# BPH Surgical Management: TURP and Laser Enucleation

## Introduction

Surgical treatment for benign prostatic hyperplasia (BPH) becomes necessary when medical therapy either fails or is not tolerated, or when absolute surgical indications arise. These indications include refractory urinary retention, recurrent urinary tract infections, bladder stones, renal insufficiency caused by obstruction, and recurrent gross hematuria. For over 80 years, transurethral resection of the prostate (TURP) has been the gold standard surgical approach. However, holmium laser enucleation of the prostate (HoLEP) and thulium laser enucleation (ThuLEP) have recently emerged as effective, size-independent alternatives. These laser techniques provide outcomes that are equivalent or superior to TURP, with reduced morbidity.

## Transurethral Resection of the Prostate (TURP)

### Technique

TURP can be performed using either monopolar or bipolar energy sources. Monopolar TURP (M-TURP) employs a cutting loop that delivers monopolar current through a resectoscope. This technique requires a hypotonic irrigant such as 1.5% glycine, sorbitol, or mannitol to conduct the electrical current. In contrast, bipolar TURP (B-TURP) passes current between active and return electrodes located on the resectoscope itself, allowing the use of normal saline as the irrigant. This eliminates the risk of TUR syndrome associated with hypotonic fluids. During the procedure, resection is performed from the bladder neck down to the verumontanum, with tissue chips evacuated and sent for pathological examination. The optimal prostate size for TURP, according to AUA guidelines, ranges from 30 to 80 grams; larger prostates increase operative time and the risk of complications. Hemostasis is achieved using coagulation current, with careful control of bleeding at the bladder neck and arterial vessels.

### Outcomes

TURP results in a significant improvement in symptoms, with a 70-80% reduction in the International Prostate Symptom Score (IPSS) and an increase in maximum urinary flow rate (Qmax) of 10-15 mL/s. The retreatment rate ranges from 5 to 15% over 8 to 10 years. Additionally, incidental prostate cancer is detected in 5-10% of TURP specimens.

### Complications

TUR syndrome is a complication unique to monopolar TURP and results from the absorption of hypotonic irrigant leading to hyponatremia. Patients may present with confusion, nausea, visual disturbances, bradycardia, and hypertension, with an incidence of 1-2%. Treatment involves stopping the procedure, administering loop diuretics, and using hypertonic saline (3%) for severe symptoms. Limiting monopolar resection time to less than 90 minutes helps reduce this risk. Bleeding occurs in 2-5% of cases requiring transfusion, with higher rates seen in larger glands and longer surgeries. Retrograde ejaculation is the most common long-term side effect, occurring in 65-75% of patients. Erectile dysfunction occurs in 5-10% of cases, although this is controversial and may reflect pre-existing conditions. Urethral strictures develop in 3-5% of patients, bladder neck contractures in 2-5%, and urinary incontinence is rare (<1%), as sphincter injury is uncommon if resection stops at the verumontanum.

<image>Intraoperative view through a resectoscope during TURP showing the cutting loop resecting prostatic adenoma tissue from the 5 o'clock position, with the verumontanum visible distally as the landmark for the distal limit of resection, and the bladder neck visible proximally with coagulated tissue edges</image>

## Holmium Laser Enucleation of the Prostate (HoLEP)

### Principles

HoLEP utilizes a holmium:YAG laser with a wavelength of 2140 nm, which is strongly absorbed by water, resulting in a shallow penetration depth of 0.4 mm. This allows for precise cutting combined with excellent hemostasis. The enucleation technique mimics open simple prostatectomy by separating the adenoma from the surgical capsule along an anatomic plane and then pushing the adenoma into the bladder. The enucleated tissue is then retrieved from the bladder using a mechanical morcellator, providing a complete specimen for histologic analysis.

### Technique

The procedure can be performed using either a three-lobe or two-lobe technique, with key anatomical landmarks including the verumontanum, ureteral orifices, and bladder neck. Typically, the median lobe is enucleated first, followed by retrograde separation of the lateral lobes from the capsule toward the bladder neck. Laser settings generally range from 80 to 120 watts (2 joules at 40-60 Hz) for enucleation. HoLEP is size-independent and effective for prostates of any size, including those greater than 100 grams, making it the endoscopic equivalent of open prostatectomy.

### Outcomes

HoLEP achieves symptom improvement comparable to TURP and open prostatectomy, with IPSS reductions similar to these techniques. The maximum urinary flow rate improves by 15-20 mL/s. Retreatment rates are less than 2% at 5 to 10 years, significantly lower than those seen with TURP. Catheterization time is typically 24 to 48 hours, and hospital stays are shorter compared to TURP. The ability to retrieve a complete histologic specimen is an advantage over vaporization techniques.

### Advantages Over TURP

HoLEP eliminates the risk of TUR syndrome by using saline irrigant and results in less bleeding with lower transfusion rates, making it safe for patients on anticoagulation. It is effective regardless of prostate size, thereby eliminating the need for open prostatectomy in large glands. The technique allows for more complete adenoma removal and has a lower long-term retreatment rate.

### Disadvantages

The main drawbacks of HoLEP include a steep learning curve, requiring 30 to 50 cases to achieve proficiency. Morcellation carries a rare risk of bladder injury. Operative times are longer initially during the learning phase. Transient dysuria and urgency are common in the first few weeks after surgery.

<image>Step-by-step illustration of HoLEP technique showing: (1) incision at the apex near the verumontanum with holmium laser fiber, (2) retrograde enucleation of the median lobe along the surgical capsule plane, (3) lateral lobe enucleation with laser fiber dissecting between adenoma and capsule, and (4) morcellation of enucleated tissue floating in the bladder</image>

## Thulium Laser Enucleation (ThuLEP)

ThuLEP uses a thulium:YAG laser with a wavelength of 1940 nm that operates in continuous wave mode, allowing for finer cutting with less tissue charring compared to holmium laser. The technique is essentially identical to HoLEP, involving enucleation along the surgical capsule. Randomized trials have demonstrated outcomes comparable to HoLEP. ThuLEP may offer a smoother enucleation plane and less tissue disruption due to its continuous wave output. Although its adoption is growing, ThuLEP has less long-term data available than HoLEP.

## Photoselective Vaporization of the Prostate (PVP/GreenLight)

Photoselective vaporization employs a potassium-titanyl-phosphate (KTP) or lithium triborate (LBO) laser with a wavelength of 532 nm, which is absorbed by hemoglobin to vaporize prostatic tissue. The current standard system delivers 180 watts of power. PVP offers excellent hemostasis and is safe for patients on anticoagulation, using saline as the irrigant. However, it does not provide tissue specimens for pathological analysis and is less durable than enucleation techniques, with retreatment rates of 6-11% at 5 years. PVP is best suited for prostates sized between 30 and 80 grams and for patients requiring anticoagulation.

## Open Simple Prostatectomy

Open simple prostatectomy can be performed via the Millin retropubic or Freyer suprapubic/transvesical approaches. This surgery is reserved for prostates larger than 80 to 100 grams when laser enucleation is not available. It provides excellent long-term outcomes with retreatment rates below 2%. However, it is associated with higher morbidity, including blood loss ranging from 300 to 1000 mL, longer catheterization times of 5 to 7 days, and hospital stays of 3 to 5 days. Increasingly, open prostatectomy is being replaced by robotic-assisted simple prostatectomy and HoLEP.

## Robotic-Assisted Simple Prostatectomy (RASP)

Robotic-assisted simple prostatectomy replicates the open simple prostatectomy through a minimally invasive approach. It reduces blood loss and shortens hospital stay compared to open surgery. This technique is suitable for prostates larger than 80 grams when HoLEP expertise is unavailable. Its adoption is growing, and it provides functional outcomes comparable to open prostatectomy.

## Selection of Surgical Approach

The choice of surgical technique depends largely on prostate size. For prostates smaller than 30 grams, options include transurethral incision of the prostate (TUIP), UroLift, and Rezum (covered in lecture 51). For prostates between 30 and 80 grams, bipolar TURP, HoLEP, and GreenLight PVP are recommended. Prostates sized 80 to 150 grams are best managed with HoLEP or ThuLEP, robotic-assisted simple prostatectomy, or open simple prostatectomy. For very large prostates greater than 150 grams, HoLEP, ThuLEP, or open simple prostatectomy are preferred.

| Prostate Size | Recommended Surgical Options |
|---|---|
| <30 g | TUIP, UroLift, Rezum |
| 30-80 g | Bipolar TURP, HoLEP, GreenLight PVP |
| 80-150 g | HoLEP/ThuLEP, RASP, open simple prostatectomy |
| >150 g | HoLEP/ThuLEP, open simple prostatectomy |

| Procedure | Retreatment Rate | Retrograde Ejaculation | TUR Syndrome Risk | Tissue Specimen |
|---|---|---|---|---|
| Monopolar TURP | 5-15% at 8-10 yrs | 65-75% | 1-2% | Yes |
| Bipolar TURP | 5-15% at 8-10 yrs | 65-75% | None (saline irrigant) | Yes |
| HoLEP | <2% at 5-10 yrs | 75-90% | None (saline irrigant) | Yes |
| GreenLight PVP | 6-11% at 5 yrs | 25-50% | None (saline irrigant) | No |
| Open simple prostatectomy | <2% | 75-90% | None | Yes |

<image>Comparison table with anatomic diagrams showing the key differences between TURP (resection of tissue chips from the surface inward), HoLEP (enucleation of intact lobes along the surgical capsule), and PVP (vaporization of tissue without specimen retrieval), with relative advantages and retreatment rates listed</image>

## Key Clinical Pearls

Bipolar TURP has largely replaced monopolar TURP because it eliminates the risk of TUR syndrome while maintaining equivalent efficacy. HoLEP is size-independent and serves as the endoscopic equivalent of open prostatectomy, making it the preferred technique for large prostates when surgical expertise is available. The verumontanum is a critical distal landmark during resection or enucleation; extending beyond it risks injury to the external sphincter and subsequent incontinence. Retrograde ejaculation is the most common complication after both TURP and HoLEP, so patients, especially those desiring fertility, should be counseled preoperatively. Tissue should always be sent for pathological examination, as incidental prostate cancer is found in 5-10% of TURP and HoLEP specimens. Finally, TUR syndrome is a complication specific to monopolar TURP and can be avoided by using bipolar TURP or laser enucleation techniques.

## References

1. Foster HE, Barry MJ, Dahm P, et al. Surgical management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline. *J Urol*. 2018;200(3):612-619.  
2. Cornu JN, Ahyai S, Bachmann A, et al. A systematic review and meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic obstruction: an update. *Eur Urol*. 2015;67(6):1066-1096.  
3. Gilling PJ, Wilson LC, King CJ, et al. Long-term results of a randomized trial comparing holmium laser enucleation of the prostate and transurethral resection of the prostate: results at 7 years. *BJU Int*. 2012;109(3):408-411.  
4. Kuntz RM, Lehrich K, Ahyai SA. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. *Eur Urol*. 2008;53(1):160-168.