Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is the noncancerous enlargement of the prostate gland surrounding the urethral passage between the bladder and penis. The condition is common in men older than 50 years, but usually does not cause any major problems. However, in some patients, this enlargement may cause significant urinary problems, which might lead to bladder and kidney damage. Thus, evaluation by a urologist is recommended when the urinary symptoms become bothersome.

Typical symptoms of BPH would include frequent urination (called frequency), trips to the bathroom at night (nocturia), diminished force of the stream, difficulty holding back urination (urgency), delay in starting the stream (hesitancy), interruption of the stream (intermittency), or sense of incomplete emptying. Patients with minor problems are usually treated by modifying fluid intake, such as cutting back on coffee, tea, or alcohol, particularly in the evening.

NON SURGICAL TREATMENT: MEDICATIONS

Some patients with troubling symptoms may benefit from saw palmetto, an over-the-counter herbal medication. Consult your doctor before taking any over-the-counter or herbal medications. Some herbal medications interfere with prescription drugs that you might be taking for another condition.

Patients with moderate to severe urinary symptoms may be treated by medications, like tamsulosin (Flomax), alfusozin (Uroxatral), doxazosin (Cardura), or terazosin (Hytrin), which relax smooth muscle within the prostate gland and allow urine to flow more freely. Alternately, patients may be treated with finasteride (Proscar) or dutasteride (Avodart), which might shrink a very enlarged prostate (over 40 cc size) over 6-12 months of treatment. Patients who fail to improve with medications would then be considered for surgical treatment, which can range from minimally invasive therapy performed in the office setting to traditional surgery under anesthesia in the operating room.

When patients cannot urinate (urinary retention) or the bladder does not empty adequately (high post-void residual), then placement of a urethral catheter to drain the bladder or using intermittent catheterization may be required until surgery or a minimally invasive treatment  is performed. 

SURGICAL OPTIONS FOR BPH

Transurethral resection of the prostate (TURP), the most commonly used technique, occurs under spinal anesthesia. During TURP, the prostate is shaved from inside the urethra using a scope that has blades at its end. The chips of tissue are vacuumed out and this procedure opens the channel for a more forceful urinary stream. The patient must wear a urethral catheter for removing any blood for a day or so until the urine clears. The TURP procedure removes the bulk of prostate tissue, with increased risk of bleeding, but improved urination is noted most rapidly. Patients are usually in hospital overnight.

Transurethral vaporization of the prostate (TUVP) is similar to TURP, except that the prostate is not shaved but vaporized. There is less bleeding during the procedure than with TURP, and TUVP may be used in patients who have been on blood thinners or in patients with small to moderate-sized prostates. A urethral catheter is used overnight while the urine clears of blood. TUVP may be performed as ambulatory surgery, which means the patient may not require an overnight stay in the hospital.

Transurethral incision of the prostate (TUIP) is a more limited procedure that cuts 1 or 2 deep grooves through the prostate rather than shaving or vaporizing prostate tissue. This procedure is quicker than the TURP, and is used on smaller prostates. A catheter is needed for a day or two while some of the edema (swelling) subsides. TUIP is usually performed as ambulatory surgery.

A more major surgical option is open, "simple" prostatectomy. This is the removal of large prostates (over 100 cc), and it requires a skin incision below the belly button. The hospital stay is 3-5 days, and recuperation takes about 1 month.

MINIMALLY INVASIVE OPTIONS

Minimally invasive treatments are procedures that have minimal bleeding risk, and they are performed under local anesthesia or intravenous sedation.

Urolume stent. This treatment is similar to the coronary stents used to keep blocked heart vessels open. A stent looks a little like the spring in a ball-point pen, except of course, it's made to go inside the body. The Urolume stent is a stainless steel wire stent that expands in the prostate to keep the urethra open. It is used for poor-risk patients who have a limited life expectancy or high-risk patients who would have problems with anesthesia, invasive prostate surgery, or delayed bleeding.

The other minimally invasive therapies involve slow heating of the prostate tissue. In these therapies, listed below, the treatments provide heat over a period as long as 3 weeks or more. These techniques are particularly useful for high-risk patients, such as those patients where anesthesia or any bleeding problems might be complicated. Patients may require a Foley catheter for a few days to several weeks, the symptoms will not begin to improve until the damaged tissue is absorbed over several weeks, maximum improvement may take 3-4 months to achieve, but the overall improvement in symptoms is comparable to TURP. The following procedures are performed in the office setting.

Transurethral microwave therapy (TUMT) uses a catheter that contains a microwave antenna, which is placed through the urethra to apply heat to the prostate. The treatment takes about 1 hour.

Transurethral needle ablation (TUNA) uses a fine needle, which is inserted through the urethra and then into several sites in the prostate to deliver the slow heat energy. Treatment takes about 30 minutes.

	TUNA system — the newest version (Prostiva) with control box above, and the pistol-grip device below which delivers the fine needles into the prostate tissue under direct vision through a cystoscope.
	TUNA procedure — schematic view of thermal (heat) ablation procedure using radiofrequency energy through the needles within the prostate tissue.

Interstitial laser employs a laser fiber inserted through the urethra into prostate tissue at several locations, and the laser heats the prostate. Treatment takes about 30 minutes.