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MANAGEMENT OF PROSTATE ENLARGEMENT/BPH JESSICA E. PAONESSA, M.D. ASSISTANT PROFESSOR DEPARTMENT OF UROLOGY SUNY UPSTATE MEDICAL UNIVERSITY
Normal Prostate The prostate is a gland that sits below the bladder
and wraps around the urethra (in males)
Normal Prostate Function - produces fluid in semen - helps to carry sperm out of the body A normal prostate is ~20-30 grams - about the size of a walnut
Prostate Growth Growth continues throughout a man’s lifetime Testosterone/DHT play a permissive role Their presence is required for prostate growth, but does not cause BPH BPH is more common in older men 18% in 40’s 29% in 50’s 40% in 60’s 56% in 70’s 88% in 80’s 100% in 90’s
Risk Factors for BPH Male Aging Family history Heart disease Obesity (strongest predictor)
Enlarged Prostate a.k.a. BPH (benign prostatic hyperplasia) BPH tissue grows from the center of the prostate
and pushes the normal prostate tissue outward (orange) Flow of urine from the bladder is obstructed by BPH tissue BPH is NOT cancer
BPH causes increased urethral resistance, resulting in compensatory changes in bladder function. Decreased diameter of the urethra causes a
decreased urine flow rate. Increased pressure is needed to generate the same velocity of stream.
Weak stream Urinary frequency (I have to go all the time...) Urinary urgency (I have to go right now…) Urgency incontinence (I leak urine before I make it to the bathroom…) Urinary hesitancy (It takes a while for my stream to get started...) Sensation of incomplete emptying Nocturia (waking up at night to urinate) Intermittent stream (stream that starts and stops) Retention (I have to urinate, but I can't…)
A urologic emergency
Size Does NOT Predict Severity Of Symptoms
We don’t know exactly who will get symptoms or why.
BPH Treatments: Medications Alpha blockers -
Relax muscular tissue in the prostate to increase urinary flow Ex. Flomax, Uroxatrol, Rapaflo, Hytrin, Cardura Side effects: dizziness, fatigue, hypotension, edema, dyspnea, retrograde ejaculation
5 alpha reductase inhibitors -
Decrease the size/volume of the prostate to improve symptoms Ex. Proscar, Avodart Side effects: ED, decreased libido, decreased ejaculate volume, gynecomastia
When Medical Management Fails . . .
Indications For Surgery Kidney failure/Hydronephrosis Retention (acute*/chronic) Recurrent UTIs
Bladder stones Blood in urine* Failed medical therapy Desire to be off medications
Additional Work-Up Cystoscopy (cysto) Look into bladder with a camera Trans-rectal ultrasound (TRUS) Measure prostate size Urodynamic studies (UDS) Assess bladder function
Urine culture Rule out bladder infection/UTI Prostate biopsy (if indicated) Rule out prostate cancer
Alternatives To Surgery Clean intermittent self-catheterization (CIC) Indwelling transurethral catheter (Foley) Suprapubic catheter (SP tube)
BPH Treatments: Surgery Enucleation (HoLEP) Resection (TURP) Vaporization (PVP or green light laser)
Open surgery Office procedures TUMT TUNA Urolift Spanner
Embolization Robotic simple prostatectomy
Resection Transurethral resection of the prostate (TURP) The gold standard for comparison Scrapes out the inside of the prostate with an
electrocautery loop Overnight hospitalization with a catheter Trial of void the following morning ~10-25% of patients discharged with a catheter (short term) for failure to void on POD#1 90% of patients have improvement in their symptoms Complications (11%)
Blood transfusion, infection, re-operation, failure to void
Vaporization PVP or Green Light Laser Heats the prostate to 100°C to vaporize/boil the tissue
away Advantages - Decreased risk of post-op bleeding/need for blood transfusion - Patients on anticoagulation may benefit
Disadvantages - Higher re-operation rates for larger prostates (25% at 4 years) - No tissue for pathology
HoLEP Holmium Laser Enucleation of the Prostate Minimally invasive procedure (no incision) A telescope is passed through the urinary opening A high-powered laser is used to "core out" the BPH
tissue and push it into the bladder
Normal prostate tissue is left in place
BPH tissue in the bladder is cut into tiny pieces and
extracted through a morcellator device
All tissue removed is sent to pathology
A catheter is placed to drain and rinse the bladder
HoLEP The catheter is removed the next morning Patients typically go home after they urinate -
~24 hour hospital stay
What To Expect After Surgery Over 99% of patients are able to urinate after catheter
removal The majority of patients have little or no pain -
Some burning with urination for a few days
Blood in the urine is common -
Usually resolves within 7-10 days Patients can return to normal activity after the urine is clear
25-30% of patients will have temporary leakage of urine -
Typically resolves within a few weeks to months
No change in erectile function or ability to have an orgasm -
Retrograde ejaculation is common
What To Expect After Surgery
Comparison Of Techniques Gland Size
No size limit
Some increased bleeding risk
0.7% at 10 years
Highest bleeding risk
10-16% at 10 Yes years
Lowest bleeding risk
25% at 4 years
Advantages Of HoLEP Can treat any sized prostate Lowest reoperation rates Need for additional procedures is rare Removes the largest amount of tissue Tissue can be examined by a pathologist afterward Rule out cancer Almost everyone can urinate after catheter removal Excellent control of bleeding Short hospital stay Short catheter time Complication rates are very low Can be successful in patients who have failed other treatments Does not preclude future treatment for prostate cancer