Minimally Invasive Management of BPH

Throughout a man's life, his prostate may grow and start to cause problems as he ages. For many years, a prostatectomy was the only treatment for this very common problem. Although effective, such major surgery requires patients to spend significant time in the hospital and at home in recovery. Fortunately, today's technological advances now provide urologists with an array of minimally invasive techniques to treat BPH. What are some of these new treatments available? The following should help answer that question as well as others.

What is the prostate?

The prostate, a part of the male reproductive system, is about the same size and shape as a walnut and weighs about an ounce. It is located below the bladder and in front of the rectum and surrounds the urethra, the tube-like structure that carries urine from the bladder out through the penis. The main function of the prostate is to produce ejaculatory fluid.

What is BPH?

Benign prostatic hyperplasia (BPH), previously referred to as prostatism, is a common urological condition caused by the non-cancerous enlargement of the prostate gland in aging men.

Risk factors for developing BPH include increasing age and a family history of BPH.

Since the prostate surrounds the urethra just below the bladder, its enlargement can result in symptoms that irritate or obstruct the bladder. A common symptom is the need to frequently empty the bladder, especially at night. Other symptoms include difficulty in starting the urine flow or dribbling after urination ends. Also, size and strength of the urine stream may decrease.

In order to help assess the severity of such symptoms, the American Urological Association (AUA) BPH Symptom Score Index was developed. The AUA diagnostic system includes a series of questions that target the frequency of the urinary systems identified above, and as a result, helps identify the severity of the BPH — ranging from mild to severe.

There are a number of diagnostic test procedures that can be used to confirm BPH. The tests vary from patient to patient, but the following are the most common: digital rectal examination (DRE), PSA test, rectal ultrasound, urine flow study, intravenous pyelogram and cystoscopy.

Catheterization: Placement of a catheter into the bladder will temporarily drain urine. Catheters can be placed intermittently every six hours — clean intermittent catheterization — or left in place for one to three months at a time (indwelling). Catheters can be placed either through the urethra or by making a small puncture into the bladder above the pubic bone (called a suprapubic tube). Infection is the biggest risk of having a catheter in place for long periods, as bacteria can stick to the surface of the catheter, making it difficult for the body's immune system or antibiotics to clear the organisms. Another risk is that after a few years there is a higher risk of bladder cancer due probably to the long-term irritation caused by the catheter sitting in the bladder. Catheterization, performed by the individual or a caregiver every six hours, minimizes the risk of infection and cancer compared with an indwelling catheter. Catheters are most useful as a treatment of choice for temporary drainage while waiting for medication to start working, surgical schedules or clearing of infection. They also might be the most appropriate choice for a patient with multiple medical problems and a short life expectancy, where the risk and discomfort of surgery outweigh the risk of infection or cancer. Catheterization is the treatment of choice over medications or surgery for patients who have neurogenic bladder in addition to prostatic obstruction.

High-intensity focused ultrasound (HIFU): Anesthesia is usually required for this procedure. A special ultrasound probe is placed into the rectum near the prostate. Ultrasound waves heat the prostate up to very high temperatures, which causes destruction to the prostate tissue. The heated prostate tissue is destroyed and initially swells but then shrinks. The need for catheterization due to retention of urine and blood in the urine has been a problem postoperatively.

Holmium laser enucleation of prostate (HoLEP): After the patient receives anesthesia, the surgeon inserts an instrument called a resectoscope through the penis into the urethra. A visual lens and laser are passed through the hollow center of the instrument. The prostate tissue is vaporized using the holium:YAG laser. There is very little bleeding and recovery time is cut significantly. Typically, the patient has a catheter removed the next day and stays overnight in the hospital one day.

Interstitial laser coagulation: Anesthesia is usually required for this procedure, but patients can usually go home the same day. The technology involves placing a "cystoscope" (metal tube through which the visual lens and laser can be passed). A laser is used to pierce through into the prostate and the laser energy burns the tissue. Complications and need for further treatment have been minimal so far, but more sophisticated studies must be performed.

Medical therapy: Today's most common method for controlling moderate symptoms of BPH.

• Alpha blockers: These drugs, originally used to treat high blood pressure, work by relaxing the smooth muscle of the prostate and bladder neck to improve urine flow and reduce bladder outlet obstruction. Although alpha blockers may relieve the symptoms of BPH, they usually do not reduce the size of the prostate. They are usually taken orally, one or twice a day just before bedtime and they work almost immediately. Commonly prescribed alpha blockers include: alfuzosin, terazosin, doxazosin and tamsulosin. Side effects can include headaches, dizziness, light-headiness, fatigue and difficulty breathing.
• 5-alpha-reductase inhibitors: Finasteride is an oral medication that works completely different than alpha blockers. In some men, finasteride can relieve BPH symptoms, increase urinary flow rate and actually shrink the prostate though it must be used indefinitely to prevent recurrence of symptoms. One study suggests that finasteride may be best suited for men with relatively large prostate glands. It may take as long as six months to a year, however, to achieve maximum benefits from this drug. Side effects can include impotence, decreased libido and reduced semen release during ejaculation.

Prostatic stent (stenting): Anesthesia is not required for this procedure. The technology involves placing a spring-like contraption inside the prostatic part of the urethra to hold it open. There are many different kinds of stents. This is usually best suited for patients who have many medical problems or who are high-risk for surgery. Serious complications include urinary incontinence, dislodgement of stent position, stone formation on the stent with blockage and difficulty removing the stent. Minor complications include urinary frequency and urgency, dribbling of urine, discomfort and light bleeding. Patients with certain conditions are often advised against stent placement including those with strictures (narrowing) in the urethra, urinary infection, bladder stones, weak bladder and cancer, and patients who will be undergoing other procedures performed through the urethra soon after stent placement (e.g., treatment of kidney stones). Generally, prostatic stents are used for the same patients who would otherwise use an indwelling catheter or transurethral microwave thermotherapy (TUMT).

Transurethral electroevaporation of the prostate (TUVP): After the patient receives anesthesia, the surgeon inserts an instrument called a resectoscope through the penis into the urethra. The resectoscope contains a light, valves for controlling irrigating fluid and a grooved rolling metal electrode. This electrode moves across the surface of the prostate and electrical current vaporizes prostate tissue. The vaporizing effect penetrates below the surface area being treated so underlying blood vessels are coagulated and sealed. Bleeding and fluid absorption are minimal and patients can usually return home without a catheter after an overnight hospital stay.

Transurethral microwave thermotherapy of the prostate (TUMT): This is an office-based procedure performed with topical and oral pain medication and does not require anesthesia. Computer-regulated microwaves are sent through a catheter to heat portions of the prostate. A cooling system works simultaneously to protect the urinary tract during the procedure. Traditionally, the best use of this procedure has been for patients who have too many medical problems for more invasive surgery or for patients who truly wish to avoid any type of anesthesia. Benefits are that there is no need for anesthesia and there is no blood loss or fluid absorption (these would be significant benefits in a person with a weak heart). Patients usually go home the same day. Many urologists have the technology available in their practice and results are pretty reliable regardless of who performs the procedure. The use of TUMT has been expanding to a broader patient population.

Transurethral radio frequency needle ablation of the prostate (TUNA): The procedure involves anesthesia and medications to make the patient sleepy. The technology involves heating of tissue using radio frequency energy transmitted by needles inserted directly into the prostate. High frequency radiowaves heat the prostate up to very high temperatures. The heated prostate tissue is destroyed and initially swells but then shrinks. Most men require a catheter for a period of time after this procedure. Advantages in the use of TUNA include the limited anesthesia requirement, the ability to perform the procedure in an office setting and avoidance of serious complications sometimes associated with other procedures.

Water-induced thermotherapy (WIT): This procedure, performed on an outpatient basis, involves no anesthesia in many cases and in other cases only requires medications to make the patient sleepy. The technology involves a catheter with an inflatable balloon that has hot water running through it. As the balloon is inflated, conductive heat allows for destruction of the prostatic tissue. It is unclear whether the depth of penetration will be sufficient for long-term therapeutic response. 

Watchful waiting: Is recommended as an important option for men who have mild symptoms and do not find them particularly bothersome. It is the least invasive treatment and avoids the risks, inconvenience and costs of medical and surgical treatments. In some men, symptoms improve over time as long as there are no high-risk symptoms like urinary retention, recurrent urinary tract infection, recurrent blood in the urine, bladder stones, kidney failure or bladder diverticula.

Frequently Asked Questions:

No, it is very common. It will affect approximately 50 percent of men between the ages of 51 and 60 and up to 90 percent of men over the age of 80.

No, BPH is not cancer and cannot lead to cancer, although both conditions can exist together. There are usually no symptoms during the early stages of prostate cancer; so yearly physical examinations and PSA testing are highly recommended.

To date, there are not enough research data to predict who will respond to medical therapy or which drug will be better for an individual patient.

If you are diagnosed with BPH, you should discuss all treatment options with your urologist. Together, you can decide whether medication or surgical treatment is best for you.

As long as your symptoms are mild, your quality of life is not very affected and you do not have any compelling reason to have invasive surgical therapy right away, you can start with watchful waiting or the medical therapies. If those options are ineffective or your symptoms worsen over time, then surgical treatment may be the answer.

Most people can have a TURP without adverse events, but it is much riskier for someone with your medical history. After discussing your options with your urologist, one of the minimally invasive procedures that does not require anesthesia might be a better choice for you, for example, TUMT.

Where can I get more information?

Benign Prostatic Hyperplasia (BPH) Treatment Choices
Benign Prostatic Hyperplasia (BPH) Treatment Choices (Zinio format)

BPH: Enlarged Prostate
BPH: Enlarged Prostate (Zinio format)

AUA Guidelines Patient Guides: BPH: A Patient's Guide

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