Prostate Surgery

Transurethral Incision Of the Prostate (TUIP)

Throughout the 20th century, the best treatment for benign prostatic hyperplasia (BPH) was TURP. This is short for transurethral resection of the prostate. It was the first minimally-invasive surgery to be successful in treating BPH.

Nowadays, TURP is still the standard treatment when everything else fails. However, new medical therapy options are becoming available and doing their job. So, the immediate need for surgical treatment is significantly reduced.

There’s a problem with alpha-blockers and similar treatment, though. They do not change the prostate size and won’t modify the rate of prostate growth. That’s why they fail to alleviate BPH symptoms in some patients. They still experience urinary retention and other bladder outlet obstruction symptoms.

But what if a patient has underlying medical conditions? What if they are not suitable for TURP or have a relatively small prostate? Transurethral incision of the prostate is an alternative in these cases. This procedure has been a useful alternative to TURP for many years. It causes fewer side effects and can be performed under local anesthesia. 

This article will explore details of this procedure and what you should expect as a patient.

What is TUIP?

TUIP is short for Transurethral incision of the prostate. It is a minimally-invasive surgical procedure to treat benign prostatic hyperplasia. This procedure is easy to do and does not require many tools or several surgeons.

It is performed under local anesthesia or spinal anesthesia. In some cases, general anesthesia will be recommended for some patients.

This procedure requires placing an instrument into the urethra. With this instrument, your surgeon will make a bladder neck incision near the prostate. It is the area where the prostate connects to the bladder. In this area, some muscles contract the urethra. Thus, they create resistance to the urine flow. In TUIP, the doctor will cut through these muscles and reduce the opposition (1).

Throughout the procedure, you will not have the prostate or part of the prostate removed. No prostate tissue will be taken out.

Why is it done?

TUIP is a suitable alternative for TURP in some patients, but not in others. Since no prostate tissue will be taken out, it works for men with a slightly enlarged prostate. It is not appropriate when the prostate is very large. 

Since TUIP is a surgical procedure, it won’t be offered to a patient with other alternatives. If your symptoms are easily managed by medical treatment, you won’t likely require TUIP. If you have a slightly enlarged prostate but no symptoms, you definitely don’t need TUIP. Two main conditions should be met: patients should have urinary symptoms and only a slightly enlarged prostate.

Transurethral incision of the prostate is also performed in men with a high risk of complications. For example, in older men who can’t receive general anesthesia or with an increased risk of bleeding. Males with serious health problems may also receive TUIP as an alternative (1). 

In younger males, TUIP is more recommended than TURP in mild or moderate BPH. In contrast to TURP, transurethral incision of the prostate has a lower risk of retrograde ejaculation. This is a condition in which the patient ejaculates during the climax, but semen is not propelled to the outside. Instead, it has a backward flow into the urinary bladder.

Your doctor might recommend TUIP if you have mild to moderate prostate enlargement and symptoms such as:

  • Urinary urgency: It is an urgent sensation of voiding that may be associated with urinary incontinence, too.

  • Difficulty to start urinating: When you need to push very hard to initiate urination.

  • Sensation of incomplete voiding: When you’re apparently done voiding but feel that the bladder is still holding urine.

  • Recurrent urinary tract infections: This is associated with other prostate complications, especially chronic bacterial prostatitis. BPH may also contribute to an abnormal urine flow and a higher risk of infection.

Indications

According to the European Association of Urology, prostate patients may undergo TUIP only if:

  • The prostate volume is not higher than 30 cm3 (assessed through transrectal ultrasonography)

  • The prostate does not have a median lobe

TUIP can also be indicated after TURP. For example, a patient who had a bladder neck obstruction after prostate resection. The same may happen after transvesical adenomectomy (2). As a rare indication, we can also consider TUIP to treat a cyst in the urethra (3).

Additionally, according to medical experience, it can also be indicated when the prostate is larger, but the patient is not a TURP candidate. Even patients with a bulky prostate adenoma may benefit from the procedure. However, the TUIP technique should be modified in these cases. The incision is usually deeper, sometimes going through the prostate capsule. When this happens, the patient has more profuse bleeding. Thus, every case should be evaluated individually to prevent this outcome (4).

What are the risks?

Before undergoing a medical procedure, your doctor should talk about the risks. Even not doing anything has an associated risk. So, medical decisions are made considering both risks and benefits.

As noted above, the risks associated with transurethral incision of the prostate are lower. They are recommended when TURP is likely to cause more harm than benefit. This procedure has more cases of bleeding and blood electrolytic disorders. It also causes erectile dysfunction and retrograde ejaculation in some cases (5).

TUIP is an excellent alternative because the risk is much lower. For example, if TURP causes retrograde ejaculation in 50-95% of cases, the incidence lowers to 10% in TUIP.

Still, there is a risk of experiencing complications. We can divide them into intraoperative complications and postoperative complications. The former includes problems during the procedure. The latter include problems after the procedure is done.

Intraoperative complications

The operating time is short, and the procedure is not complicated. This shortens the list of intraoperative complications. However, some doctors have reported only one complication. It is very uncommon, though:

  • Uncontrolled bleeding: It is more common when the incision is deep in senior patients. Still, the need for blood transfusion is much lower than TURP. Around 20% of patients have bleeding problems during TURP. But only 1.6% have the same problem during TUIP (6).

Postoperative complications

The rate of postoperative complications is also lower. Some of them have been reported, though (7):

  • Transient urinary retention: In some cases, a blood clot forms in the urethra. It causes temporary urinary retention in a minimal proportion of patients. Around 1% of patients have this problem.

  • Retrograde ejaculation: It is also a possibility, but more unlikely as compared to TURP. Around 6% of patients have this problem.

  • Erection problems: This is pretty unlikely after TUIP. Only 4% of patients have this problem. The incidence is much higher in transurethral resection of the prostate.

  • Incontinence: This is also a very rare adverse event. Around 1% of patients report incontinence. It is usually urgency incontinence, but also overflow incontinence.

  • Recurrence of urinary symptoms: Some patients may develop new urinary symptoms after some time. 10% of them require a second operation after 15 years.

Is there any other alternative?

TUIP does not have as many risks as TURP. However, you may want to explore other options as well. You can discuss with your doctors the alternatives. For example:

  • Holmium laser enucleation of the prostate: It’s a laser therapy to cut away prostate tissue. This relieves pressure upon the urethra and improves the symptoms.

  • Transurethral laser vaporization or resection of the prostate: This is another alternative to TURP. It burns away the excess tissue of the prostate instead of taking it out.

  • Prostatic urethral lift: This procedure does not require taking out the prostate, either. It is an implant that keeps the prostate far from the urethra. The pressure is relieved, and the urethra is not blocked.

Keep in mind that these procedures are not available for everyone. Similar to TUIP, you need to fulfill a few requisites. Otherwise, it could be not effective or might be dangerous for you. So, the best recommendation would be to discuss the benefits and risks of each one with your doctor.

What are the benefits?

If your doctor recommends TUIP, it is because the benefits outweigh the risks. In most cases, this is the most likely event. TUIP improves urinary symptoms in most men. According to literature, around 8 out of 10 men feel much better after recovery.

There are many ways to measure urinary symptom severity. One of them is known as the American Urological Association Symptom Index Score. It uses different questions and assessments and gives you a number or symptom score. Around 70% of patients have a significant improvement in this score (7). 

To give you an idea, here’s an example. If you had severe symptoms with a score of 25 before surgery, you’re likely to end up with mild symptoms with a score of 7. Of course, this is only an example. Real improvement depends on different factors, and every patient is different from the rest.

Compared to TURP, the outcome is basically the same for selected patients. In other words, if you’re chosen appropriately, you’re very likely to have excellent results. But at the same time, you won’t have as many side effects. This is a tremendous benefit for young patients with urinary symptoms, especially for patients who are worried about their sexual health after surgery.

How can you prepare for the procedure?

Your doctor will give you clear instructions before surgery to maximize the outcome. This is what you need to consider:

  • You may need to discontinue some medications: Some medications can increase your risk of bleeding. An obvious example is warfarin, clopidogrel, and similar blood-thinning medications. But some pain relievers may also have the same effect. For example, ibuprofen, aspirin, and naproxen sodium. They have a relative blood-thinning effect. You need to discontinue this type of medication several days before the procedure.

  • You may need to take an antibiotic: Taking an antibiotic before the surgery reduces the risk of urinary tract infections. The risk is low if you take the antibiotic as instructed by your doctor.

  • Arrange transportation: After surgery, you won’t be able to drive back home. Thus, it is imperative to arrange transportation before surgery. After the surgery, you will stay with a catheter in the bladder. Driving is also uncomfortable in this situation. So, you might also need to arrange transportation or program some rest days after surgery.

  • Limit physical activity: This is a minimally-invasive procedure. But it is still surgery, and you will go through recovery time. Your doctor will tell you how much time you need to stay away from physical activity. It is usually around 6 weeks. You might also need to stay away from your job, so make your arrangements beforehand. 

What to expect

If you’re going through a transurethral incision of the prostate, you won’t likely have many problems during and after surgery. It is a minimally-invasive procedure. Depending on each case, you might stay awake during the procedure or not. It is a very fast surgery, and you will leave the doctor’s office with a catheter placed.

It is usually very fast, and you might need to stay overnight to make sure that everything is alright. After that, you want to follow your doctor’s advice to recover properly.

During the procedure

Anesthesia is a common concern in surgery patients, but not in TUIP. This procedure is often done with regional anesthesia. In other words, you will be awake and only feel numbness from the waist down. But in other cases, general anesthesia may be preferred. It depends on the hospital and your particular circumstances.

After the anesthesia takes effect, the procedure begins. The doctor will probe inside the urethra and reach the space where the prostate is located. Your surgeon will be able to see everything through a small video camera at the far end of the probe. When he reaches the prostatic urethra, he will make two small incisions. They are meant to relieve pressure upon the prostate gland.

Right after that, he will take out the probe and insert a Foley catheter. Through the catheter, any trace of blood clots will be taken out. If nothing unexpected happens, this marks the end of the procedure. After that, you will be released to recovery.

After the procedure

After TUIP, you will be taken to a recovery area for a few hours. Recovering from anesthesia can be uncomfortable, and you may feel a bit dizzy. Keep in communication with the nurse team if you feel anxious or have unexpected symptoms. 

After the effect of anesthesia is gone, you will likely stay overnight in the hospital. This is a period of observation to make sure that everything is going alright. After one day has passed and nothing unexpected happens, you will be discharged. Before going home, your doctor will give you several instructions. Take notes, ask questions, and do as told.

Before going back home, it is crucial to understand clearly these aspects of recovery:

  • The approximate recovery time based on your particular case

  • When you can go back to work, based on what you do

  • What types of day-to-day activities are you able to do during recovery?

  • When is it appropriate to resume sports and strenuous activities?

  • Warning signs and symptoms that you need to watch for

  • When is your doctor removing the urinary catheter?

Results

Transurethral incision of the prostate has an impressively high satisfaction rate. According to some studies, it is placed in 94%. This means that close to 10 out of 10 patients are satisfied after the procedure. In this regard, the results are clearly superior to those of TURP (8).

A satisfaction score is essential, but it is subjective. Urodynamic exams and pressure-flow studies are useful objective tools to assess the results. They also reveal a significant difference in urinary flow and detrusor pressure (9). 

Both subjectively and objectively, the results tend to be very positive. Thus, if you’re a suitable candidate for TUIP, you’re very likely to benefit significantly from the procedure.

Conclusion

Males can experience lower urinary tract symptoms, even with a relatively small prostate. Prostate surgery can be an option for these patients. But transurethral incision of the prostate (TUIP) is better than transurethral resection of the prostate (TURP) in mild BPH. It is not appropriate for prostate cancer and may not alleviate severe BPH symptoms.

Candidates for TUIP are usually younger and feel worried about sexual health problems after surgery. They may also have fragile health and not be the right candidate for TURP. Either way, this procedure is very fast and has a lower risk of complications. If you’re a candidate for TUIP, the satisfaction score is very high, and you will likely feel much better after surgery.

Sources

  1. Geavlete, P., Niţă, G., Persu, C., & Geavlete, B. (2016). Endoscopic Incision of the Prostate (TUIP). In Endoscopic Diagnosis and Treatment in Prostate Pathology (pp. 93-105). Academic Press.
  2. Jocius, K. K., & Sukys, D. (2002). Treatment of bladder neck obstruction (sclerosis): personal experience and literature review. Medicina (Kaunas, Lithuania), 38, 48-55.
  3. Fuse, H., Nishio, R., Murakami, K., & Okumura, A. (2003). Transurethral incision for hematospermia caused by ejaculatory duct obstruction. Archives of andrology, 49(6), 433-438.
  4. Orandi, A. (1985). Transurethral incision of prostate (TUIP): 646 cases in 15 years—a chronological appraisal. British journal of urology, 57(6), 703-707.
  5. Rassweiler, J., Teber, D., Kuntz, R., & Hofmann, R. (2006). Complications of transurethral resection of the prostate (TURP)—incidence, management, and prevention. European urology, 50(5), 969-980.
  6. Edwards, L., & Powell, C. (1982). An objective comparison of transurethral resection and bladder neck incision in the treatment of prostatic hypertrophy. The Journal of urology, 128(2), 325-327.
  7. Fitzpatrick, J. M. (2006). Minimally invasive and endoscopic management of benign prostatic hyperplasia. Campbell-Walsh Urology, 3107-3129.
  8. Greenstein, A., Ratliff, J. E., Marks, S., & Guice, J. (1990). Transurethral incision of the bladder neck and prostate. The Journal of urology, 144(3), 694-696.
  9. Sirls, L. T., Ganabathi, K., Zimmern, P. E., Roskamp, D. A., Wolde-Tsadik, G., & Leach, G. E. (1993). Transurethral incision of the prostate: an objective and subjective evaluation of long-term efficacy. The Journal of urology, 150(5 Part 2), 1615-1621.

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