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in one study probably related to more significant comorbidities in the TURP patients compared with the patients who received open surgical treatment Several other studies could not confirm the difference in mortality when controlling for age and comorbidities The risks of TURP include retrograde ejaculation (75%), impotence (5 10%), and urinary incontinence (< 1%) Complications include bleeding, urethral stricture or bladder neck contracture, perforation of the prostate capsule with extravasation, and, if severe, transurethral resection syndrome, a hypervolemic, hyponatremic state resulting from absorption of the hypotonic irrigating solution Clinical manifestations of the syndrome include nausea, vomiting, confusion, hypertension, bradycardia, and visual disturbances The risk of transurethral resection syndrome increases with resection times over 90 minutes Treatment includes diuresis and, in severe cases, hypertonic saline administration 2 Transurethral incision of the prostate (TUIP) Men with moderate to severe symptoms and small prostates often have posterior commissure hyperplasia or an elevated bladder neck These patients will often benefit from incision of the prostate The procedure is more rapid and less morbid than TURP Outcomes in well-selected patients are comparable, though a lower rate of retrograde ejaculation has been reported (25%) 3 Open simple prostatectomy When the prostate is too large to remove endoscopically, open enucleation is necessary What size is too large depends upon the surgeon s experience with TURP Glands over 100 g are usually considered for open enucleation In addition to size, other relative indications for open prostatectomy include concomitant bladder diverticulum or bladder stone and whether dorsal lithotomy positioning is or is not possible Open prostatectomies can be performed with either a suprapubic or retropubic approach Simple suprapubic prostatectomy is performed transvesically and is the operation of choice if there is concomitant bladder pathology After the adenoma is removed, both a urethral and a suprapubic catheter are inserted prior to closure In simple retropubic prostatectomy, the bladder is not entered but rather a transverse incision is made in the surgical capsule of the prostate and the adenoma is enucleated as described above; only a urethral catheter is needed at the end of the case.

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1 Laser therapy Several different coagulation necrosis techniques have been utilized Transurethral laser-induced prostatectomy (TULIP) is performed under transrectal ultrasound guidance The instrument is placed in the urethra and transrectal ultrasound is used to direct the device as it is slowly pulled from the bladder neck to the apex The depth of treatment is monitored with ultrasound Most urologists prefer to use visually directed laser techniques Visual coagulative necrosis is performed under cystoscopic control, and the laser fiber is pulled through the prostate at several designated areas depending upon the size and configuration of the gland Four-quadrant and sextant

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1 Transurethral resection of the prostate (TURP) Ninety-five percent of simple prostatectomies can be performed endoscopically Most of these procedures are performed under a spinal anesthetic and require a 1- to 2-day hospital stay Symptom scores and flow rate improvement are superior following TURP relative to any minimally invasive therapy; however, the length of the hospital stay is greater Much controversy revolves around possible higher rates of morbidity and mortality associated with TURP in comparison with open surgery, but the higher rates observed

dard loop, this procedure usually takes longer than a standard TURP Long-term comparative data are needed 4 Hyperthermia Microwave hyperthermia is most commonly delivered with a transurethral catheter Some devices cool the urethral mucosa to decrease the risk of injury However, if temperatures do not go above 45 C, cooling is unnecessary Symptom score and flow rate improvement are obtained, but (as with laser surgery) large randomized studies with long-term follow-up are needed to assess durability and cost-effectiveness

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