Consequences of prostate surgery

• Prostate surgery, regardless of the technique used, is performed with the aim of relieving the symptoms of benign prostatic hyperplasia.
• As with any intervention, prostate surgery has both positive and possible negative consequences.
• The percentage of negative consequences following prostate surgery is very low, with a higher percentage of positive consequences.

Benign prostatic hyperplasia (BPH) is an anatomic clinical entity characterised by an increase in prostate size at the expense of glandular tissue. 

This enlargement leads to a clinical manifestation of obstruction of urine outflow through the urethra causing difficulty in urination. In a large number of these cases, the only possible solution to alleviate these symptoms will be prostate surgery.

Among all the treatments available for the management of this pathology, prostate reduction surgery is the definitive treatment that resolves the main complications and symptoms that characterise this pathology. 

There are a series of different surgical alternatives depending on the characteristics of each patient's prostate. 

The main ones are:

Transurethral Resection of the Prostate (TURP): This is an operation of intermediate difficulty that consists of the introduction of an apparatus called a resectoscope through the urethra, which is the tube that runs from the tip of the penis to the bladder. The resectoscope allows instruments to be inserted when the location of the prostate has been reached so that the prostate can be fractionated from the inside and removed.

Laser prostate operation:

• Thulium laser: This technique is a great alternative in small (<30g) and medium sized prostates (30-60 grams).
• Holmium laser: This is an alternative for small and medium-sized prostates (<60g) in patients with/without added risk factors.
• GreenLight laser: This laser is much older than the Tulio and Holmium lasers, although it was one of the first lasers to be used with the prostate vaporisation system. It is recommended for prostates <50 grams.
• Urolift system: This is an intervention in which by placing implants on both sides of the prostate attached to natural elements, an increase in the calibre of the urinary stream is achieved by compressing the prostate gland on both sides of the urethra, thereby improving the symptoms of benign prostatic hyperplasia. It is recommended for use in prostates <50 grams.

Positive consequences of prostate surgery: Improvement of symptoms

The direct consequences of any prostate operation for the resolution of benign prostatic hyperplasia are improved urinary flow, less urine retained in the bladder after each urination and improved quality of life for patients with enlarged prostates, which can be measured with the international standardised questionnaires (IPSS).

All of this directly improves the quality of life of patients, improving the quality of sleep by not having to get up at night with the need to urinate, improving the quality of urine flow and reducing common complications of benign prostatic hyperplasia such as urinary tract infections and erectile dysfunction.

Taking into account the different techniques discussed above, we can establish the following consequences:

• TURP as well as Holmium, Thulium and GreenLight laser intervention improve peak urinary flow to normal in 90% of cases. Urolift system improves these parameters in about 95% of cases.
• Urine residue in the bladder after urination (a parameter that gives a glimpse of the frequency of urination) is restored to normal in 95% of cases with Holmium laser intervention, and between 80-85% with TUR and the Tulio and Verde laser. The urolift system improves this parameter in 90% of cases.
• The improvement in the IPSS quality of life and symptomatology scale is more than 50% of the total value in all the techniques described, with the effect of the Holmium laser and the urolift system being slightly greater than that of TUR and the Tulio laser.

Despite the data, in cases where excellent improvement of symptoms of benign prostatic hyperplasia is not achieved, it is due to associated problems of the patient or the severity of the pathology.

Possible negative consequences of prostate surgery

Any surgical intervention carries a series of risks of possible unfavourable consequences during the immediate and medium-term postoperative period. With the advance of technology and new surgical techniques, the percentage of these adverse effects has decreased to minimum percentages that ensure uncomplicated cure rates in the vast majority of patients. 

The characteristics of each intervention and the morbidity or associated pathologies of each patient determine the indication of the intervention in one direction or another according to the expected benefits.

Generally speaking, we can speak of immediate adverse effects (in the immediate postoperative period) and possible adverse effects in the short or medium term. The main ones are:

• Intraoperative bleeding: the possibility of minor bleeding during the course of the operation is measured, from a clinical point of view, in the decrease in haemoglobin in the analytical controls and the need for blood transfusions immediately after the operation. In this sense, prostate surgery with the Urolift system is the technique with the best results, as it does not lower haemoglobin levels and blood transfusion is only necessary in less than 0.5% of cases. Laser surgery (both Tulio, Holmium and Verde) does not lower haemoglobin levels and the need for blood transfusion is less than 1% of cases.
• Urinary incontinence, defined as difficulty in holding urine on demand, is a very rare complication related to a partial lesion of one of the sphincters surrounding the prostate, which are responsible for keeping urine inside the bladder. In this regard, the Urolift system presents this complication in less than 1% of cases, laser treatment in around 1-2% and TURP in around 3% of cases.
• Retrograde ejaculation is defined as the outflow of sperm after each ejaculation into the bladder, preventing its exit through the urethra or penis. This complication is caused by the involvement during surgery of part of the detrusor muscle of the bladder in the area most adjacent to the prostate. In this regard, the Urolift system has an incidence of less than 5% of cases, laser surgery around 30-50% and TUR surgery in 50-70% of patients.
• Erectile dysfunction is a complex pathology in which several genetic, emotional, organic and vascular factors are involved. In relation to prostate surgery, it is possible to partially damage the barriers surrounding the penis and the urethra, making it difficult to fill the corpora cavernosa that form the penis and hindering erection. TUR is the procedure that causes a slightly increased risk of this complication at around 5-7% of cases, followed by laser with less than 4% of cases. The Urolift system has less than a 2% chance of causing erectile dysfunction.