PROSTT OPN FTHR

Surgery

Surgery is usually reserved for those with a large prostate or failure to respond to an adequate trial of medical therapy.[2][11]  

• Surgery is required if there is acute urinary retention, failed voiding trials, recurrent gross haematuria, UTI, renal insufficiency due to obstruction or failure of medical treatment.
• Open prostatectomy - transurethral vaporisation of the prostate (TUVP) is reserved for those with a prostate larger than 80 g, bladder stones or bladder diverticula and patients who cannot be positioned for transurethral surgery. The inner core of the prostate adenoma is shelled out, leaving the peripheral zone behind. There may be significant blood loss requiring transfusion. Open prostatectomy usually has excellent results in terms of improvement of urinary flow and urinary symptoms.
• Transurethral resection of the prostate (TURP) is now the standard technique. A working sheath is placed in the urethra through which a hand-held device with an attached wire loop is placed. A cutting diathermy is run through the loop so that it can be used to shave away prostatic tissue. When successful, it is an excellent operation that does not involve entering the abdomen but it can have complications. Bleeding may be difficult to control. Irrigating fluid may be absorbed into the circulation via cut veins. An indwelling catheter is required until bleeding has stopped. Urethral stricture can occur. There can be retrograde ejaculation after operation or damage to the nerves can cause erectile dysfunction.
• Insertion of prostatic urethral lift implants may be used when the man wishes to have a procedure with a lower risk of causing sexual dysfunction.[19] 
• Holmium laser enucleation of the prostate (HoLEP) is equally effective, has a lower morbidity rate and is being considered as first choice where available.
• Minimally invasive therapies usually involve heat destruction of prostatic tissue. Via the urethra, energy is transferred to destroy tissue, in the form of laser, microwaves, radiofrequency waves, high-intensity ultrasound and high-voltage electrical energy.
• Estimated prostate size smaller than 30 g: transurethral incision of the prostate (TUIP) or transurethral needle ablation (TUNA) can be offered as an alternative to TURP for patients wishing to avoid, or who are unfit for, more invasive surgery. Both treatments, however, have a higher recurrence rate than TURP. If the prostate size is larger than 80 g, this narrows the options to TURP, TUVP or HoLEP.
• It should be noted that surgical options are unlikely to be definitive procedures.