Lower urinary tract symptoms (LUTS) describe issues with storing and passing urine. When these symptoms disrupt a person’s life and do not respond to other treatments, surgery becomes a consideration. These procedures are not a one-size-fits-all operation but a range of interventions tailored to the specific problem. The primary objective is to alleviate symptoms by addressing the underlying issue, restoring function, and improving quality of life.
Determining the Need for Surgery
The path to surgery for LUTS follows a “step-up” approach, where it is considered only after conservative options prove insufficient. Initially, physicians recommend lifestyle adjustments, such as managing fluid intake, modifying diet to avoid bladder irritants, and pelvic floor exercises. These changes can sometimes provide enough relief without further medical action.
If symptoms persist, the next step involves medications. For men with enlarged prostates, doctors might prescribe alpha-blockers to relax muscles or 5-alpha-reductase inhibitors to shrink the prostate. For bladder storage issues like overactive bladder, other medications can help calm the bladder muscle. Surgery is reserved for those who do not get relief from these therapies or who develop complications like recurrent infections.
To confirm the cause of LUTS before an operation, urologists perform diagnostic tests. Uroflowmetry measures the speed and volume of the urine stream to detect blockages. A post-void residual volume test uses ultrasound to see how much urine is left in the bladder after urination, indicating incomplete emptying. A cystoscopy uses a thin tube with a camera to inspect the bladder and prostate for abnormalities.
Procedures for Obstructive Symptoms
Surgical procedures for obstructive LUTS focus on removing a physical blockage. These symptoms often include a weak or intermittent stream, difficulty starting urination, and a feeling that the bladder has not fully emptied. In men, the most frequent cause is benign prostatic hyperplasia (BPH), a non-cancerous prostate enlargement that squeezes the urethra.
The traditional surgical treatment for BPH is transurethral resection of the prostate (TURP). During this procedure, a surgeon inserts an instrument through the urethra to trim away excess prostate tissue, thereby widening the urinary channel. Newer laser-based procedures achieve similar outcomes with fewer side effects by vaporizing (GreenLight) or cutting out (Holmium Laser Enucleation of the Prostate, or HoLEP) obstructive tissue.
Minimally Invasive Surgical Therapies (MIST) are less invasive options. The UroLift system places small, permanent implants that pull the enlarged prostate lobes apart, like tie-backs on a curtain, to open the urethra. Another MIST procedure, Rezum, uses targeted steam injections to destroy excess prostate cells, which the body then absorbs. These options offer a quicker recovery and may be best for men with smaller prostates or those who wish to preserve sexual function.
Procedures for Storage and Incontinence Symptoms
Surgery can also address storage-related symptoms, which are often related to an overactive bladder (OAB) or poor structural support. These issues include:
- Urinating too frequently
- A sudden and urgent need to urinate
- Waking up multiple times at night to urinate (nocturia)
- Involuntary leakage of urine (incontinence)
For severe OAB unresponsive to medication, two procedures are common. One is the injection of onabotulinumtoxinA (Botox) directly into the bladder muscle. This treatment relaxes the bladder by blocking nerve signals that cause excessive contractions, reducing urinary frequency and urgency. Another option is sacral neuromodulation, which involves implanting a small device that sends mild electrical impulses to the sacral nerves controlling the bladder to restore normal activity.
When the primary issue is stress urinary incontinence (SUI), where urine leaks during physical activity, surgery focuses on supporting the urethra. The most common SUI procedure is the sling, where a piece of synthetic mesh or the patient’s own tissue is placed under the urethra to act as a supportive hammock. For more severe SUI, an artificial urinary sphincter may be implanted. This device has an inflatable cuff around the urethra that keeps it closed until the patient is ready to urinate.
The Surgical and Recovery Timeline
The surgical process begins with pre-operative preparations. In the days or weeks before the procedure, patients may be asked to stop certain medications, such as blood thinners, to reduce bleeding risk. Fasting is also standard, typically starting the night before surgery.
On the day of the procedure, patients receive anesthesia. The type, whether general or spinal, depends on the surgery and the patient’s health. After the operation, many patients have a urinary catheter, a thin tube that drains urine from the bladder, allowing the urinary tract to heal.
The post-operative period involves a hospital stay, ranging from a few hours for MIST procedures to several days for more complex surgeries. Pain is managed with medication, and movement is encouraged once it is safe. After discharge, there are restrictions on activities like heavy lifting for several weeks. The timeline for returning to normal activities varies based on the surgery and can range from a few days to over a month.
Long-Term Outcomes and Potential Risks
After recovery, most patients experience significant symptom improvement and a better quality of life. Success rates for modern LUTS surgeries are high, with procedures like TURP and HoLEP providing lasting relief. However, potential long-term risks and side effects are an important consideration.
A common long-term side effect, particularly after surgeries for an enlarged prostate, is a change in sexual function. Retrograde ejaculation, where semen enters the bladder during orgasm, is a frequent outcome of procedures like TURP. This is not harmful but does affect fertility. Erectile dysfunction is also a risk, though newer procedures are designed to minimize it.
Other potential issues include new or persistent urinary incontinence, which may be temporary or permanent. There is also a risk of urethral strictures (scarring that narrows the urethra) or bladder neck contracture, which can cause obstructive symptoms to return. In some instances, the original symptoms may recur, and a small percentage of patients may require a repeat procedure years later. A thorough discussion with a surgeon about these outcomes is a necessary part of making a decision.