TURP & HOLEP

TURP and HoLEP are two established endoscopic procedures used to treat urinary problems caused by an enlarged prostate. Both procedures are performed through the natural urinary passage, without an external abdominal incision, and aim to remove or separate prostate tissue that is obstructing the flow of urine.

An enlarged prostate, medically known as benign prostatic hyperplasia (BPH), becomes increasingly common with age. The prostate surrounds the urethra just below the bladder. As prostate tissue grows, it can gradually narrow the urinary channel and make it harder for the bladder to empty.

Patients may initially notice a weaker urinary stream or increased frequency of urination. Over time, symptoms can become more disruptive, with difficulty starting urination, prolonged emptying, repeated night-time urination, urgency, dribbling or a persistent sensation that the bladder has not emptied completely.

Medication can control symptoms in many men, but it does not always provide adequate relief. Some patients develop complications or have persistent obstruction despite medication. In such cases, an endoscopic procedure such as transurethral resection of the prostate (TURP) or holmium laser enucleation of the prostate (HoLEP) may be recommended.

At [Hospital/Clinic Name], the choice between TURP, HoLEP and other BPH treatments is based on prostate size and anatomy, symptom severity, urinary flow, bladder function, previous treatment and the patient’s overall health.

Understanding Benign Prostatic Hyperplasia

BPH is a non-cancerous enlargement of the prostate. It is important to distinguish BPH from prostate cancer. Having an enlarged prostate does not mean that a man has prostate cancer, although both conditions can occur in the same person.

As the prostate enlarges, it can compress the urethra and increase resistance to urine flow. The bladder may initially compensate by working harder to push urine through the narrowed passage. Over time, however, the bladder can become more sensitive or less effective at emptying.

Common symptoms include:

• Weak or slow urinary stream
• Difficulty starting urination
• Intermittent or interrupted flow
• Increased frequency of urination
• Urgency
• Waking multiple times at night to urinate
• Dribbling after urination
• Straining to pass urine
• Feeling that the bladder has not emptied completely

Severe obstruction can sometimes lead to acute urinary retention, in which a man is suddenly unable to pass urine. This requires prompt medical attention and often temporary catheterisation.

When Is Surgery Considered?

Not every man with BPH requires surgery.

For men with mild or moderate symptoms, lifestyle measures and medication may be sufficient. However, surgery may be considered when symptoms remain troublesome despite medication or when obstruction has resulted in complications.

Reasons for considering a procedure may include recurrent urinary retention, repeated urinary tract infections, bladder stones, significant bleeding related to BPH, deterioration in kidney function caused by obstruction or persistent symptoms that substantially affect daily life.

The decision should be based on more than prostate size. A relatively large prostate does not automatically require surgery, while a smaller prostate can still produce significant obstruction in some patients.

What Is TURP?

Transurethral resection of the prostate (TURP) is one of the established surgical treatments for BPH.

During TURP, a specialised instrument called a resectoscope is passed through the urethra. The surgeon reaches the prostate through the urinary passage, so there is no external surgical incision.

Small pieces of obstructing prostate tissue are removed from around the urethral channel. The removed tissue is collected and can be sent for pathological examination.

The aim is not to remove the entire prostate. Instead, TURP removes the portion of prostate tissue that is causing the urinary obstruction.

Once the obstructing tissue has been removed, urine can pass more freely through the enlarged prostate region.

A urinary catheter is usually placed after the procedure to allow the bladder to drain while the urinary passage heals. The catheter is generally removed after an appropriate period based on the patient’s urine appearance, bleeding and recovery.

What Is HoLEP?

Holmium laser enucleation of the prostate (HoLEP) is another endoscopic treatment for BPH.

Instead of shaving away small pieces of prostate tissue as in conventional TURP, HoLEP uses a holmium laser to separate the enlarged inner prostate tissue from the outer portion of the gland.

The enucleated tissue is then moved into the bladder and broken into smaller pieces using a specialised instrument called a morcellator. The tissue can subsequently be removed and sent for pathological examination.

Because the obstructing prostate tissue is enucleated rather than simply resected in small fragments, HoLEP can be used for a broad range of prostate sizes, including substantially enlarged prostates.

The procedure is performed through the urethra and therefore does not require an external abdominal incision.

TURP vs HoLEP

Although both procedures treat the same underlying problem, the surgical techniques are different.

TURP removes obstructing prostate tissue using a resection technique. It has been used for many decades and remains an important surgical treatment for BPH.

HoLEP uses laser energy to enucleate the enlarged prostate tissue, followed by morcellation and removal of the tissue.

Both procedures are designed to improve urinary flow by removing the obstruction.

HoLEP can be particularly useful when the prostate is significantly enlarged because the enucleation technique allows a substantial amount of obstructing tissue to be removed endoscopically.

The most appropriate procedure depends on the patient’s prostate anatomy, medical condition, surgeon expertise and available technology. There is no need to assume that one procedure is universally appropriate for every patient.

What Happens Before TURP or HoLEP?

Before surgery, the urologist assesses both the prostate and the urinary system.

The evaluation may include a medical history, physical examination, urine testing, PSA testing when appropriate, ultrasound, measurement of post-void residual urine and uroflowmetry.

In selected patients, additional tests such as cystoscopy or a formal bladder function study may be recommended.

The purpose of this assessment is to determine whether the symptoms are actually being caused by prostate obstruction. Urinary frequency, urgency and night-time urination can have causes other than BPH, including overactive bladder, urinary infection, diabetes or bladder dysfunction.

Understanding the cause helps ensure that surgery is recommended only when it is likely to address the underlying problem.

The TURP Procedure

TURP is performed under anaesthesia.

The resectoscope is introduced through the urethra and advanced to the prostate. The surgeon identifies the obstructing tissue and removes it in small sections.

The tissue fragments are removed from the bladder, and the surgical area is carefully inspected for bleeding.

A catheter is then placed into the bladder. Continuous bladder irrigation may be used after surgery to prevent blood clots from blocking the catheter while the urine clears.

Hospital stay varies depending on the patient’s recovery, urine appearance, bleeding and other medical factors.

The HoLEP Procedure

HoLEP is also performed under anaesthesia.

A laser fibre is introduced through an endoscopic instrument. The surgeon follows the natural plane between the enlarged inner prostate tissue and the surrounding outer prostate layer.

The obstructing tissue is carefully enucleated into the bladder.

Once enucleation is complete, a morcellator is used to fragment and remove the prostate tissue from the bladder.

The tissue is usually sent for pathological examination.

A urinary catheter is placed after the procedure and is removed when the surgical team determines that it is appropriate.

Recovery After TURP and HoLEP

Recovery varies from one patient to another.

It is common to experience some burning or discomfort while urinating during the early recovery period. Urinary frequency and urgency may temporarily increase as the bladder adjusts after the obstruction has been relieved.

A small amount of blood in the urine can also occur during the healing period. Patients are generally advised to maintain appropriate fluid intake unless they have a medical condition requiring fluid restriction.

Heavy lifting and strenuous activity may need to be avoided for a period after surgery. The surgeon will provide specific instructions regarding exercise, work and sexual activity.

Urinary symptoms usually improve progressively rather than immediately in every patient. The bladder may have adapted to years of obstruction, so it can take time for normal urinary patterns to stabilise.

Expected Improvement in Urination

The primary objective of TURP and HoLEP is to relieve obstruction and improve urinary flow.

Many patients experience a stronger urinary stream and improved bladder emptying following successful treatment.

However, the degree of improvement depends on how much obstruction was present before surgery and whether the bladder itself has developed long-term dysfunction.

For example, a patient whose main problem is mechanical obstruction may experience substantial improvement after the prostate tissue is removed. A patient with significant underlying overactive bladder or poorly functioning bladder may continue to experience some frequency or urgency even after successful prostate surgery.

This is why preoperative evaluation is important.

Sexual Function After TURP and HoLEP

Sexual function is an important consideration for men undergoing BPH surgery.

TURP and HoLEP can result in retrograde ejaculation, sometimes called dry orgasm. In this situation, semen enters the bladder during orgasm rather than travelling forward through the penis. The sensation of orgasm may remain, but little or no semen may be visible.

This is different from erectile dysfunction.

Most men who undergo these procedures are able to achieve erections, but erectile function can be influenced by age, diabetes, vascular disease, medications and other factors.

Patients who are concerned about ejaculation or erectile function should discuss these concerns with their urologist before choosing a procedure.

Potential Risks and Complications

TURP and HoLEP are established procedures, but both carry potential risks.

Possible complications include bleeding, urinary infection, temporary difficulty urinating, urinary urgency or frequency, urethral narrowing, bladder neck narrowing and the need for additional treatment.

Some patients experience temporary leakage of urine, particularly during the early recovery period.

Retrograde ejaculation is common after procedures that remove obstructing prostate tissue and should be discussed before surgery.

Rare but important complications can include significant bleeding, injury to surrounding structures or fluid and electrolyte disturbances.

The exact risks depend on the procedure, prostate characteristics and the patient’s medical condition.

TURP and HoLEP for Large Prostates

Prostate size is an important factor when selecting a BPH procedure.

TURP is well established for treating obstructive prostate tissue, particularly in appropriately selected moderate-sized glands.

HoLEP has an important role in treating larger prostates because the laser enucleation technique allows the surgeon to remove a substantial amount of adenomatous tissue through the urethra.

However, prostate size alone does not determine the best treatment. Prostate shape, the location of the obstructing tissue, bladder function, previous procedures and the patient’s overall health are also relevant.

Why Treating BPH Matters

Persistent urinary obstruction should not simply be accepted as an unavoidable consequence of ageing.

Severe or prolonged obstruction can contribute to recurrent urinary retention, infections, bladder stones and, in some cases, deterioration of the upper urinary tract.

At the same time, surgery should not be performed solely because the prostate is enlarged. The symptoms, objective evidence of obstruction and potential benefits of treatment need to be considered together.

A specialist evaluation can determine whether medication, monitoring or a surgical procedure is the most appropriate next step.

Personalised BPH Treatment

TURP and HoLEP are both important options for men whose urinary symptoms are caused by benign prostate enlargement.

The difference lies primarily in how the obstructing prostate tissue is removed. TURP resects the tissue through a specialised endoscopic instrument, while HoLEP uses a holmium laser to enucleate the enlarged prostate tissue before it is removed.

At [Hospital/Clinic Name], treatment is planned after assessing prostate size, urinary symptoms, bladder function, previous treatment and overall health.

Where surgery is appropriate, patients can discuss the advantages, limitations, recovery and potential side effects of TURP, HoLEP and other available BPH treatments before making an informed decision.

Take the Next Step

If you are experiencing a weak urinary stream, frequent urination, repeated night-time urination, difficulty emptying your bladder or recurrent urinary retention, these symptoms should not automatically be attributed to ageing.

A urological evaluation can determine whether an enlarged prostate is causing the obstruction and whether medication or a procedure may provide better long-term relief.

At [Hospital/Clinic Name], patients with symptomatic BPH can receive a structured assessment and discuss appropriate treatment options, including TURP and HoLEP, based on their individual prostate anatomy and urinary symptoms.