Benign Prostatic Hyperplasia (BPH) or Enlarged Prostate
The prostate is a male sexual organ. It is located between the bladder and the penis and the urethra and therefore the urine runs through it. As patients get older, the prostate gland enlarges. The relative incidence of enlargement is roughly that of a person’s age, that is 50% of men aged 50 will have enlargement of the prostate and 90% of 90-year-old men will have enlargement of the prostate.
Not all patients who have enlarged prostate will have symptoms. There are two components to prostatic tissue and enlargement and that includes the glandular tissue and the muscle. In some patients who just have an enlarged gland without any muscle enlargement or without much muscle tone, they may not have much in the way of symptoms.
Symptoms of prostatic enlargement include slowness or delaying of the urinary stream, having to strain to get started, and the bladder not emptying well. As these symptoms progress, the patients will develop going more frequently at night and going more often during the day as well as having a hurry to get to the bathroom.
Because the bladder’s response to the enlargement is to have to squeeze harder, the muscle in the bladder gets thicker over time. Eventually it is replaced by a scar tissue and the bladder becomes less and less functional. Unfortunately as these changes progress, they become less and less reversible.
The way that urologists evaluate somebody with these symptoms includes finger examination of the prostate and assessment of the urinary symptoms. Sometimes, it is necessary to do cystoscopy, which is looking in the bladder or to check urine flow rate. The other issues more complicated testing include the urodynamic evaluation in which the pressure in the bladder is measured while the patient is voiding. An additional test that is now often required is transrectal ultrasound measurement of the prostate to assess the prostate size.
Historically, treatment for patients with prostate enlargement was strictly transurethral resection of the prostate or TURP. Once this treatment was developed, nobody really looked for other treatments. This is still a commonly used procedure, but about 20 years ago, it was the most common procedure of all surgical procedures done in United States. When the government realized that it was such a large source of Medicare spending, they decided to fund research for other treatments. This initially led to medical therapy.
The original class of medicines used to treat the prostate was called alpha-blockers. These medications work on the muscle component of the prostate and work by relaxing the muscle on the prostate to allow the urine to flow more freely.
Unfortunately, while this was still a very common treatment, it does nothing about the disease process itself, that is, the prostate continues to grow. In our practice, we have seen many patients that appeared to be doing fairly well on the alpha-blockers for a long period of time; however, wake up one day and have difficulty voiding. When we see them at this point their prostate has become so large that at times we are not able to treat it with even a simple surgical procedure such as the TURP, but we actually have to perform an open surgery. We have to make an incision to shell out the inside of the prostate, which is riskier procedure often requiring transfusions and a minimum of two days in the hospital.
This led to a second type of drug to treat the prostate and these are medications that work by changing the hormone levels in the prostate. This group of medications actually works to shrink the prostate. The first of these drugs is a drug called Proscar, and because that is now off of patent (available in generic form), you have been seeing ads on television for a newer drug called Avodart.
The different roles of medical therapy and which of these medications could be used has been recently studied in a very elegant study by the VACURG, that is, Veterans Administration Cooperative Urologic Research Group. In following men with symptoms of enlargement of prostate and measuring their prostates may determine that if a patient takes only alpha blocker, his disease will progress within five years two-thirds of the time. Similarly, if the patient takes only a medication to shrink the prostate, his symptoms will get worse two-thirds of the time in five years. They found that in order to avoid progression, the patients had to take two drugs if their prostate was larger than 40 grams and that is why the ultrasound has become such an important tool in picking the right treatments for enlarged prostate.
Even if the patients take both of these medications medically, they still have progression of symptoms in five years a third of the time. Also as we had mentioned before with the enlargement of the prostate it comes a condition in which the bladder gets worse too and once there is damage to the bladder not all the changes are reversible and that is why it might be better to do something aggressive earlier on in the course of disease before there is irreversible bladder damage.
Concurrent with this recent study, there have been some advances in treatment for the prostate allowing for less intrusive means of treating it. There are laser procedures that can be performed in the office and hospital setting. We have extensive experience with this technology as well. A problem with the laser that is used in the office is that it is much less effective than other procedures that will be explained in more detail later in this document. The problem with the other laser procedure is that it has to be done in the hospital. The hospital laser uses high energy and has some sexual side effects; this can also be seen with TURP. Also because so much energy is used, many patients have some irritation, annoying sensation of urgency or burning or pelvic pain that can last for two or three weeks. Unlike the original surgery though, the risk of blood loss is quite low and it does not require hospitalization.
There have been also several new developments for treatment of enlarged prostate that can be done in the office. Initially, the first of these was microwave therapy which came out about eight or nine years ago. A catheter is placed in the urethra in the middle of the prostate and it actually has a microwave emitter within the catheter. This heat-treats the prostate.
When this was initially developed, the way of heating the prostate, the recipe in terms of how much energy was delivered was not well clarified. There was so much discomfort from the patients that the machine had to be turned off and on and initial results were poor. These results have steadily improved over time. Some other improvements have been made to the microwave as well which include putting a balloon in the microwave, which allows the prostate to be open by the balloon so that in many cases patients don’t required to go home with a catheter. We use this technology frequently in the patients who have larger prostate gland in particular.
A treatment that we have found to be very successful is called Prostiva, formerly the TUNA procedure. This stands for transurethral needle ablation of the prostate. This is an office-based procedure that involves a cystoscopic examination. There are radiofrequency transmitters that heat-treat the prostate, which take 12-15 minutes. This destroys the glandular and nervous tissue that is causing constriction by the urethra and is working quite well. The Journal of Urology (the most prestigious source of information for urologists) published in their record a large and prolonged study of patients undergoing TUNA, which showed equal results to the TURP at six years but with insignificant amount of sexual side effects.
We see the major advantages of the TUNA being that it is an office-based procedure that is done under local anesthesia. The amount of tissue that is treated is very specifically localized per the individual prostate rather than the microwave catheter, which is not detailed to the individual anatomy, which can vary from patient to patient. Also, there is preservation of sexual abilities with low or no incidence of retrograde ejaculation.
Overall, our patients that have had the TUNA procedure are very happy. The patient’s symptomatic improvement is marked. Their recovery from the procedure is nearly immediate, without significant activity restrictions, though it does take a few weeks for the inflammation from the treatment to resolve. Consequently, voiding may be slightly worse after the procedure in the first two weeks, but then rapidly improve. In addition, patients continue to have symptomatic improvement until about three months. Our patient responses today have been quite durable and we feel that the TUNA procedure is definitely here to stay.
