Lower Urinary Tract Symptoms (LUTS) describe a collection of uncomfortable urinary issues. These symptoms are categorized as storage problems, such as increased frequency, urgency, or nocturia (waking at night to urinate). Voiding symptoms involve the flow of urine, presenting as a poor stream, hesitancy, or a feeling of incomplete bladder emptying. While LUTS affect both men and women, they are most frequently associated with Benign Prostatic Hyperplasia (BPH) in men, where the enlarged prostate obstructs the urethra. Surgery for LUTS is typically reserved for patients whose quality of life remains significantly impaired after initial medical treatments have proven ineffective.
Deciding on Surgical Treatment
The decision to move from managing LUTS with medication to pursuing surgical intervention is guided by specific clinical indicators. A primary factor is the failure of a comprehensive medical regimen, such as alpha-blockers or 5-alpha-reductase inhibitors, to adequately relieve symptoms. Physicians assess symptom severity using standardized questionnaires like the American Urological Association Symptom Index (AUA-SI). A score of 8 to 19 is considered moderate, and 20 to 35 indicates severe symptoms.
Surgery is also considered immediately if LUTS have led to complications that pose a direct threat to the urinary tract or kidney function. These serious indicators include:
- Refractory urinary retention (inability to urinate).
- Recurrent urinary tract infections (UTIs).
- Bladder stones.
- Persistent blood in the urine (gross hematuria).
- Kidney impairment caused by the obstruction.
In these instances, surgical relief of the blockage becomes necessary regardless of the patient’s prior response to medication.
Minimally Invasive Procedures
Minimally invasive surgical treatments have gained favor for LUTS due to their reduced recovery times and lower risk profile compared to traditional surgery.
Prostatic Urethral Lift (UroLift)
The Prostatic Urethral Lift (PUL), marketed as UroLift, is a non-ablative procedure that physically compresses the enlarged prostate tissue. Small, permanent implants are deployed transurethrally to pull the obstructive prostate lobes away from the center of the urethra. This mechanical action immediately creates a wider channel for urine flow without cutting, heating, or removing any tissue.
Water Vapor Thermal Therapy (Rezum)
Water Vapor Thermal Therapy (Rezum) uses targeted thermal energy to shrink the prostate tissue. A transurethral device delivers controlled bursts of sterile, heated water vapor directly into the obstructive tissue. When the steam contacts the cooler prostate tissue, it condenses and releases thermal energy, causing the death of obstructive cells. Over the following weeks and months, the body reabsorbs the treated tissue, reducing prostate volume and opening the urethra.
Photoselective Vaporization of the Prostate (GreenLight Laser)
Photoselective Vaporization of the Prostate (PVP), commonly referred to as GreenLight Laser, uses a high-powered laser to vaporize the overgrown tissue. A thin fiber is inserted through the urethra, and the green laser energy is specifically absorbed by the prostate’s highly vascularized tissue. This absorption causes the tissue to instantly turn into steam, effectively removing the obstruction in a precise and virtually bloodless manner. PVP is often utilized for patients taking blood thinners due to its hemostatic properties.
Established Resective Surgery
Transurethral Resection of the Prostate (TURP) is considered the historical benchmark surgical procedure for LUTS caused by Benign Prostatic Hyperplasia. This procedure involves inserting a resectoscope through the urethra, which contains a camera and an electrified wire loop. The surgeon uses this loop to systematically cut away small pieces of excess prostate tissue, relieving the obstruction.
TURP is highly effective and is typically recommended for patients with larger prostate glands, generally exceeding 30 to 40 grams, where minimally invasive options may be less durable. The excised tissue fragments are flushed into the bladder and removed at the end of the procedure. Bipolar TURP uses a saline-based irrigation fluid, which significantly reduces the risk of a rare complication called TUR syndrome associated with older techniques.
Transurethral Incision of the Prostate (TUIP) is a less extensive procedure than TURP, reserved for smaller prostate glands, often under 30 grams. Instead of removing tissue, TUIP involves making one or two deep, full-thickness incisions into the prostate and bladder neck. These incisions relax the prostate and widen the urethral channel without tissue removal. TUIP is often favored in younger men with smaller prostates as it carries a lower rate of retrograde ejaculation compared to TURP.
Post-Operative Care and Recovery
Immediate post-operative care often involves placing a urinary catheter to drain the bladder and flush out any blood or debris. After resective procedures like TURP, the catheter remains in place for 24 to 48 hours or longer, sometimes with continuous irrigation, until the urine clears. Minimally invasive procedures like UroLift or PVP frequently allow for catheter removal within hours, and some patients may be discharged without one.
Temporary side effects are common as the surgical area heals. Patients frequently experience dysuria (burning during urination) and mild hematuria (blood in the urine), which can persist intermittently for several weeks. Increased urinary frequency and urgency are also expected for a few weeks as the bladder adjusts to the loss of obstruction.
Activity restrictions are necessary to prevent bleeding. Patients are advised to avoid strenuous physical activity, heavy lifting over 10 pounds, and activities that put pressure on the pelvic area, such as cycling, for at least four to six weeks. Sexual activity is also typically restricted for about four weeks post-procedure. Recovery is generally quicker following minimally invasive treatments, while full recovery from a resective procedure can take up to six weeks.