Surgery for enlarged prostate

The prostate is a gland placed below the bladder, and a part of the urinary tube passes through it. Only men have the prostate. Its role is still incompletely tested, but it is known that this gland produces a liquid part of semen. It has the same size as a chestnut and begins to grow immediately after the age of 25.

Symptoms

Prostate enlargement is the consequence of the male sex hormone – testosterone (dihydrotestosterone). Somewhere around the age of 50, a man begins to feel symptoms of enlarged prostate. They are manifested in frequent nocturnal enuresis, slowed or delayed urination, weak urine flow, inability to delay urination, incomplete bladder emptying, the abruptness of urine flow during bladder emptying, urine dripping, which takes a few seconds at the end of urination, urination accompanied with pain, hematuria - the presence of blood in urine, urine retention, frequent urination, strong and sudden urge to urinate, incontinence - uncontrolled urination. Symptoms appear gradually, and a patient goes to the doctor only when these symptoms begin to disrupt normal life.

Treatment

Once the diagnosis is established, the enlarged prostate treatment may begin. Treatment can be:

(1) hormonal – a group of drugs that blocks alfa1 adrenoceptor (floma x, x atral, Cardura, etc.) and drugs that inhibit 5 alpha-reductase, an enzyme that is located in the prostate and is responsible for prostate growth (Proscar, Avodart). These drugs do not reduce prostate but mitigate the above symptoms of enlarged prostate.

(2) invasive - microwaves, laser, or Cryotherapy (freezing).

(3) surgical - through the urinary tube by Transurethral resection (TUR), or, if a prostate is very large, doctors perform the open surgery, in which the entire prostate is removed.

It is believed that Transurethral resection (TUR) is the gold standard in the treatment of enlarged prostate. Surgery is usually indicated in men with symptoms of incontinence, blood in the urine, urine retention, and recurrent urinary tract infections.

Benign prostatic hyperplasia (BPH) is a noncancerous enlargement of the prostate gland due to androgenic stimulus exerted by dihydrotestosterone, a metabolite derived from testosterone by the action of the enzyme 5-alpha reductase. The most important risk factors for developing BPH include age and the presence of functioning testicles (due to their hormonal influence); a family history of this condition and obesity. A total of 50% of 60-year-old men and 90% of 85-year-olds have microscopic BPH; however, only 50% of patients with this histological finding will have a macroscopic enlargement of the gland, and about 50% of these will develop symptoms. Therefore, the most appropriate name for this entity is “lower urinary tract symptoms” (LUTS), considering that prostate enlargement is only one of the factors related to the presence of symptoms. The prevalence of LUTS is between 10% and 30% for men in their 60–70s and 30% in their 80s.

Transurethral resection of the prostate (TURP) is the gold standard surgical procedure, but other alternatives using laser (HoLEP and ThuLEP) and robotic water jets (Aquablation) are emerging treatments aimed at reducing postoperative morbidity.
Minimally invasive procedures conducted in outpatient settings and under local anesthesia or sedation are increasingly being used, especially in those patients with high surgical risk due to comorbidities. These procedures include prostatic arterial embolization, water vapor thermal therapy (Rezum), prostatic urethral lift (Urolift), temporary implantable nitinol device (TIND/iTIND), and transurethral microwave thermotherapy (TUMT).
For those with moderate symptoms, alpha-blockers are the first treatment option, reducing symptoms by 30–40% and improving urinary flow by 20–25%. Common side effects include hypotension and ejaculatory dysfunction. However, 5-alpha reductase inhibitors (5-ARI) can cause a moderate reduction in symptoms (15–30%) and prostate size, reducing the risk of AUR and the need for surgery, but there is a latency for this improvement (3–6 months), and they are most effective in patients with larger prostates (>30 cc) that will be treated on a long-term basis.

In a recent analysis of the uncertainties of the evidence surrounding these new procedures, we found ten ongoing trials comparing them to TURP or alternatives to TURP, which would further clarify their role in the treatment of LUTS due to BPH. Interestingly, we have identified four trials comparing these procedures with medical management which highlights the emerging role as initial treatment of this condition. More recently, it has been proposed that WVTT can be a cost-effective first-line therapy, but this is reliant in the previously described weak evidence base.

✓ Fact confirmed: Update on the management of benign prostatic hyperplasia and the role of minimally invasive procedures Juan V.A. Franco, Pablo Tesolin, and Jae Hung Jung; 2023 Jan 10.

Complications of surgical treatment are very rare, sharing the same risk with all other surgical procedures. Open prostatectomy is usually performed with general or spinal anesthesia. This procedure is time-consuming and requires staying in the hospital for seven to ten days.

American doctors are experimenting with a new and appears to be an effective method of enlarged prostate treatment with laser. Strongly focused green laser light could be a solution for common health problems among older men. Excess tissue, which causes urological disorders, is removed by simple surgery thanks to this device.

The surgery has no side effects, which normally occur in conventional prostate surgery. The procedure is done outpatient, and patients can be released from the hospital on the same day. Laser light is so strong that surgeons and nurses have to wear special protective glasses.

This procedure is particularly suitable for patients who don't feel any improvement after drug therapy, and for those who for some reason cannot or do not want to undergo traditional surgery with a scalpel. The surgery is so precise that the removal of tissue doesn't affect the surrounding nerves and other sensitive cells.