anaesthetist will explain the pros and cons of each type of anaesthetic to you. The operation, on average, takes 45-120 minutes, depending on the size of your prostate.

You will usually be given an injectable antibiotic before the procedure after checking for any drug allergies.

The laser is used to separate the obstructing prostate tissue from its surrounding capsule and to push it in large chunks into the bladder. An instrument is then used through the telescope to remove the prostate tissue from the bladder. A catheter is normally left to drain the bladder at the end of the procedure.

What happens immediately after the procedure?

There is always some bleeding from the prostate area after the operation. The urine is usually clear of blood after 24 hours, although it is quite common to see some blood in the urine, often intermittently, for even up to 6 weeks after surgery. This is not a concern surgically, and although blood in the urine may seem alarming to some people it is usually only a small amount of blood that is lost. It is very unusual to require a blood transfusion after laser surgery.

It is useful to drink more fluid than normal in the first 24 hours after the operation because this helps the urine clear of any blood more quickly. Sometimes, fluid is flushed through the catheter to clear the urine of blood. Many men are surprised at how comfortable they are after laser prostate surgery. Apart from some minor discomfort from the catheter irritating the penis and bladder, it is usual not to have any pain as such.

You will be able to eat and drink on the same day as the operation when you feel able to.

The catheter is generally removed the morning after surgery. At first, it may be painful to pass your urine and it may come more frequently than normal. Any initial discomfort can be relieved by tablets or injections and the frequency usually improves within a few days. Some of your symptoms, especially frequency,urgency and getting up at night to pass urine, may not improve for several months because these are often due to bladder over activity (which takes time to resolve after prostate surgery) rather than prostate blockage. Since a large portion of prostate tissue is removing with the laser technique (which means you will have excellent relief of prostate blockage and have a very low risk of ever needing a repeat prostate operation), there may be some temporary loss of urinary control until your pelvic floor muscles strengthen and recover. This is why pelvic floor exercises are taught prior to surgery. If you do these exercises as advised, the risk or urinary incontinence after surgery is very low and if it does occur it normally resolves completely within a few months (often within days). Any incontinence is normally managed by wearing a pad inside the underpants. The need to use pads beyond 3 months occurs in less than 2% of men. Let your nurse know if you are unable to pass urine and feel as if your bladder is full after the catheter is removed.

Some patients, particularly those with small prostate glands, are unable to pass urine at all after the operation due to temporary swelling of the prostate area. If this should happen, we normally pass a catheter again to allow the swelling to resolve and the bladder to regain its function. Usually, patients who require re-catheterisation go home with a catheter in place and then return within a week for a second catheter removal which is successful in almost all cases.

The average hospital stay is 1-2 days.

What should I expect when I get home?

Most patients feel tired and below par for a week or two because this is major surgery. You may notice that you pass very small flecks of tissue in the urine at times within the first month as the prostate area heals.This does not usually interfere with the urinary stream or cause discomfort.

What else should I look out for?

If you experience increasing frequency, burning or difficulty in passing urine or worrying bleeding, please contact your doctor.

About 1 man in 5 experiences bleeding some 10-14 days after getting home; this is due to scabs separating from the cavity of the prostate. Increasing your fluid intake should help stop this bleeding within 24 hours but, if it does not, you should contact your urologist or your GP who may prescribe some antibiotics for you.

In the unlikely event of severe bleeding, passage of clots or sudden difficulty in passing urine, you should contact your GP immediately since it may be necessary for you to be re-admitted to hospital.

Are there any other important points?

Removal of your prostate should not adversely affect your ability to have an erection provided you are getting normal erections before the surgery. It is very common not to be able to ejaculate any semen at the point of orgasm after prostate surgery. This is because after surgery it is much easier for the semen to travel back into the bladder than down and out through the penis. This is not an uncomfortable or harmful consequence of surgery and most men say the experience of orgasm remains a pleasurable sensation. This is only a major issue if you intend fathering children in future. Sexual activity can be resumed as soon as you are comfortable, usually after 3-4 weeks.

It is often helpful to recommence pelvic floor exercises as soon as possible after the operation since this can improve your control when you get home.The symptoms of an overactive bladder may take 3 months to resolve whereas the flow is improved almost immediately.

The results of any tissue removed will be available after 14 – 21 days and you and your GP will usually be informed of the results by letter. If any results are best discussed with you in person, an appointment will be made for you to be seen in the clinic soon after the results become available.

You will be reviewed in the outpatient clinic and several tests repeated (including a flow rate, bladder scan & symptom score) to help assess the effects of the surgery. This is usually 3 months after the surgery to allow time for your waterworks to settle into a new pattern.

Most patients require a recovery period of 1-2 weeks at home before they feel ready for work. We recommend 2 weeks rest before resuming any job, especially if it is physically strenuous and you should avoid any heavy lifting during this time. You should not drive until you feel fully recovered; 1 week is the minimum period that most patients require before resuming driving.

Are there any side-effects of the operation?

Common side-effects (greater than 1 in 10)

  • · Temporary mild burning, bleeding and frequency of urination after the procedure
  • · No semen is produced during an orgasm in approximately 75% if the prostate is fully enucleated
  • · Treatment may not relieve all the urinary symptoms, but if this is the case a medication can sometimes help if required
  • · Infection of the bladder, testicle or kidney requiring antibiotics (approx 10-15%)
  • · Failure to pass urine immediately after surgery requiring placement of a new catheter which is then removed (almost always successfully) within a week (10-15%)

Occasional side-effects (between 1 in 10 and 1 in 50)

  • · Loss of complete urinary control (incontinence) which normally resolves within 6 weeks (less than 10%); this can usually be improved with pelvic floor exercises
  • · Weaker or no erections. 2 recent studies have shown no significant difference in ability to have an erection in men before and after HoLEP surgery but there is still a small risk (probably less than 5%) of a decreased ability to have an erection. Erections in some men actually improve after surgery
  • · Injury to the urethra causing delayed scar formation requiring further minor surgery (5%)
  • · Finding unsuspected cancer in the removed tissue which may need further treatment (5%)

Rare side-effects (less than 1 in 50)

  • · Need to repeat treatment later due to re-obstruction from prostate regrowth (approx 1% in the first 7 years after surgery)
  • · Self-catheterisation or permanent catheter to empty bladder if the bladder is weak (1%)
  • · Persistent loss of urinary control which may require a further operation (less than 1%)
  • · Retained tissue fragments floating in the bladder which may require a second telescopic procedure for their removal (less than 1%)
  • · Very rarely, perforation of the bladder requiring a temporary urinary catheter or open surgical repair (less than 0.5%)
  • · Bleeding requiring return to theatre and/or blood transfusion (less than 0.5%)

Transurethral resection of the Prostate (TURP)

What does the procedure involve?

This operation involves the telescopic removal or incision of the obstructing, central part of the prostate with heat diathermy and temporary insertion of a catheter for bladder irrigation

What are the alternatives to this procedure?

Drugs, use of a catheter/stent, observation or open operation, laser enucleation of the prostate (HoLEP), laser ablation (e.g. GreenLight)

What should I expect before the procedure?

You will usually be admitted on the same day as your surgery. After admission, you will be seen by members of the medical team which may include the Consultant, Specialist Registrar, and your named nurse. You will be asked not to eat or drink for 6 hours before your operation.

What happens during the procedure?

Either a full general anaesthetic (where you will be asleep throughout the procedure) or a spinal anaesthetic (where you are awake but unable to feel anything from the waist down) will be used. All methods minimise pain; your anaesthetist will explain the pros and cons of each type of anaesthetic to you. A telescope is passed into the bladder and the central part of the prostate removed piecemeal using heat diathermy. The prostate fragments are evacuated using suction and sent for pathological analysis. A catheter is usually inserted after the procedure. The procedure takes 45-60 minutes. You will usually be given injectable antibiotics before the procedure, after checking for any allergies.

What happens immediately after the procedure?

There is always some bleeding from the prostate area after the operation. The urine is usually clear of blood after 48 hours, although some patients lose more blood for longer. If the loss is moderate, you may require a blood transfusion to prevent you from becoming anaemic. You will be able to eat and drink the morning after the operation although this may be allowed earlier after a spinal anaesthetic.

The catheter is generally removed after 2-3 days, following which urine can be passed in the normal way. At first, it may be painful to pass your urine and it may come more frequently than normal. Any initial discomfort can be relieved by tablets or injections and the frequency usually improves within a few days. It is not unusual for your urine to turn bloody again for the first 24-48 hours after catheter removal. A few patients are unable to pass urine at all after the operation. If this should happen, we normally pass a catheter again to allow the bladder to regain its function before trying again without the catheter. The average hospital stay is 2 days for a routine admission.

Are there any side-effects?

Most procedures have a potential for side-effects. You should be reassured that, although all these complications are well-recognised, the majority of patients do not suffer any problems after a urological procedure.

The operation leaves a raw area in the urine passage, which then rapidly heals over. Occasionally you can get quite heavy bleeding from the raw area either during or shortly after the operation. This is usually corrected by flushing the bladder through the catheter. The chance of this happening is about 3 in a 100 (3%). Very occasionally we have to give a further anaesthetic to flush the bladder and stop the bleeding with the telescope. Some men do have some bleeding in the week after the operation at home; this can be set off by straining to open your bowels for example. Usually this settles by drinking plenty but you may have to return to the ward for a simple bladder flush. Please take it easy during the first 2 weeks after surgery to minimise the risk of bleeding.

Having an anaesthetic and an operation may make other illnesses such as angina or bronchitis worse. If you suffer such health problems the anesthetist, surgeon and ward staff will take special care during your hospital stay. The chance (risk) of having something go wrong with your general health whilst you are in hospital is about 2 in a 100 (2%), but this depends upon your age and other health problems you may suffer from.

Enlargement of the prostate is caused by benign changes in the gland. We do however get our pathologist (a doctor who examines tissue under the microscope) to look carefully at the pieces of the prostate removed during the operation. This careful examination sometimes reveals abnormal cells, which are a form of prostate tumour or cancer. However most of these tumours are tiny and dormant and won’t cause any further trouble. We will usually continue to keep an eye on the prostate if such a tumour is found for a number of years just to be sure. We find such tumours in about 1 out of every 10 (10%) men who have a prostate operation. You will be told about the results of the tissue examination by letter or at your follow up appointment.

The main side effect of the operation is re-routing of the ejaculation of semen that occurs when you have sexual intercourse. Instead of coming out of the tip of the penis it goes into the bladder. This means that your ejaculation will be “dry” but you may find your urine is cloudy with the semen the next time you go to the toilet. This happens to about 75% men who have a TURP, but to only 50% men who have a BNI.

Some men (10-15%) find that their sex life isn’t as good after the operation either because the feelings are less strong or their erection is less stiff. Other men find their sex life is improved since they don’t have to worry about their urinary symptoms.

A few men find that the urine flow slows down again a few months after the operation. This is usually due to a narrowing in the urine tube that can be simply fixed by gently stretching the tube under anaesthetic.

IS THE OPERATION ALWAYS SUCCESSFUL?

When men are asked about their prostate operation about 80% say they are extremely happy with the results. If we put this the other way around it means that about 2 out of every 10 (20%) men who have prostate operations feel that they haven’t gained much benefit. The operation is very unlikely to make your symptoms worse however.

Symptoms such as having to rush to the toilet (urgency) are caused by over activity of the bladder muscle, and it is often this symptom that doesn’t get better after the operation and which makes men unhappy with the result. It can however be controlled to some extent by tablets. Most men find that their symptoms are dramatically better immediately after the operation; other men feel that they gradually improve over 2 – 3 months.

Since we don’t remove all the prostate gland it will continue to grow to some extent. We find that about 1 in 10 (10%) of men will need a second operation in their lifetime, usually 10 – 15 years after the first one.

Incontinence is rare after a TURP but it does occur in less than 2%. It may be temporary or permanent and further treatment may be required.

What should I expect when I get home?

When you leave hospital, you will be given a “draft” discharge summary of your admission. This holds important information about your inpatient stay and your operation. If, in the first few weeks after your discharge, you need to call your GP for any reason or to attend another hospital, please take this summary with you to allow the doctors to see details of your treatment. This is particularly important if you need to consult another doctor within a few days of your discharge. Most patients feel tired and below par for a week or two because this is major surgery. Over this period, any frequency usually settles gradually.

What else should I look out for?

If you experience increasing frequency, burning or difficulty on passing urine or worrying bleeding, contact your GP.

Are there any other important points?

Removal of your prostate should not adversely affect your sex life provided you are getting normal erections before the surgery. Sexual activity can be resumed as soon as you are comfortable, usually after 3-4 weeks. It is often helpful to start pelvic floor exercises as soon as possible after the operation since this can improve your control when you get home. The symptoms of an overactive bladder may take 3 months to resolve whereas the flow is improved immediately. If you need any specific information on these exercises, please contact the ward staff or the Specialist Nurses.

Most patients require a recovery period of 2-3 weeks at home before they feel ready for work. We recommend 3-4 weeks’ rest before resuming any job, especially if it is physically strenuous and you should avoid any heavy lifting during this time. You should not drive until you feel fully recovered; two weeks is the minimum period that most patients require before resuming driving.

Laser Prostatectomy using Greenlight KTP Laser

Why is laser prostatectomy being recommended?

Photoselective vaporisation of the prostate (PVP) is used to treat bladder obstruction caused by benign (non-cancerous) enlargement of the prostate.

A high-powered laser is used to core out the prostate by vaporising the centre of the gland, leaving a wide channel and so relieving urinary symptoms. If a catheter is required following surgery it can usually be removed within 24 hours.

The risk of bleeding both during and after the operation is reduced compared to the ‘gold standard’ operation (called TURP), minimising the need for blood transfusion.

Overall the surgery places less strain on the body and may be a better option for men who have other health problems. An appointment will be arranged to provide you with information, to try to answer questions that you may have and check that we have sufficient information about you.

Before your procedure

What pre operative preparation is needed?

Before your admission to hospital you will be asked to attend the pre assessment clinic. Pre anaesthetic checks which may be carried out include blood tests, urine tests, heart tracing (ECG) and sometimes a chest x-ray. A nurse will complete the relevant documentation giving you further opportunity to ask any questions you may have.

At the pre assessment clinic you will be asked about your current medication. We particularly need the details of medication that may affect bleeding.

You will come into hospital either the day before or on the day of your operation and be seen by the nursing and medical staff on the ward. You will also be seen by the anaesthetist who will discuss the type of anaesthetic you will have.

On the day of the operation you will be advised to have nothing to eat or drink for several hours before surgery. You will be asked to change into a hospital gown and be taken to the operating department.

During your procedure

How is the operation carried out?

The duration of the operation itself depends on the prostate size. The total time spent in the operating theatre suite is likely to be several hours.

The first part of the operation is to give you an anaesthetic. You may be completely asleep (general anaesthetic), or just the body from the waist down made numb (spinal anaesthetic), and then a sedative may be given to help the time pass comfortably.

The bladder and prostate gland are accessed via the penis along the urethra (urinary passageway), and the operating instrument, the cystoscope, (sometimes referred to as a ‘telescope’), is passed accompanied by sterile (saline) salt-water. The laser fibre is introduced through the cystoscope and the procedure started. As the laser light is shone onto the prostate surface the prostate tissue can be seen to disappear gradually.

When the surgeon is happy that a clear channel has been created, the need for a catheter (urinary drainage tube) is considered. Rarely will irrigation (a bag of fluid to continually flush the catheter, as is used after TURP) be required.

After your procedure

What will happen after the operation is completed?

You will wake up in the recovery area in your bed and when the nurses are happy with your condition a nurse from the ward will come to take you back to the ward.

You will have a drip running into your arm or hand. This is to prevent dehydration until you are drinking. You will be given a drink when the nurse feels you are ready and able to tolerate it. You should be given a light meal soon after.

If a catheter was inserted, it will be removed a few hours after surgery or the following day. The timing of the catheter removal will depend upon several factors, including the type of anaesthetic you have had, how well you recover from the anaesthetic and how much blood there is in the urine. You may go home once you are passing urine and emptying your bladder satisfactorily.

What problems can occur?

Before your planned surgery it is important that you understand what the surgery entails and the possible side effects. On rare occasions, as with the standard TURP operation, there will be patients who are unsuccessful in passing urine following the laser operation. This may require the re-insertion of a catheter for a period of time and a further or alternative operation may need to be considered at a later date.

Urinary control

Some men experience discomfort in the penis or urethra immediately after the operation (typically in recovery). This usually lasts a few hours, easing when urine is passed. Painkillers can be given which will help. If passing urine frequently and with ‘urgency’ (difficulty holding on) was a problem beforehand, this may continue after the operation and may be temporarily worse.

Some men may develop ‘cystitis’ symptoms up to two weeks after the operation, passing urine frequently with a burning sensation. Infection should be ruled out initially and sometimes a course of medication is required.

Bleeding

Some patients have noted bleeding after the operation, (sometimes not appearing until approximately two weeks later), probably due to the separation of scabs internally. Again, infection should be ruled out but rarely does this require further treatment.

Effects on your sex life

Approximately 25% of men may experience retrograde ejaculation (semen going into the bladder) resulting in a ‘dry orgasm’. If this occurs it may affect your ability to father children but you cannot rely on this as a method of contraception. Some men report a change in sensation of orgasm.

Impaired erection

There have been no reported cases in men undergoing this procedure to date, however there cannot be a complete guarantee that this will never occur.

As with any operation, other surgical complications can occur. These include infections, heart problems or deep vein thrombosis (blood clots in the legs). The risks of these will be discuss in the pre admission clinic and where necessary specific preventative measures will be taken.

Are there any alternatives to this surgery?

At the present time the standard operation performed for relieving symptoms cause by enlargement of the prostate gland is called transurethral resection of the prostate gland (TURP), when the enlarged prostate tissue is shaved away from the inside surface, again using cystoscopic instruments. Please refer to the ‘TURP’ patient information available at Newcastle Urology.

As the PVP procedure is relatively new it is not possible to predict the long term outcome of this operation. However, based on the currently available information it appears favourable and equivalent to TURP. Caution about the long term is a point stressed by NICE (www.nice.org.uk the independent body that assesses treatments offered by the NHS).

After you have been discharged home

What can I do when I get home?

Strenuous activity (e.g. digging, carrying heavy items) should be avoided for two weeks following your operation. Driving can be resumed after one week (some car insurance is not valid during the recovery period after an operation. Check with your insurance company). Sports such as golf or cycling may be resumed after two weeks.

Avoid becoming constipated as straining may lead to bleeding from your prostate cavity. If necessary you can be given a mild laxative to take home after your procedure.

Sexual activity may be resumed as soon as you feel ready. If you do ejaculate there may be some discolouration of the semen for some weeks. This is normal and soon settles.

Bearing in mind the type of activity and responsibility involved, you may return to work when you feel fit which is usually between 2-7 days.

Follow up

You will be sent home with a letter for your General Practitioner and with any medication you need.

A follow up appointment will be made for you about three months after your operation. At this appointment you will be asked to provide a urinary flow rate test, so come with a full bladder if possible. You will also be asked to repeat the symptom score that you had completed before your surgery.

Contact points

If you have any problems following your discharge from hospital you may contact the ward you were on for advice. Alternatively you may contact your GP. If the matter is urgent and you are unable to contact the hospital please contact the emergency medical services in the usual way. In addition to the information that we ask for please do not hesitate to feed back any comments directly to the team involved.