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Category Archives: Urology

Prostate Enlargement – Newer Treatment Modalities

Dr V Surya Prakash

Prostate is a walnut-shaped gland seen only in men. It is part of the male reproductive system, situated below the bladder and in front of seminal vesicles. The urethra (urine passage) runs through the prostate.

The most common prostate health problems are – enlarged prostate (benign prostatic hyperplasia – BPH), inflammatory disease (prostatitis) and prostate cancer. Men who have problems when urinating should talk to their health care provider about their prostate health.

The prostate may become larger and start to cause problems as a man ages. Enlarged prostate is also known as benign prostatic hyperplasia (BPH). The risk factors for an enlarged prostate are -aging, family history, obesity and hormonal changes in aging male.

As the prostate enlarges, it can squeeze the urethra. This can cause some men to have lower urinary tract symptoms (LUTS).  LUTS  include- sense of incomplete bladder emptying, urgency, poor urinary stream, ddribbling of urine, hesitancy and frequent night time urination and straining to pass urine. The symptom severity is assessed by International Prostate symptom score (IPSS) and BPH bothersome index.

Men with enlarged prostate with the above mentioned urinary symptoms need to see a urologist for symptom relief. The urologist after eliciting a detailed history will examine the patient. A digital rectal examination (DRE) is done to know the size and consistency of the prostate. On DRE, prostate which is nodular and hard to feel is abnormal and is highly suspicious of prostate cancer. Noncancerous (Benign) enlargement of prostate is firm on DRE.  The investigations to diagnose the symptom severity due to BPH are complete urine examination, ultrasound of KUB (kidney, ureter and bladder), renal function tests and uroflowmetry.

Ultrasound examination will show the status of kidney, bladder (wall thickening, post void residual urine) and prostate size. In Uroflowmetry test patient is asked to pass urine in a flow meter machine which records the flow rate and the volume of the urine voided. Usually a peak urine flow rate below 15ml/sec is considered abnormal. A complete urine test is done to rule out urine infection. Patients with long standing diabetes, past history of stroke, prior spine surgery need further detailed evaluation in the form of Urodynamic study. Urodynamic study shows the bladder function in the setting of prostatic obstruction. Patients with weak bladder may not respond well to the BPH treatment modalities.

The treatment of BPH depends on the symptom severity. Men with mild symptoms (IPSS score- less than 7) are advised life style modifications in the form of reduced water intake, restriction of caffeine and alcohol and bladder retraining.

Medications for BPH: Men with moderate to severe bothersome symptoms (IPSS8-19) usually require medication. There has been a dramatic change in the management of BPH in the last two decades with the discovery of many effective drugs with minimal side effects. Drugs like alpha blockers, 5 alpha reductase inhibitors and anticholinergics are used alone or in combination to relieve the BPH symptoms. The commonly used medicines are- Tamsulosin, Silodosin, Finasteride, dutasteride, Tolterodine and Darifenacin. These medicines are to be taken only on the advice of urologist. These drugs are associated with adverse effects like- dizziness, ejaculatory disturbances, constipation and dryness of mouth.

BPH can progress and can cause sudden stoppage of urine. This condition is called acute urinary retention and is very painful. It is relieved by passing a catheter into the urinary bladder bypassing the prostatic obstruction. Patients who have acute urinary retention are given drug therapy for 2-3 days before removal of catheter.

Surgery for BPH: Patients who do not respond to drug therapy require surgical treatment. Other definite indications for surgical therapy are- recurrent urinary tract infection, kidney failure due to prostatic obstruction, repeated acute retention of urine, passing blood in the urine, stones in the urinary bladder with prostatic enlargement.

BPH surgery has become minimally invasive in the last two decades.  Open surgery which used to be done in a significant number of patients has largely been replaced by minimally invasive surgery. Among the minimally invasive procedures TURP (Transurethral resection of prostate) is considered as the standard procedure.  In TURP, an endoscope is passed through the Penis into the prostate and prostate gland is resected into small pieces using electric current. The resected tissue bits are evacuated at the end of the procedure.

Though considered as the standard treatment, TURP has many limitations. The procedure cannot be performed for longer than one hour due the risk of electrolyte disturbances. Up to 25 percent of patients may experience some type of complication after TURP, including bleeding, hyponatremia, urinary incontinence and erectile dysfunction. The risk of bleeding is also significant in large vascular glands. TURP also subjects patients to risks inherent in any surgical procedure, as well as a hospital stay of one to four days and recovery time of four to six weeks.

Many procedures are described to overcome the limitations of TURP. Of these, HOLEP is considered as gold standard procedure. HOLEP stands for – ‘Holmium Laser Enucleation of Prostate’.

In HOLEP the prostate gland is enucleated using a laser technology. The surgeon pushes the enucleated prostate gland tissue into the bladder and then uses a morcellation device to grind up and remove the tissue. The standard laser used is Pulse 120H/Pulse 100H holmium lasers system by Lumenis. The laser energy is delivered through a thin (500micron) fiber into the prostate to enucleate the gland.

The Lumenis Pulse 120H and Pulse 100H lasers are better suited to perform the procedure. The distinct advantages of HOLEP with Lumenis holmium laser devices include very minimal bleeding complete removal of the enlarged gland. The procedure can be performed even in patients who are taking blood thinner drugs like Aspirin. HOLEP with Lumenis holmium lasers is the gold standard procedure for large prostates which are difficult to be managed by TURP. The recovery is quick with very less complications. As the gland is completely removed there is very little chance of recurrence. In my practice, I have offered HOLEP with Lumenis Pulse 100H for patients with large prostates.

Distinct advantages of HOLEP with Pulse 100H are:

  • Treatment of any size prostate gland
  • Complete removal of the obstructing prostate tissue down to the prostate’s capsule with a re-treatment rate of less than 2 percent.
  • Early catheter removal
  • Early and immediate symptom relief and fast return to normal activity
  • Fewer potential complications. The low depth of penetration of the Lumenis holmium lasers causes little damage to healthy tissue.
  • Short hospital stay for the patients.

MS FRCSED MCh DNB, Senior Consultan, Dept of Urology and Renal Transplantation, VIRINCHI HOSPITAL