Surgery for Enlarged Prostate: Options and Procedures

As many men get older, they notice urinary symptoms that inconvenience them in various ways. Perhaps they experience a weaker urine stream, frequent night-time trips to the toilet, or a constant feeling that the bladder never fully empties. This is often caused by an enlarged prostate, medically known as benign prostatic hyperplasia (BPH), which is a common condition that comes with ageing.

For some, these issues improve with monitoring or medication. However, when symptoms persist for long periods, affecting sleep and daily routines or lead to complications such as urinary retention or recurrent infections, surgery may become an option worth considering.

When Do Urologists Recommend Surgery for Enlarged Prostates?

Surgical treatment is not usually the first option for managing prostate enlargement. It is generally considered when symptoms persist despite medication, begin to interfere with daily life or when other complications develop. Before moving on to surgery, a consultant urologist will usually conduct a pre-surgical evaluation to assess whether the degree of prostate obstruction requires physical removal or reshaping of tissue.

Surgery may be recommended in the following situations:

• Persistent Urinary Retention: Occurs when there is ongoing difficulty emptying the bladder or a sudden inability to pass urine.
• Recurrent Urinary Tract Infections (UTIs): These infections may recur due to incomplete bladder emptying.
• Bladder Stones: Stones can form when urine remains stagnant in the bladder for prolonged periods.
• Reduced Kidney Function: Kidney impairment may occur due to long-term back pressure from bladder outlet obstruction.
• Haematuria: May occur when bleeding from the prostate persists despite other treatments.
• Significant Impact on Quality of Life: Symptoms may continue despite appropriate and maximal medical therapy, affecting daily activities and well-being.

What to Expect During the Pre-Surgical Evaluation

A thorough pre-surgical assessment allows the urologist to determine the severity of prostate obstruction and confirm that the patient is medically fit for surgery.

Common investigations include:

• Digital Rectal Examination (DRE): This examination helps assess the size, texture and consistency of the prostate.
• Urinary Flow Studies (Uroflowmetry): These tests objectively measure the speed and pattern of urine flow.
• Ultrasound Scan: Ultrasound imaging is used to determine prostate size and to measure the amount of urine remaining in the bladder after voiding, known as post-void residual volume.
• Blood Tests: Blood tests may include prostate-specific antigen (PSA) testing when clinically indicated, as well as tests to assess kidney function.

The findings from these investigations guide treatment planning and help ensure that surgery is appropriate and safe.

How Does My Doctor Determine Which Procedure to Perform?

To select a procedure, your urologist must consider:

• Prostate size and its anatomical configuration
• Severity of urinary symptoms (as measured by scores like the International Prostate Symptom Score)
• The patient’s overall age and medical co-morbidities, which affect tolerance to anaesthesia and the length of recovery
• The presence of associated complications (e.g., bladder diverticula or kidney swelling)
• Patient's personal preferences, particularly regarding the potential side effects like temporary incontinence or impact on sexual function

These factors will help your urologist conclude as to which procedure to recommend.

Types of Procedures for Enlarged Prostate

Current surgical options for BPH vary in how invasive they are. The ideal procedure for each patient varies, but there are two main types: minimally invasive procedures and traditional abdominal surgery.

Minimally Invasive Procedures

These endoscopic procedures involve inserting instruments through the urethra to access the prostate, thereby avoiding an abdominal incision. They are suitable for many prostate sizes and often result in shorter hospital stays and faster recovery.

• Transurethral Resection of the Prostate (TURP)

  This is often referred to as the 'gold standard' procedure for BPH. A wire loop is used to meticulously remove small chips of obstructing prostate tissue, creating a wide channel for urine flow. It offers excellent long-term results and is a tried-and-tested method used globally, including in Singapore.

• Laser-Based Procedures

  Laser energy is utilised to either vaporise the tissue or enucleate (cut out) the enlarged inner portion of the gland.

  • Holmium Laser Enucleation of the Prostate (HoLEP): This technique is particularly effective for very large prostates, offering results comparable to open surgery but delivered minimally invasively.
  • Photoselective Vaporisation of the Prostate (PVP, or GreenLight Laser): This rapidly vaporises the tissue, which can be beneficial for patients on certain blood thinners due to minimal blood loss.

• Prostatic Urethral Lift (PUL)

  This procedure uses tiny implants to hold the enlarged lobes of the prostate open, thereby relieving compression on the urethra. It is a suitable option for selected patients with specific prostate characteristics and can preserve ejaculatory function for some.

• Water Vapour Therapy (e.g., Steam-Based techniques)

  Controlled, heated water vapour is delivered to the obstructing prostate tissue. The steam destroys the excess cells, which the body then naturally absorbs over several weeks, leading to a reduction in prostate size and improved urinary flow.

Traditional Surgical Options

In men with very large prostates, often defined as larger than 80 to 100 cubic centimetres, traditional surgical approaches may be the most suitable option. A simple prostatectomy involves removing the benign obstructive tissue, either through an open incision or using minimally invasive techniques such as laparoscopic or robotic surgery.

Unlike radical prostatectomy, which is performed for cancer, this procedure removes only the enlarged inner portion of the prostate while preserving the outer capsule.

Recovery and Aftercare for Prostate Surgery

Recovery time is highly variable and correlates with the invasiveness of the procedure. While minimally invasive techniques typically allow for discharge within 1 to 3 days, open surgery may require a longer hospital stay.

Patients should expect a temporary period where they may need a catheter and experience urinary frequency or urgency. Regular follow-up appointments are crucial to monitor healing, assess the improvement in urinary function and address any potential post-operative issues.

Getting the Right Help for Enlarged Prostate Symptoms

If urinary symptoms persist despite medication, or complications like urinary retention or recurrent UTIs develop, it may be worth visiting a urology clinic to discuss the next steps. Our experienced urologist, Dr Jonathan Teo, can provide a diagnosis, and if an enlarged prostate is identified, recommend appropriate follow-up options.

Contact us today to book an appointment, and let us help identify suitable support plans and protect your long-term quality of life.