A marked weakening of the urine stream, getting up frequently at night to urinate, having to wait to start urinating or recurrent urinary tract infections show how much prostate enlargement can affect daily life. At this point, the question patients ask most often is: What are the prostate surgery methods and which one is more suitable for me? The answer is not based on prostate size alone. The severity of the complaints, the strength of the bladder, any blood thinners being used, suspicion of prostate cancer and the patient's general health are assessed together.
When we talk about prostate surgery, two different disease groups must be distinguished. In benign prostatic hyperplasia (BPH), the aim is to remove the prostate tissue blocking the urethra so that the patient can urinate comfortably. In prostate cancer, on the other hand, removal of the entire prostate gland may come into consideration depending on the stage of the disease. The surgical technique used, the expected results and the possible side effects differ markedly between these two situations.
What are the prostate surgery methods for benign prostatic hyperplasia?
Benign prostatic hyperplasia develops as the prostate presses on the urethra with age. Surgical treatment may be considered in patients whose complaints persist despite medication, who experience urinary retention, or in whom a bladder stone or kidney involvement is found. The current approach, in suitable patients, is to relieve the obstruction with closed, minimally invasive methods.
TURP: The classic closed prostate operation
TURP (transurethral resection of the prostate) is a closed method in which the obstructing part of the prostate is removed piece by piece with electrical energy through the urethra. It is one of the surgical options that has been performed for many years and whose results are well known. It can be effective particularly in small and medium-sized prostates.
Monopolar or bipolar energy may be used. Because bipolar TURP can be performed with saline, it may reduce some risks related to fluid absorption. However, as prostate volume increases, operating time, the likelihood of bleeding and the amount of tissue to be removed may increase. In some patients, re-intervention may become necessary in later years because of the remaining prostate tissue.
HoLEP: Holmium laser enucleation of the prostate
HoLEP is based on using a holmium laser to separate the inner part of the prostate that blocks the urethra from its capsule. The separated tissue is broken into small pieces inside the bladder and removed. Technically, it aims to clear the obstructing prostate tissue more completely.
HoLEP is a strong option that can be an alternative to open surgery, particularly in large prostates. Its relatively low bleeding risk and the possibility of a shorter hospital stay and catheter time in suitable patients are among its important advantages. It can also be considered as an option for patients taking blood thinners; however, the decision to stop or adjust the medication must always be made individually together with the relevant specialties.
Not every laser operation is the same. HoLEP is a technique that requires experience and equipment. In the first weeks after the operation, frequent urination, burning or a sudden urge may be felt. Temporary urinary incontinence may occur in some patients and usually improves over time with pelvic floor exercises. For this reason, the surgeon's experience and the post-operative follow-up plan matter as much as the method.
ThuFLEP: Thulium fiber laser enucleation
ThuFLEP is prostate enucleation performed with a thulium fiber laser. Similar to HoLEP, the aim is to separate the obstructing prostate tissue from the capsule; the difference lies in the laser energy used. The cutting and bleeding-control properties of the thulium fiber laser on tissue may offer advantages in suitable patients.
For ThuFLEP, too, prostate volume is not the only deciding factor. The patient's anatomy, previous prostate procedures, accompanying bladder problems and the technical experience of the center must be taken into account. The presence of a laser alone does not guarantee the best result. The success of treatment increases when the right indication, the right surgical technique and close follow-up are planned together.
Photoselective vaporization and other laser options
In some laser methods, prostate tissue is vaporized to widen the urethra. These approaches may be preferred for certain prostate sizes and particularly in patients whose bleeding risk needs to be considered. On the other hand, in very large prostates the vaporization time may be prolonged and the removed tissue may not be available for pathological examination.
The need for pathology is not the same in every prostate operation. However, if there is an elevated PSA, a suspicious finding on examination or suspicion of cancer on imaging, this issue should be addressed separately before the surgical plan. An operation performed for benign enlargement does not replace an investigation for prostate cancer.
Open or simple prostatectomy
In very large prostates and in some special situations with additional problems such as a bladder stone, simple prostatectomy by open surgery or other closed approaches may come into consideration. In this operation, not the whole prostate but the inner part that blocks the urine flow is removed. Because it is a more extensive surgical procedure, the recovery period and hospital stay may be longer than with laser enucleation methods.
Today, in experienced centers, closed treatment with laser enucleation techniques such as HoLEP or ThuFLEP may be possible for a large proportion of large prostates. Even so, it is not right to recommend the same method to every patient. Previous operations, abdominal conditions and accompanying surgical needs can change the decision.
Surgical options in prostate cancer
The operation performed for prostate cancer is called radical prostatectomy. The aim is to remove the entire prostate gland, together with surrounding tissues and lymph nodes when necessary. This procedure can be performed with open, laparoscopic or robotic surgery. Which approach is suitable is determined according to the stage of the cancer, PSA level, biopsy result, imaging findings, age and general health.
Robotic radical prostatectomy can provide the surgeon with three-dimensional imaging and precise range of movement. It offers the possibility of detailed dissection, particularly for preserving the structures that maintain urinary continence and the nerves involved in erection. However, whether nerve-sparing surgery can be performed depends above all on how close the cancer is to these areas and on oncological safety. The goal of fully controlling the cancer must be balanced with the goal of preserving function.
The risk of urinary incontinence and erection problems after radical prostatectomy varies from patient to patient. Age, erection quality before surgery, additional conditions such as diabetes or vascular disease, the extent of the tumor and the surgical technique used affect the results. Discussing these risks openly before surgery creates realistic expectations and makes the recovery process more manageable.
What is assessed when choosing a method?
The surgical decision is not just about the prostate volume measured on ultrasound. The examination, PSA assessment, urinalysis, kidney function, ultrasonography, a flow test in selected patients and the amount of urine remaining in the bladder after urination are assessed together. If cancer is suspected, additional tests such as multiparametric MRI and biopsy may be needed.
The patient's most dominant complaint is also a guide. The prostate may not be the only cause of getting up frequently at night to urinate; conditions such as sleep disorders, diabetes, heart failure or overactive bladder may also contribute to this picture. If the bladder muscle has weakened because of long-standing obstruction, urinary complaints may not be expected to disappear completely even after a technically successful prostate operation.
Expectations regarding sexual life are also a natural part of the consultation. In operations for benign prostatic hyperplasia, erectile function is preserved in most patients; however, retrograde ejaculation, meaning that semen flows back into the bladder, may be common. This is not harmful to health, but it must be discussed before surgery with patients who plan to have children or who value the sensation of ejaculation.
What can the patient expect after surgery?
After closed prostate operations, a urinary catheter is used for a short time. After the catheter is removed, burning, mild blood in the urine, a feeling of urgency and more frequent urination may be seen in the first days. Drinking plenty of fluids, avoiding heavy lifting and taking the medications recommended by the doctor regularly support recovery.
During recovery, in situations such as bright red and heavy bleeding, urine with clots, fever, severe pain or being unable to urinate at all, you should go to a healthcare facility without delay. Keeping follow-up appointments is necessary both for monitoring recovery and for setting up the next plan correctly in patients who require pathology or PSA follow-up.
In prostate surgery, the most appropriate method is not the one with the newest name; it is the one planned to suit the patient's disease, life expectancy and priorities. A detailed assessment, a transparent discussion of the surgical options and accessible post-operative follow-up are the foundation of a safe treatment process.
