This was posted on a News Group in 2006 by a Spanish urologist Dr Sancha. It is one of thousands that I kept. Too many complex and metaphysical questions for a relatively simple subject. This urethral lining problem mesmerizes a lot of patients. I will try to help. 1. prostatic urethral lining. If you think of the prostatic urethra as the throat of a boy, and of the prostatic hyperplasia as the tonsils in a boy's throat, you will quickly understand that removing the hyperplastic tissue works exactly as removing the tonsils. You have to cut through the epithelial lining of the prostatic urethra to reach the hyperplastic tissue. When you finish there is a wound in both cases, there is a surface that needs to undergo repairs, and the borders of the wound start to grow new epithelial cells that will eventually cover the wound surface. if you look inside the boy's throat just after the operation you will see two wound surfaces, if you look inside the prostatic urethra after TURP or PVP, there is a 360º wound surface. After tonsillectomy, it is impossible for those surfaces to stick together, because they are never in contact. After TURP or PVP it is theoretically possible that two surfaces in contact could develop adherences, but this is extremely rare. TURP and PVP cavities usually have a diameter of 2-3 cm, so surfaces do not stick together, and the urine gets between these surfaces, making it difficult to develop adherences. 2. Prostatic ducts obstruction Prostatic ducts can become obstructed, the glands keep secreting and then you have a retention cyst. They are very common and easy to see with ultrasound of the prostate. You can also see retention cysts after TURP. So some of these ducts get obstructed with the surgery as you sugggest, but this does not derive into major clinical problems. A TURP could cut the ejaculatory ducts if it is very aggressive and penetrates the so called central zone of the prostate, but usually TURP and PVP are restricted to the hyperplastic tissue, that derives from the transitional zone of the prostate. So it is relatively rare to obstruct the ejaculatory ducts with prostatic surgery. It is not a cause of much concern for patients or urologists. Some young people suffer obstruction of the ejaculatory ducts after infections, or for unknown causes and they notice they ejaculate less volume of semen, and they have fertility problems, but this obstruction rarely causes pain or other symptoms. 3. prostatic urethra as a tube or duct: I have not seen two prostatic urethras looking exactly the same. They tend to be different, as prostatic shapes vary from person to person. You never see two mouths that are exactly the same, do you? Some prostatic urethras look from the inside like an open tube, other prostatic urethras are not an open tube, but an obstructed tube, because there are two masses of tissue that grow from the sides and coapt in the midline. Some urethras look like a tube with a full bladder (there is pressure inside the prostatic urethral lumen and it opens up) and as a colapsed tube when the bladder is empty. In the embryo, the urethra is a tube that is only lined with epithelial cells. Then some buds start to develop from the urethra and these buds invade the surrounding mesenchyma (this is the name of embryonal tissue that has not yet differenciated into a mature tissue). These buds are hollow bags of epithelial cells that will later differenciate into the prostatic glands (the parenchyma - the glandular tissue) - these cells will secrete the prostatic secretion, and will produce the famous PSA. The surrounding tissue will differenciate into the prostatic stroma (collagen, smooth muscle fibers, elastin, and other components) - a scaffold that will support the prostatic glands. 4. TURP and PVP and vaporization TURP and PVP are performed with surgical instruments that allow for continuous irrigation of the prostatic urethra and bladder. When tissue is vaporized with a greenlight laser, or cut with a TURP resectoscope, there are many tissue particles that float in this irrigation fluid and are taken out of the patient through the scope. They just do not condensate. TURP and PVP destroy the urethral lining (the correct word should be endothelial - rather than epithelial, endo means inside, and epi outside, so the epithelium applies to the skin, and the endothelium to all "internal skins", it is used for any lining of internal organs), but this epithelium grows again and when you look inside after some time, you see it has regenerated completely. In some areas there is some scar tissue, specially after TURP, but as it happens with wounds in the skin, the regenerative process manages to cover the wound surface completely. 5. Prostatic capsule. The prostate does not have a proper capsule. It is surrounded by fascial sheaths that are almost only visible under the microscope. In a 20 year old prostate, there is an area near the bladder neck, surrounding the urethral endothelium, the transitional zone, that will be the origin of the benign hyperplastic tissue. It will start to grow and it will progressively push the original prostatic tissue outwards. In an old man with a big prostate, this growth of tissue from the area surrounding the urethra will have pushed the original prostatic tissue outwards, and between these two parts of the prostate, the central hyperplastic tissue and the external original prostatic tissue there is a very clear cleavage plane. When an open prostatectomy is performed, the surgeon incises the prostate until he reaches this cleavage plane, and then uses his finger to enucleate the hyperplastic tissue, he breaks the urethra and extracts the BPH tissue with a hole in the middle (like a donut) - the urethra. Then the incission is closed with a suture. This gives the impression of a "surgical capsule", that is tipically 5-10 mm thick, and this is really the original prostate. We surgeons talk about the capsule knowing that we refer to the original prostatic tissue. When we perform TURP (well, I do not perform TURP any longer) or PVP, we want to reach the "capsule" (the surgical capsule), to make sure we remove all the hyperplastic tissue. Apparently, some prostates are more distensible than others, and that explains in part that some men with relatively small prostates are very obstructed (the growth is not able to push the prostate outwards, so it obstructs the urethral lumen) and some men with much bigger prostates can urinate very well (a more distensible original prostate allows this tissue to enlarge the prostate, and the urethra is not so compressed). This also happens with e.g. kidney tumors. A tumor inside the kidney can push the renal tissue and compress it and when you look at the kidney it appears to be encapsulated, but what you see is renal tissue that has been compressed and seems to form a capsule around the tumor. Open prostatectomies on very big prostates are like opening the skin of an orange (the surgical capsule or the original prostatic tissue) and extracting the flesh (the hyperplastic tissue)... 6.- liposuction of the prostate... Prostatic tissue is quite elastic, but it is also quite rubery or tough... there is no way of performing what you suggest...The hiperplastic tissue is a benign tumor of the prostate, it has stroma (collagen, muscle fibres, etc..) and parenchyma (glandular tissue). Ellen Shapiro from new york has been studying the proportion of stroma and parenchyma in BPH, a difficult question to investigate.... but there are two components also in BPH. The smooth muscle in the stroma responds with relaxation to alpha blockers. The glandular tissue responds to finasteride with atrophy. Both mechanisms derive in symptoms improvement in patients through different mechanisms. It is a pity these google groups do not allow for drawing. It would be very nice to use some drawings to explain these things. My best wishes to all, I hope this was helpful. Fernando Gómez Sancha
Wow, that was a fascinating read.
Thanks for posting!
i had a TURP last july and haven’t been the same since.
id never recommend this awful operation.
my penis has lost an inch in length and now during erection pulls downwards .
constant infections, low sex drive, only semi firm erections and RG !
this has forever changed my life and im not better off than before the TURP , i still get up 4 times per night for peeing .
i should have done more investagating before i trusted this urologist
The problem was not the TURP but the surgeon. I had a TURP 10 or 11 weeks ago and it was the best thing I’ve ever done to relieve my BPH symptoms. My stream is stronger, I can hold twice as much in my bladder before I have to void, and my nighttime trips to the bathroom have been cut in half. No infections, no pain pills, just 3 or 4 days of minor discomfort.
I also had a very bad outcome from my procedure (Greenlight). I thought I had chosen a good doctor, but I think he was “too experienced”, as he was in his 60s.
I have come to believe that BPH needs a new name, as there is nothing benign, given the chance of poor outcomes.
Derek,
Thank you for posting that !
It was an excellent piece, from which I have learned a lot.
Chuck
If you search on Youtube Dr Sancha has many videos of his procedures, demonstrations and lectures.
Thanks for that report WOW . In your finale estimation,would you say no for a old man with a large prostate 116 grams and at age 89 to not do Turp or VIP ?
thanks,