The money shot....

I did a TURP (Transurethral Resection of the Prostate) yesterday, which is no longer a commonly performed operation. The procedure is for patients who are suffering from symptomatic BPH (benign prostatic hyperplasia), and since we've had newer advances in drugs and minimally invasive procedures (such as lasers, microwave therapy etc...), this once common operation is now a rarity. One of my attendings from residency told me he used to do about 10 TURPS a week 30 years ago. I think I have done about 10 TURPS in the last two years.

There is something innately satisfying about a TURP, since you are actually carving away the prostate tissue that is causing obstruction. It's one of those operations where there is a fair amount of "artistry" involved, but the key to success is to adhere to the caveat: "le meilleur est l'enemie du bien". (perfection is the enemy of good).

So while I was performing the operation, I was reminded of a patient whom I saw as a resident at the VA hospital. He was a gentleman in his 50s, suffering from urinary obstruction because of BPH. He was failing medical therapy, and becoming more symptomatic by the day, to the point where the only treatment was a TURP. Unfortunately, one of the more common side effect of a TURP is retrograde ejaculation. That is, when the post-TURP patient ejaculates, the semen actually goes back into the bladder instead of coming out the urethra. So though he is experiencing the normal sensation of an orgasm, there is nothing to show for it. It causes problems for couples who are trying to conceive, but for these older patients, this is usually a non-issue.

However, this particular patient made his living as a porn star, known for his (ahem) "money shot", and a TURP would have been the end of his career. What to do? He was quite torn about his choices, and we (the residents) became quite involved with this "drama". He was basically deciding between the ability to urinate freely versus the ability to continue with his chosen profession.

He eventually decided to start self-catheterizing in order to pursue his career. I left the VA at the end of my rotation, and I don't know what has happened to this patient since. But what a dilemma....