24 Jun 2014

What’s the Best Treatment for the Enlarged Prostate?

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This is a question that I am frequently asked by my patients, friends and fellow gym members.

Benign prostatic hypertrophy (BPH) or the enlarged prostate is a common problem that affects the aging male starting at about 45-50 years of age. The enlarging prostate narrows the urethra and causes slow and difficult urination. It can be bothersome to the patient and if untreated, it can lead to complications including permanent damage to the kidneys and bladder.

Treatment of the enlarged prostate depends on many factors such as the severity of the symptoms, the size of the prostate gland, age, health condition of the patient, etc. The first line of treatment is to give the patient a pill that can help relax and/or shrink the prostate. Most patients treated with medication eventually end up needing a more permanent treatment that entails some type of surgery.

One procedure that is like a bridge or transitional step between medical therapy and surgery, is a one-hour office procedure called “transurethral microwave thermotherapy of the prostate” or TUMT. It consists of heating the prostatic tissue by exposing it to microwave energy delivered through a special catheter that creates a temperature of 50◦ C within the gland. TUMT works by relaxing the prostatic muscle fibers and by producing some shrinkage of the gland. About 75-80% of the patients treated by TUMT report clinical improvement in their urinary symptoms. Since this is not a surgical procedure, it is difficult to predict how long the procedure will be effective. I tell my patients this is a safe “delaying tactic” usually of several years until a more permanent surgical procedure becomes necessary.

Surgery for BPH is the gold standard treatment for BPH. Today, almost all prostate surgeries are done by a minimally invasive transurethral approach. In rare cases, when the gland is extremely large, urologists still recommend an open surgical procedure called retropubic prostatectomy.

Transurethral resection of the prostate (TURP) is the historic gold standard for the surgical treatment of BPH. It uses electricity to resect and cauterize tissue. However, with advances in laser technology, an increasing number of prostate surgeries are being performed by using laser as the energy source to perform the laser vaporization of the prostate (LVP).

The big question is which modality is best? The answer depends on the treating urologist’s training, experience and comfort with new technology, the patient characteristics, etc.

During the recent annual congress of the European Association of Urology held in Stockholm, Sweden, research data from the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database for the years 2006 to 2011, was presented by a team of Harvard researchers. This was a multi-institutional study. They did a detailed analysis by comparing clinical data from about 4800 patients who underwent TURP to data from 2600 patients who had a laser procedure. They compared patient characteristics, operative time, blood transfusions, length of stay, perioperative complications, re-interventions and perioperative mortality.

The study showed that both TURP and LVP appeared to be generally safe. While pretty close with respect to overall complications and perioperative mortality, some significant differences were noted in some specific areas. The laser procedure was associated with a decreased risk for prolonged length of stay compared to TURP. LVP had a shorter operative time, reduced need for transfusion, and a lower 30-day re-intervention rate than TURP. Compared to the laser procedure, TURP was associated with a higher rate of pulmonary complications, partly explained by the increased use of general anesthesia in men undergoing TURP. The researchers concluded by stating that in general, the comparative morbidity was slightly higher with TURP but the overall morbidity was relatively low and they considered both procedures to be relatively benign.

I have always been interested in lasers in urology. I took my first training course on lasers in the early 1980’s at the Mayo Clinic when medical lasers were still in their infancy. Over the years, I have tried all kinds of lasers as they have become available for clinical use. I have used the Yag laser, Holmium laser. KTP laser and more recently the Thulium laser for various urological procedures.

My preferred procedure to treat the enlarged prostate is the Thulium laser prostatectomy, also known as Quanta or Revolix laser prostatectomy. I like it because it is safe, does not cause coagulation necrosis, there is no intra-operative bleeding and there is no intravascular absorption of the irrigation fluid that can lead to complications. Being an end-firing laser, the Thulium laser allows both precise cutting and vaporization of tissue making the procedure faster. It is an outpatient procedure. Because of its safety characteristics, larger glands can be treated without added risk. Post-operative recovery is quick and uncomplicated. I still do an occasional bipolar TURP when the laser is not available. The “button” TURP, as the bipolar TURP is often referred to, is a great improvement over the conventional TURP. The bottom line however is that I am a laser prostate guy.

Garo M. Tertzakian, M.D.

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