EAU Update Series 2 (2004) 15–23

Surgical Treatment of BPH: Technique and Results

Florian May, Rudolf Hartung*
Department of Urology, Klinikum rechts der Isar, Technische Universität München, Ismaningerstr. 22, 81675 Munich, Germany

Abstract
In the past decade, there have been significant changes in the available treatment options for lower urinary tract
symptoms secondary to benign prostatic enlargement. New forms of medical and minimally invasive treatments
have been introduced, while other therapies have become obsolete and well-established surgical treatments are
being reassessed. Standard surgical options include: transurethral resection of the prostate (TURP), transurethral
incision of the prostate (TUIP), and open prostatectomy (adenoma enucleation through a suprapubic transvesical or
a retropubic approach) and a discussion of these treatment options is provided in this article. These techniques can
still be considered the surgical standard for their respective indications to which other therapies should be compared.
The rate of complication is low and the clinical outcome due to removal of the obstruction is excellent and durable
over time.
# 2004 Elsevier B.V. All rights reserved.

Keywords: BPH; TURP; TUIP; Open prostatectomy; Technique; Morbidity

1. Introduction benign prostatic syndrome has been reduced for several

In the first half of the 20th century, two treatment
options were available for BPH—open prostatectomy
and TURP. TURP became the preferred treatment, not
only for severe conditions secondary to BPH, such as
urinary retention and hydronephrosis, but for less
severe yet bothersome symptoms, such as urgency
and frequency. Currently, at the beginning of this
new century, TURP is still the benchmark therapy of
BPH. In the past decade, there have been significant
changes in the available treatment options for BPH.
New forms of medical and minimally invasive treat-
ments have been introduced, while other therapies have
become obsolete and well-established surgical treat-
ments are being reassessed. Due to specific medical
therapy, the frequency of surgical interventions for
Abbreviations: TUIP, transurethral incision of the prostate; TURP,
transurethral resection of the prostate; BPH, benign prostatic hyperplasia;
LUTS, lower urinary tract symptoms; TUR syndrome, transurethral
resection syndrome; I-PSS, International Prostate Symptom Score; ILC,
Interstitial Laser Coagulation; HIFU, high-intensity focused ultrasound;
TUNA, transurethral needle ablation; TUVP, transurethral vaporesection;
VLAP, visual laser ablation
*
Corresponding author. Tel. þ49-89-41402520/21/22;
Fax: þ49-89-41404843.
E-mail address: r.hartung@lrz.tu-muenchen.de (R. Hartung).
1570-9124/$ – see front matter # 2004 Elsevier B.V. All rights reserved.
doi:10.1016/j.euus.2004.02.001
years. Now we observe an increase of surgical inter-
ventions due to long-term failure of medication or
failure of initial non-ablative treatment procedures.
TURP, TUIP and open prostatectomy (adenoma enu-
cleation through a suprapubic transvesical or a retro-
pubic approach) are three surgical standard options for
the treatment of BPH and a discussion of these treat-
ment options is provided in the following section.
Due to improvements of endoscopic instruments and
new high-frequency technology, TURP has become an
increasingly safe procedure. It can now be offered in an
improved form based on innovative high-frequency
technology—Coagulating Intermittent Cutting—and
allows a blood-sparing cut significantly lowering blood
loss and morbidity [1]. During the last decade, TURP
itself has been redefined in terms of outcome and
morbidity and now stands for a safe and minimally
invasive approach. Modified optical devices and video
cameras enable experts and residents to teach and learn
this technique like any open procedure. Although the
incidence of perioperative complications with TURP
has been reduced nowadays, these problems led to
the development of instrumental alternative methods,
aimed at less morbidity. Some of those therapies, intro-
duced since 1990, such as balloon dilatation, transrectal
16 F. May, R. Hartung / EAU Update Series 2 (2004) 15–23
hyperthermia and high-energy focused ultrasound have
already been dropped from the therapeutic arsenal due to
insufficient long-term clinical results. Further alterna-
tive treatments proposed over the years specifically
addressed the issue of intraoperative bleeding by chan-
ging the way radiofrequency energy (vaportrode) or the
type of energy (holmium laser enucleation) is used. In
procedures without immediate removal of necrotic tis-
sue (TUMT, TUNA, VLAP and ILC), the early post-
operative period is characterized by a longer phase of
postoperative urinary retention requiring catherization
in many patients and necrotic tissue being sloughed per
urethra adds also to the early postoperative morbidity.
The detailed quality of life study of this patient group
showed a morbidity shift from the intraoperative to the
postoperative period after less invasive methods [2].
Therefore, some centers combine ILC [3] or laser
resection [4] with TURP. Regarding the failure of
several minimally invasive procedures, long-term data
including the retreatment rate and a careful cost analysis
are of particular importance.
2. Indications for surgery
The correct indication based on clinical symptoms
and reliable objective findings in the evaluation of
benign prostatic obstruction still has crucial impor-
tance for long-term outcome. The risk of needing
surgery for BPH increases with age and with the degree
of clinical symptoms at baseline. Evaluating symptom
severity with a symptom score is an important part of
the initial assessment of a man. It is helpful in allocat-
ing treatment, and both predicting and monitoring the
response to therapy. Among all different validated
symptom score systems, the use of I-PSS (International
Prostate Symptom Score) is recommended. Although
symptoms constitute the primary reason for recom-
mending intervention, there are some absolute indica-
tions for surgical treatment. Contemporary guidelines
on BPH recommend surgery, rather than any of the
other available treatment options, in any of the follow-
ing conditions secondary to BPH [5,6]:
1. refractory urinary retention,
2. recurrent urinary tract infection,
3. recurrent haematuria refractory to medical treat-
ment (finasteride),
4. renal insufficiency,
5. bladder stones.
Increased post-void residual volume is not a useful
criterion, because there is a great intra-individual
variability and an upper limit requiring intervention
has not been defined. Due to its invasive nature and
associated morbidity, cystoscopic examinations or ure-
thral imaging should not be performed routinely prior to
surgery. Although pressure-flow studies are the only
means of diagnosing obstruction accurately, they
remain optional tests in patients presenting with LUTS.
They are regarded as invasive investigations and meth-
odological studies have demonstrated a considerable
variation regarding intraindividual variation in pres-
sure-flow results [7] as well as intra- and interindividual
observer accuracy in interpretation of pressure-flow
curves [8]. Pressure-flow studies should be considered
in specific subgroups, such as suspicion of neurogenic
bladder dysfunction or previous unsuccessful invasive
treatment.
The differential indications for the various surgical
treatment alternatives are not clearly defined. Rando-
mized controlled trials comparing TURP and TUIP
show similar improvements of LUTS in patients with
small prostates (<20–30 ml) and no middle lobe [9].
TURP is the treatment of choice for prostates up to
80–100 ml resection weight. The procedure should be
completed in less than 60 min, because intra- and
postoperative complications are correlated with the
size of the prostate and the length of the procedure.
Patients with large glands (>80–100 ml), large bladder
stones, or if resection of large bladder diverticula is
indicated, are candidates for open surgery.
3. Transurethral incision of the prostate
Instead of removing prostatic tissue, an electrical
knife is used to make incision(s) from inside the bladder
neck down to the verumontanum. These incisions
should be deep enough to penetrate the prostate tissue
down to the prostate capsule [10]. The presence of fat
tissue at the bottom of the incision indicates that the
incision is of the correct depth. Several variations of the
TUIP procedure have been introduced. Traditionally, a
single incision at the 6 o’clock position is performed;
alternatively, bilateral incisions are performed at the 5
and 7 o’clock positions. The operation is fast and less
expensive than other surgical procedures.
4. Transurethral resection of the prostate
TURP is the most frequently used method in patients
requiring instrumental management for benign pro-
static hyperplasia. Various techniques have been sug-
gested for systematic removal of the adenomateous
tissue. They are all based on the principle that the
 F. May, R. Hartung / EAU Update Series 2 (2004) 15–23
resection should be done step by step. In the following
subsection, the resection technique performed at our
institution is described that was initially developed by
Wolfgang Mauermayer [11] and could be improved in
many parts by the authors [12].
4.1. Coagulating Intermittent Cutting
To minimize the risk of bleeding a Coagulating
Intermittent Cutting device with constant voltage
pulses and controlled pulse intervals was developed
at our institution in several steps previously published
[1]: A standard high-frequency generator was extended
in its function by additional electronics (Karl STORZ
GmbH, Tuttlingen, Germany) to the effect that each cut
results in an efficient coagulation zone with excellent
cutting quality. In Coagulating Intermittent Cutting,
phases with predominant cutting effect alternate with
coagulating phases during each cut. The coagulating
effect is achieved by a pulsed output signal using
voltages with high amplitudes. There is a controlled
pause between two pulses: if the necessary power
decreases, the lag between two pulses increases with
less power being delivered to the patient. The different
time periods between the single pulses are shown in
Fig. 1. The impact of Coagulating Intermittent Cutting
on bleeding and blood transfusion rates as well as the
occurrence of the TUR syndrome were evaluated in a
prospective multicenter trial including 778 patients
from 5 different European institutions [13]. Using
Coagulating Intermittent Cutting, blood transfusions
were required in 25 patients (3.2%) and clinical signs
of irrigation fluid absorption were noted in 1.3% of
patients. Regarding the last 100 consecutive patients at
our institution operated with the improved technology,
only 2 patients required blood transfusions. Analysis of
Fig. 1. Coagulating Intermittent Cutting with constant voltage pulses and control of pulse intervals: Oscillogram with representation for voltage and electrical
current.
17
the subgroup of patients who received blood transfu-
sions shows certain characteristic features: Their mean
age was 75 years compared to 61 years within the
whole series (p ¼ 0:0095) and mean resection weight
of patients with transfusions was 57 g compared to 33 g
in the multicenter series (p < 0:005). This series shows
that the standard of TURP is further improved by
Coagulating Intermittent Cutting, which further
decreases the morbidity resulting from blood loss
and the TUR syndrome. The trained surgeon has no
additional learning curve, as classic techniques are
maintained and the procedure can be performed with
standard resection equipment.
4.2. Crucial surgical steps
Resection begins at the proximal portion of the
middle lobe at the 6 o’clock position (Fig. 2) and
should be carried out with long cuts towards the
verumontanum always controlling the end point of
each cut to avoid any damage to the external sphincter.
A large overhanging middle lobe should be resected
with special care, as the surgeon may not be aware that
he is cutting down the trigone towards the ureteric
orifices. Subsequent long cuts should be made next to
each other down to the peripheral tissue to achieve a
smooth surface. The peripheral tissue is recognized as a
rather fibrous structure compared with the granular
appearance of the prostatic adenoma. After resection
of the middle lobe, the area next to the verumontanum
is resected with particular care (Figs. 3 and 4). The
surgeon must always be aware of the position of the
external sphincter to avoid any sphincter lesion. Then
resection is carried to the side lobes. Very sizable side
lobes should be resected using a modified technique:
A cleavage of both side lobes is performed at 9 and 3
18 F. May, R. Hartung / EAU Update Series 2 (2004) 15–23

Fig. 2. Resection begins at the proximal portion of the middle lobe at the 6
o’clock position.

o’clock (Figs. 5 and 6). The groove should be extended

towards the peripheral fibrous prostatic tissue. This
speeds up subsequent resection of the lobes and also
facilitates control of bleeding by coagulation of arterial
branches entering the prostate in this area. Resection of
the apex is carried out with controlled short cuts next to
each other. After thorough resection, the remaining
apical tissue has become quite mobile. Identification
is easy moving the instrument slowly back and forth in
the apical area requiring an empty bladder and full
irrigation fluid pressure (Figs. 7 and 8). Beginning next
to the verumontanum, the whole apex is resected in a
clockwise manner. The apical tissue is resected by
controlled short cuts to create a round or oval apical
outlet. Complete control of the full excursion of the
loop is mandatory to restrict each cut to the remaining
apical tissue. The hydraulic sphincter test should be
repeated occasionally for a clear identification of the
external sphincter. The verumontanum is located within
the prostate and not at its extreme distal end. Therefore,
adenomatous tissue can be safely resected lateral and
Figs. 3 and 4. Resection of the area next to the verumontanum.
even distal to the verumontanum without jeopardizing
the external sphincter mechanism. Especially after
resection of small adenomas and in patients with a in the prostatic fossa. Final balloon inflation that should
deep recessus vesicalis, bilateral incisions of the sphinc- fill the prostatic fossa corresponds to the weight of the
ter internus area are done at 5 and 7 o’clock positions, to resected adenoma (Fig. 10).
prevent formation of a bladder neck contracture (Fig. 9).
Adequate depth of the incision is indicated by visua-
lization of fibers from the prostatic capsule or even 5. Suprapubic prostatectomy
protrusion of periprostatic fat. For drainage, we prefer
to place a 20 Fr 3-way catheter. It should always be Suprapubic prostatectomy is the enucleation of the
inserted with the finger in the rectum pressing tissue up hyperplastic prostatic adenoma through an extraperito-
to avoid damage to the bladder neck andd trigone. The neal incision of the lower anterior bladder wall (Fig. 11).
balloon inflated to 20–30 ml, the catheter is withdrawn This approach to open prostatectomy was made popular
 F. May, R. Hartung / EAU Update Series 2 (2004) 15–23
Figs. 5 and 6. Cleavage of sizable side lobes.
by Peter Freyer of London, England, who described the
procedure in Lancet in 1900 [14]. The major advantage
of this procedure over the retropubic approach is that it
allows for greater visualization of the bladder neck and
bladder. As a result, this operation is ideally suited for
patients who have (1) a large median lobe protruding
into the bladder; (2) a concomitant, symptomatic blad-
der diverticulum; or (3) a large bladder calculus.
5.1. Crucial surgical steps
After exposure of the bladder neck and circumfer-
ential incision of the mucosa, the enucleation is done
under digital control with special care. By using the
index finger of the dominant hand, the plane between
the adenoma (i.e. transition zone) and the surgical
capsule (i.e. compressed peripheral zone) must be
clearly identified. This is imperative, as otherwise
either adenomateous tissue is left behind or, by perfor-
ating through the surgical capsule or the peripheral
19
Figs. 7 and 8. Residual apical tissue.
zone, it is possible to remove the posterior structures,
including the seminal vesicles, together with the ade-
noma. The urethra can be divided at the apex by
pinching it between two fingers or by sharp transection.
A large intravesical lobe often requires sharp dissection
at the level of the bladder neck; great care is necessary
in order that neither the ureteral orifices nor the ureters
are injured. After removal of the adenoma, the fossa
is packed with a warm moist vaginal pack. Deep
sutures including the main prostatic arteries are placed,
avoiding the ureteral orifices. If haemostasis is less than
20 F. May, R. Hartung / EAU Update Series 2 (2004) 15–23
Fig. 9. Incision of the sphincter internus.
adequate, consider plication sutures of the prostatic
fossa and in case of severe haemostasis, insert the
resectoscope and try to fulgurate bleeding vessels [15].
6. Retropubic prostatectomy
Retropubic prostatectomy is the enucleation of
the hyperplastic prostatic adenoma through a direct
Fig. 10. Catheter drainage.
Fig. 11. Suprapubic prostatectomy (Freyer) [From J. Sökeland, editor,
Benigne Prostata-Hyperplasie, Georg Thieme Verlag 1995, with permis-
sion].
incision of the anterior prostatic capsule (Fig. 12). This
approach was made popular by Terrence Millin, who
reported the results of the procedure on twenty patients
in Lancet in 1945 [16]. The incision in the capsule
allows for improved exposure and inspection of the
prostatic fossa to control bleeding. This is offset by an
increased risk of intraoperative problems due to injury
and bleeding from the dorsal vein complex of Santorini.
Fig. 12. Retropubic prostatectomy (Millin) [From J. Sökeland, editor,
Benigne Prostata-Hyperplasie, Georg Thieme Verlag 1995, with permis-
sion].
 F. May, R. Hartung / EAU Update Series 2 (2004) 15–23
The advantages of this procedure over the suprapubic
approach are (1) excellent anatomic exposure of the
prostate, (2) direct visualization of the prostatic ade-
noma during enucleation to ensure complete removal,
(3) precise transection of the urethra distally to preserve
urinary continence, (4) clear visualization of the pro-
static fossa after enucleation to control all bleeding
sites, and (5) minimal to no trauma to the urinary
bladder.
6.1. Crucial surgical steps
After exposure of the prostate and prior to proceed-
ing with enucleation of the adenoma, it is important to
achieve complete control of the dorsal vein complex as
well as the lateral pedicles at the bladder neck [17]. The
capsule is incised in a transverse orientation with
electrocautery. It is imperative that the plane between
the surgical capsule (i.e. peripheral zone) and the
adenomateous tissue (i.e. transition zone) is identified
correctly to facilitate enucleation of the adenoma.
Curved scissors may help to develop the plane between
the capsule and the adenomateous tissue, but in general
the index finger of the dominant hand is used to
enucleate the adenoma. Similar to suprapubic prosta-
tectomy, the urethra may be transected sharply and it is
possible to lift the adenoma out of the wound with the
help of Babcock clamps, facilitating either blunt or
sharp dissection and transection of the adenoma at the
bladder neck.
7. Morbidity
7.1. Early complications
Historically, TURP is an invasive surgical procedure
with the risk of blood loss and irrigation fluid absorp-
tion [18]. Using Coagulating Intermittent Cutting
representing an improved high-frequency technology,
the rates of blood transfusions and TUR syndromes
were significantly reduced compared to standard
TURP data in our series [13]. Therefore, we meanwhile
have abandoned routine alcohol absorption tests for
intraoperative control of irrigation fluid absorption.
The risk of a TUR syndrome (fluid intoxication, serum
Naþ <125 nmol/l) is in the range of 2%. Risk factors
are excessive bleeding with opening of large sinuses,
prolonged operation time and large glands. There is an
increased risk of blood transfusions in open prostatect-
omy ranging from 5 to 9% in contemporary series
[19,20], while the risk of blood transfusions in TUIP is
negligible [9]. Even men older than 80 years of age
benefit from TURP due to its low morbidity in con-
temporary series [21]. The perioperative mortality rate
21
has decreased from 2.5% in 1962 [22] and is less than
0.25% today [18,23].
7.2. Late complications
Complications following suprapubic prostatectomy
include excessive hemorrhage and urinary extravasa-
tion in the postoperative period. Potential long-term
complications include urge or stress urinary inconti-
nence, bladder neck contracture, retrograde ejaculation
and erectile dysfunction. All are rare except for retro-
grade ejaculation, which occurs in most patients. Stress
urinary incontinence is rare and usually results from
perforation and partial avulsion of the prostatic cap-
sule, avulsion of the urethra at the apex of the prostate,
or both. With careful enucleation of the adenoma, the
capsule will not be perforated. With sharp excision of
the urethra at the apex rather than avulsion, stress
incontinence should not occur. Urethral stricture and
bladder neck contracture are uncommon following
suprapubic prostatectomy due to the suprapubic
approach and the size of the adenoma removed. Erec-
tile dysfunction should not develop unless the capsule
has been violated.
In retropubic prostatectomy with precise enucleation
of the prostatic adenoma under direct vision, risk of
injury to the external sphincter is minimal. In men who
have a relatively small bladder neck at the end of the
operation, it may be appropriate to perform a wedge
resection and advance the bladder mucosa into the
prostatic fossa to prevent bladder neck contracture.
As with any pelvic surgery, there is a risk of deep vein
thrombosis and pulmonary embolus.
Late complications after TURP mainly consist in
stress incontinence, bladder neck contractions, urethral
strictures and erectile dysfunction. Stress incontinence
as caused by sphincter damage occurs in less than 1%
of patients after TURP [27]. The incidence of urethral
stricture is highly variable in the peer review literature
and ranges from 0.5% to 6.3% [27]. Retrograde eja-
culation resulting from the destruction of the bladder
neck is reported in 80% after open prostatectomy, 65–
70% after TURP and 40% after TUIP [24]. The inci-
dence of complications is lowest in TUIP treated
patients. Retrograde ejaculation can be further pre-
served in TUIP by limiting the lowermost part of
the incision above the verumontanum. There is no
consensus on the impact of surgical interventions,
particularly TURP, on erectile function. The only
randomized controlled trial comparing TURP to ‘‘wait
and see’’ reported identical rates of erectile dysfunction
in both arms [25] and a recent study involving surgical
intervention suggests a potential for improvement of
sexual function by reducing symptoms of BPH [26].
22 F. May, R. Hartung / EAU Update Series 2 (2004) 15–23
8. Long-term outcome and retreatment rate
TUIP, TURP and open prostatectomy are character-
ized by immediate treatment success due to the
removal of the obstruction combined with excellent
long-term outcome. Results are superior to medical or
minimally invasive treatment. They give the patient a
mean probability of symptomatic improvement of over
70%, with open prostatectomy producing a slightly
superior outcome [24]. The rate of secondary inter-
vention is the essential parameter for evaluating long-
term efficacy and the incidence of secondary interven-
tion after TURP is well documented. In a multicenter
study of 39,077 patients undergoing TURP, the rate of
reintervention after TURP increased from 2.3 to 4.3%
within 12 months after surgery to 8.9–9.7% after 5
years and to 12.0–15.5% 8 years after surgery [28]. The
need for secondary intervention is substantially higher
for minimally invasive techniques. Schatzl et al.
demonstrated that up to 25% of all patients initially
treated by less invasive procedures (HIFU, TUNA,
TUVP and VLAP) ended up with TURP within 2 years
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CME questions
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then be attributed automatically.
1. TURP should commence with:
A. resection of the area next to the verumonta-
num;
B. resection of the middle lobe;
C. resection of the side lobe;
D. resection of the apex.
2. An absolute indication for surgical treatment of
BPH is:
A. post-void residual urine volume of 250 ml;
B. recurrent urinary tract infection secondary to
BPH;
23
[26] Brookes ST, Donovan JL, Peters TJ, Abrams P, Neal DE. Sexual
dysfunction in men after treatment for lower urinary tract symptoms:
evidence from randomised controlled trial. BMJ 2002;324:1059–64.
[27] Tubaro A, Vicentini C, Renzetti R, Miano L. Invasive and minimally
invasive treatment modalities for lower urinary tract symptoms: what
are the relevant differences in randomised controlled trials? Eur Urol
2000;38(Suppl 1):7–17.
[28] Roos NP, Wenneberg JE, Malenka DJ, et al. Mortality and
reoperation after open and transurethral resection of the prostate
for benign prostatic hyperplasia. N Engl J Med 1989;320:1120–4.
[29] Schatzl G, Madersbacher S, Djavan B, Lang T, Marberger M. Two-
year results of transurethral resection of the prostate versus four ‘‘less
invasive’’ treatment options. Eur Urol 2000;37:695–701.
C. International Prostate Symptom Score of 20 or
greater;
D. urodynamically assessed outflow obstruction.
3. What is the most common adverse event related to
the open prostatectomy?
A. erectile dysfunction;
B. retrograde ejaculation;
C. stress urinary incontinence;
D. deep vein thrombosis.
4. The suprapubic approach to prostatectomy is ideal
for the patient with a large prostatic adenoma and:
A. multiple small bladder calculi;
B. erectile dysfunction;
C. a symptomatic bladder diverticulum;
D. concomitant ureteral calculi.