The prostate, part of the male sexual apparatus is a gland located just beneath the bladder and is normally about the size and shape of a walnut. Its primary function is to produce most of the seminal fluid, the fluid that carries sperm. The prostate surrounds the first portion of the urethra - the tract that carries urine from the bladder to the outside.

Benign Prostatic Hyperplasia (BPH), also known as enlarged prostate, is a non-cancerous condition in which the prostate cells begin to increase in number and size. This growth which is very common and is thought to be a normal part of aging, causes the gland to compress or 'squeeze' the urethra making urination difficult or painful (see symptoms below).

Although it is not known exactly what causes prostate to enlarge, it is a very common condition generally affecting men over age 50.  In fact probably more than half of all men between the ages of 40-60 have symptoms of an enlarged prostate.  The symptoms are not specific, and thus can be due to other conditions, so a thorough history and physical (with perhaps other tests) by your doctor or urologist are imperative to make the diagnosis.  Enlarged prostate is not life threatening nor is it cancerous; but if left untreated, can lead to problems over time such as urinary retention (complete inability to urinate), bladder stones, urinary infections or kidney damage.

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Symptoms:

• Frequent need to urinate both day and night
• Difficulty starting urination
• Weak urine flow
• Stopping and starting of urine flow
• Feeling of being unable to completely empty your bladder
• Urinary incontinence (rare)

Again, these symptoms can be signs of other diseases, and need evaluation before a diagnosis of BPH is confirmed.

Treatment Options:

There are numerous ways to treat BPH, and the selection of therapy by you and your doctor will depend on several factors, such as your degree of symptoms, your amount of bother by these symptoms, your age and general health status, and your opinion on medical versus 'device' or surgical therapies.




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Diet/Herbal therapy:
Many men 'treat' their enlarged prostate with an antioxidant-laden, low fat diet, and many supplement this with Saw Palmetto or other herbal products.  Saw Palmetto has shown the most promise, and may be a completely adequate treatment especially for those men with mild symptoms who wish to avoid prescription medicine and/or surgery.




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Medical Therapy:
Two main classes of drugs are used for BPH therapy.




• Alpha Blockers, such as Flomax (and others) are the primarily used drugs to treat this condition as they act rapidly and have fairly good results at improving symptoms.  They do NOT however 'shrink' prostate tissue, but rather relax the smooth muscle surrounding the prostate and bladder neck, and thus work by this mechanism (i.e. they do not in effect treat the 'underlying problem').  They may also lose their effectiveness over time, and of course the therapy may need to be life-long which can be an expensive endeavor.  Side effects often include light-headedness or dizziness, especially during the first few doses, lethargy, tiredness, and in some cases retrograde ejaculation, or a situation whereby the semen doesn't flow 'forward' but rather travels backward into the bladder during sexually activity--this is NOT dangerous, but obviously alarms patients and is not conducive to fertility if the couple is still trying to have children.

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• Proscar, and other 5-alpha reductase (5-AR) inhibitors act by lowering a hormone called DHT (dihydrotestosterone) which is a very active form of testosterone (male hormone) and shrinks prostate tissue by roughly 20-30% over time.  Symptom improvement may not result, however, and in many cases, results of therapy take 3-6 months to be seen.  Proscar MAY reduce urinary retention rates, and MAY reduce prostate cancer risk, though this latter conclusion is still 'up in the air', in my opinion.  Proscar reliably cuts the PSA number in half, but this doesn't mean your cancer risk is halved just because one takes it...for screening purposes, urologists simply take the PSA number of a man on Proscar and double it to get the 'true' PSA number.  Side effects from Proscar, which is a once a day medication, are low and include a mild decrease in semen volume, some sexual side effects in some men, and may cause hair growth in some.  This drug can cause birth defects if handled by women who are pregnant or who become pregnant, so women of child-bearing age should not even handle these tablets!

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• Combination Therapy:  Recent studies done at UT Southwestern in Dallas have shown that using alpha blockers and 5-AR medicines like Proscar in combination may be better than using either alone.  Of course the expense of 2 medicines, and the added side effects of each may limit the feasibility of such a strategy.

"Minimally Invasive Therapies":

MIT, or minimally invasive therapies have been studied for about 15 years, with a constant stream of 'new ideas' having been put forth, many of them going the way of the dinosaur rather quickly.  The newest generation of technologies chiefly involve the use of thermal (heat) energy to treat the prostatic enlargement.

We at Denton Urology previously were performing TUMT procedures, but were not completely satisfied with their results.  We are no longer routinely offering these, and instead have opted to pursue PVP (Photoselective Vaporization of the Prostate) as a better solution for our BPH patients.  The PVP procedure (discussed below) is more invasive than TUMT, and requires anesthesia and a hospital setting to deliver, but appears to deliver better results with lower potential for blood loss and complications.
 

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Other MITs that are out there include TUNA (TransUrethral Needle Ablation), utilizing radiofrequency energy to create the prostatic heat, WIT (water induced thermotherapy), and various forms of laser technology therapies that treat BPH.  I will not go into detail about them at this point, and will expand this section as more is learned.  Many of these latter therapies have required more sedation and even general anesthesia, making them less attractive as 'minimally invasive' maneuvers.

One therapy briefly to be mentioned is the placement of a urethral 'wall stent'.  This type of stent, similar in concept to the one commonly used in heart patients is used to keep the prostatic urethra open via a titanium mesh 'stent' that is placed through a telescope and is designed to hold the prostatic urethra open mechanically.  This is not a common procedure and is usually chosen in men who are very poor surgical candidates since the procedure can be done very quickly and with little anesthesia in those men with concomitant medical problems or who are on blood thinners and who more aggressive surgery is not able to be performed.  It should be noted that although PVP requires anesthesia, limiting its use in men with high anesthesia risk, it can be done with men on blood thinners since it has a very low blood loss/bleeding risk.

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PVP
(Laserscope or "Greenlight Laser" Prostate Surgery)

PVP (Photoselective Vaporization of the Prostate, or also known as LPA or Laser Prostatic Ablation) utilizes a special wavelength of laser light, (KTP or "Greenlight" laser - 532 nanometer [nm]) to essentially vaporize prostate tissue as a method of removing the obstructing part of the prostate gland.  The procedure, usually done in the hospital's operating room, but often as either single day surgery or occasionally with an overnight's stay, has been around several years and has gained favor over other "minimally invasive procedures" by many of America's leading urologists.  Laserscope***, the company who manufactures the KTP laser device, has a great website to learn more (click link).  (***Laserscope was purchased/acquired by American Medical Systems -- a.k.a. AMS in 2006-2007, and the device is now is manufactured by this older more august corporation....10/17/07).

Another link from Laserscope is available here, as well.
(http://www.bphtreatment.org/)
 

Dr. Admire and Dr. Casey are both fully trained on the Laserscope PVP treatment, including the newer higher powered XPS system (see below^^).  The delivery of Laserscope PVP therapy to Denton Urology patients is now available to Denton Urology patients, and is generally delivered at THR Presbyterian Hospital of Denton.

The procedure is done under anesthesia, much like the anesthesia that would be given for a TURP.  The procedure will likely be most commonly performed in the hospital OR or cystoscopy suite.  The operation takes roughly 30-60 minutes, and a catheter is placed afterwards.  The patient usually is able to void on his own nearly immediately (often the patient has the catheter removed 4-6 hours after surgery on the same day, and there is usually very little to no blood in the urine.)  The benefits over TURP are this immediacy of results, and the need for little if any hospital stay.  The laser vaporizes prostate tissue while it coagulates small blood vessels, leaving an excellent field of vision for the surgeon during the procedure so that the likelihood of complications is lessened.  Less blood loss should also translate into a much lower need for blood or blood product replacement (as compared with TURP).  There is also less or no absorption of the irrigant fluids, making the procedure much safer for patients with heart, lung, and/or kidney disease who may otherwise have difficulties with the potentially massive amounts of fluids that can be absorbed into the bloodstream during an "old fashioned" TURP.

In essence, the Laserscope PVP is a great new addition to our armamentarium, and should allow us to do no-compromise prostate surgery for our patients with BPH with a lower incidence of adverse events, and a more rapid resumption of spontaneous catheter-free voiding and symptom improvement nearly on the order of that seen with the 'gold standard' TURP.  (^^As of October, 2012, we now have access to the new HPS Laser system, which basically is the "Turbo" Greenlight, having wattage up to 180W, instead of the original Greenlight which only went up to 80W, making treatment even faster, and perhaps even more effective than before.)

Other laser TUR surgeries utilize the Holmium-YAG laser at a high wattage (80W).  Presbyterian Hospital of Denton has a Holmium-YAG laser, but it is a lower wattage machine used only for fragmenting ureteral (kidney) stones, and perhaps a few other applications, but it is not powered for prostate treatment.  These Holmium treatments are called HoLAP or HoLEP (Holmium Laser Ablation of the Prostate, or Holmium Laser Enucleation of the Prostate respectively.)  Although some urologic surgeons may offer and even prefer the HoLAP or HoLEP procedures, we at Denton Urology are firmly sold on the Greenlight system (KTP Laser).

*Since this page was first authored, another technology deemed "Plasma Button" bipolar cautery therapy is also available to Denton Urology patients.  This therapy can be learned about here.

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Standard Surgery:
(TURP and Open Prostatectomy)

TURP, or TransUrethral Resection of the Prostate, is a tried and true therapy that urologists have been using for at least 60 years to treat enlarged prostates.  This is a surgical procedure done in the operating room whereby the obstructing prostate tissue is physically removed with a specially designed scope inserted into the urethra and utilizes electrical current to 'trim' the excessive and obstructing prostate tissue.  The therapy is very effective in a vast majority of patients, and is still chosen by many patients, though quite fewer procedures are done now than say 15 years ago owing to the advent of the medical therapies and other MIT type therapies.  The TURP operation typically requires a 2 day hospital stay, and is associated with the occasional need for blood transfusion (rare) and some complications such as incontinence (inability to control the urine) in about 1% and sexual dysfunction (poor erections) in 3-5% depending on the study one reads.  The therapy, however does have higher symptom improvement rates and increases urinary flow better than any of the other therapies that have already been mentioned.

Open Prostatectomy ("Simple Prostatectomy") is done in lieu of TURP in patients whose glands are so massively large that TURP done telescopically is not feasible due to the extremely large size of the glands.  This is a fairly rare surgery, but still quite effective.  It obviously requires an open incision.  The most common open simple prostatectomy is called a suprapubic prostatectomy whereby the bladder (urinary) is opened and the obstructing part of the  prostate is physically separated and removed in its entirety through the bladder incision.  Another type called a retropubic approach simply gets at the prostatic 'adenoma' or obstructing glandular tissue without entering the bladder.  Both procedures have fairly equivalent effectiveness, and are selected, as mentioned in men with VERY large prostates...

Open surgery is still a very good and viable option, with the highest chance of symptom improvement, but the risks are higher, as mentioned.

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Summary:

In summary, the therapies for BPH are numerous and are evolving.  PVP and TURP appear to be the most attractive surgical therapies available, though many men choose medical therapy and are very happy with their choice.  Over time we will tell if medical therapy alone can sustain men over long periods of time in regards to their BPH symptoms, and much is yet to be learned.

Thanks for your attention, and please call for your appointment to discuss your urinary symptoms (LUTS - Lower Urinary Tract Symptoms) with one of the doctors at Denton Urology if you are bothered by the symptoms outlined above.

To check your symptoms, use our Symptom Score Questionnaire Online to get your AUA-SS Number.

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