Small tight prostates are best managed by bladder neck incisional surgery rather than formal resection of prostatic tissue. Bladder neck incisional surg ery involves an endoscopic procedure under general anaesthetic; the trigone, bladder neck and prostate gland are incised deeply in the midline to the level of the verumontanum. This relieves the obstructive effect of the prostate on the bladder neck and prostatic urethra. This is a minimal procedure with good long-term relief of symptoms for well-selected patients. Bladder neck dyssynergia occurs in men in their thirties and forties, and is due to spasticity of the bladder neck mechanism. These men have obstructive and irritative symptoms similar to those in older men with BPH. The diagnosis is made by urodynamic evaluation. This also excludes the presence of a urethral stricture. Younger men with bladder neck dyssynergia may elect to watchfully wait or undergo alpha blockade or bladder neck incisional surgery. The surgery involves a 25% occurrence of retrograde ejaculation and, hence, subfertility. Bladder neck incision surgery should not be performed on a man who wishes to retain fertility.

Very large benign prostates causing significant BNO may need to be resected via an open suprapubic approach. An assessment is made under an anaesthetic with cystourethroscopy as to the size of the transition zone. When it is estimated that an endoscopic resection would involve the removal of in excess of 60-80 g, an open procedure is best considered under the same anaesthetic. Open or suprapubic prostatectomy is the enucleation of the transition zone via a lower abdominal, horizontal skin incision. The bladder is opened and the enucleation occurs by means of resection through the urethra and the removal of the transition zone. Bladder stones can also be removed at the time of open prostatectomy. Patients are usually hospitalised for four days. They are discharged with an indwelling catheter and leg bag for one week. Suprapubic prostatectomy should not be confused with radical retropubic prostatec- tomy, which is an operation performed for early prostate cancer. Radical prostatectomy for early prostate cancer involves total removal of the prostate and its capsule. Via the suprapubic approach, only the transition zone is removed; the posterior or peripheral zone of the prostate remains in place. Patients who have suprapubic prostatectomy should therefore have ongoing screening for prostate cancer. Unlike radical prostatectomy, the neurovascular bundles that s u b s e rve erectile function are not at risk. Retrograde ejaculation will occur after suprapubic prostatectomy.

Holmium laser resection of very large benign prostate glands is also an option. Via a modified endoscope a Holmium laser fibre is passed into the prostatic urethra and is used to resect large glands with minimum blood loss. The difficulty with holmium laser resection is that large pieces of benign prostate tissue are released into the bladder. The removal of bulky tissue can be difficult, which requires an extended period of urethral instrumentation. Morcellation (grinding) devices are under investigation. Their purpose is to mince large benign fragments of prostate within the bladder, and thus facilitate their removal.

The sub-committee of the American Urological Association that recently reviewed this matter considers contemporary transurethral resection of the prostate (TURP) to be the gold-standard therapy for prostatic BNO. Contemporary TURP refers to the operation being performed by well-trained specialist urological surgeons using continuous flow resectoscopes and three chip digital cameras (see figures 4-10). On average, a patient is admitted for 48 hours and has the procedure performed under a spinal anaesthetic. Return to sedentary work within five days is feasible. The incidence of sphincter weakness urinary incontinence is very low when an experienced surgeon perf o rms the proced u re. Vi g o rous post-operative pelvic floor training should be performed by men with mild to moderate post-operative stress incontinence. The incidence of blood transfusions is now very low. Improved haemostasis is possible using modern diathermic technology with current spray capability. The TURP syndrome is now an uncommon occurrence during endoscopic prostatic resection. This syndrome refers to the excess absorption of glycine irrigating fluid during the operation, usually via large prostatic venous plexuses. This syndrome may cause c a rdiovascular and electro l y t e disturbances during the intraoperative and immediate postoperative period. It is more likely to occur when very large prostate glands are subject to endoscopic resection. Management strategies include cardiovascular support and correction of electrolyte disturbances. C o n t e m p o r a ry transure t h r a l prostatectomy is now a lowmorbidity procedure. Following relief of prostatic obstruction, the patient experiences an immediate impro v ement in urinary flow, but irritative symptoms such as frequency, urgency and nocturia may take three, and on occasion, six months to settle. The resolution of these symptoms depends on the degree of pre-operative detrusor instability that developed secondary to the chronic outflow obstruction. Occasionally, anticholinergic medications such as oxybutynin are necessary for a varying period of time. Fifteen per cent of men with chronic detrusor instability prior to surgery continue to have symptoms post-operatively and may require chronic oxybutynin medication. Their obstructive symptoms, however, will have been relieved. Transurethral prostatectomy does not cause erectile dysfunction, as it is not associated with damage to the neurovascular complex that proceeds to the erectile bodies. Retrograde ejaculation is inevitable and men should be warned of this event. Men still have a normal feeling of orgasm; ejaculatory fluid is passed with the first post-ejaculatory void. TURP removes the periurethral adenoma, now called the transition zone of the p rostate. It does not protect from prostate cancer and men should continue to have a digital rectal examination and PSA determination on an annual basis.

Prostatic BNO is a common condition in men aged 50 years and over, and it adversely affects quality of life. Accurate diagnosis and judicious treatment will result in a good clinical outcome.