Alternative Treatments for Benign Prostatic Hyperplasia (BPH)
Benign Prostatic Hyperplasia (BPH) is the term used to describe the non-malignant growth of the prostate gland that is responsible for blocking the flow of urine out of the urinary bladder.
Transurethral Resection of the Prostate (TURP)
Transurethral resection of the prostate (TURP) has been the primary choice for the past 50 years of treatment for BPH that is causing obstruction of the bladder outlet.
Approximately 400,000 transurethral resections of the prostate are performed annually in the United States. TURP is a safe procedure with four out of five patients experiencing resolution of their voiding symptoms with improvement of all of their urinary flow measurements. Essentially, TURP is the removal of the obstructing portions of the prostate with a telescopic knife. The TURP requires an anesthetic and takes about 30-60 minutes to perform. A tube or catheter is inserted into the bladder and is left in place for 24 to 48 hours. The hospitalization lasts from 1-3 days and requires two weeks of severe activity restrictions and another two weeks of modest restrictions. No treatment to date has bettered the long term effectiveness of TURP in alleviating obstruction caused by benign prostatic hyperplasia.
But because TURP is a surgical procedure with some risks, and because of the costs and time off work, other methods of therapy are being looked at intensively by the medical community. These include medical treatments and alternative surgical treatments which are less complicated than transurethral resection of the prostate.
Transurethral Incision of the Prostate (TUIP)
A transurethral incision of the prostate (TUIP), is the alternative to TURP that comes closest to matching its results in both terms of symptom relief and improvement in flow rates. The basic goal of the procedure is to remove just a minimum amount of prostate tissue to allow adequate flow through the prostate. This is done by making a simple cut or incision along the entire length of the prostate. Because of the circular muscle fibers running around the prostate, the TUIP allows the bladder neck to spring open and allows free urinary flow. TUIP is particularly beneficial for smaller prostates and does have a lower incidence of ejaculation disturbances. The success rates for TUIP are about the same as transurethral resection of the prostate, but only in those patients that are carefully selected. Hospital stays and recovery are much shorter.
For the past few years, balloon dilation has been used clinically as an alternative to prostatectomy. It is very similar to the angioplasties done for coronary artery disease. Basically, a balloon is placed into the prostatic channel, either by finger guidance or telescopic guidance, and the balloon is then inflated to stretch the prostate channel. This has the apparent end result of tearing the prostate gland, creating an opening in the urinary channel. No prostate tissue is removed and the procedure does not work well for very large prostates. It appears that most of the patients after balloon dilation have recurrence of their symptoms relatively soon and require repeat treatments within two years. Balloons are receiving less acceptance as time goes on.
Transurethral laser ablation of the prostate (VLAP)
The laser is a high energy source, which has been used in medicine since the early seventies.
Essentially the procedure consists of passing a laser into the prostatic channel under telescopic guidance. The laser is the used to destroy or heat up the obstructing portions of the prostate. Compared to transurethral resection, then advantages of the VLAP procedure are: no signifcant bleeding, shorter hospitalization, reduced operating time, an apparent decreased incidence of postoperative scarring and decreased incidence of lack of ejaculation. The VLAP is not optimum in the treatment of the very large prostate yet because of the necessity for multiple treatments. Another concern is that no prostate tissue is removed so that we cannot be certain that cancer does not exist. Given the excellent diagnostic techniques available today with PSA and Ultrasound, the lack of tissue does not seem to be very important. There is also a fair amount of swelling of the prostate channel initially (3-10 days) which requires temporary catheterization (tube through penis into the bladder). A couple of weeks of frequency and irritation or urination occurs while the prostatic channel is healing. Biggest advantages: Quick and NO Bleeding!
Stents are wire devices shaped like small springs or coils. Stents are placed within the prostate channel and are used to keep the channel open.
Stents require about 30 minutes to place in the prostate, and the major problems revolve around the irritation and debris that form on the stent. These procedures are not FDA approved as of yet.
Hyperthermia of the Prostate
In concept, hyperthermia is similar to the transurethral laser procedure. In this, a microwave probe is placed into the prostatic channel and the prostate is heated up to temperatures above 105 degrees Fahrenheit. This causes destruction to the prostate tissue and shrinkage of the gland. Again, no prostate is removed for pathologic diagnosis. Some of the newer techniques revolve around a catheter that cools the lining of the prostate while the prostate tissue deep inside is heated, and this allows for very good recovery times. Multiple centers in the United States are now testing these procedures, and they are also available in Canada and Mexico. Hyperthermia is not FDA approved.
Non-surgical or Medical Treatments for BPH
Medical treatment for prostate disease has gone in multiple directions over the period of the last few years. The two major thrusts are in reducing prostate size and secondly, to relax the muscles that surround the prostate to allow flow through urinary channel.
The new drug, Proscar or finasteride, suppresses the action of the hormone testosterone in the prostate cells without affecting the level of testosterone in the blood stream. This allows men to have normal libido, but at the same time the prostate does not see the testosterone. Early studies show that 70 percent of patients are finding reduction in prostate volume with a regression of their symptoms and improvement in flow rates over a four to twelve month period. The drug is taken once a day, has very little in the way of side effects and the cost is approximately $45 a month.
Bladder Muscle Relaxing Medications
The smooth muscle that runs around the prostate channel can be relaxed by taking specific medications. Most of these drugs are blood pressure medications, including Hytrin or Minipress (terazosin and prazosin). The muscles around the neck of the bladder and prostate are relaxed by these medications, and many men have both subjective and objective improvement of their urinary flow. The medicine will not stop the growth of the prostate, and theoretically, as the prostate grows over the years, these medicines will become ineffective. A percentage of men will have difficulties with lowering of their blood pressure to a point where dizziness and even fainting can occur, and certainly, men with any type of heart disease would not be put on these medications without some risk. The action is immediate, however, and certainly, in those patients with blood pressure problems these might be used adjunctively with normal blood pressure treatment.
Not every man needs treatment for mild prostatic obstruction. It is normal for a man's urinary flow to reduce as he ages. Mandatory reasons to proceed with some form of treatment include recurring infections, repeated bleeding episodes, bladder or kidney damage, and the presence of cancer. When any of the above problems occur, or one's lifestyle is changed by the presence of prostate obstruction, consideration to treat the prostate enlargement should be given.
As time goes on, additional medications and surgical procedures will be developed to treat prostatic enlargement. The armamentarium that we have now is quite ample to handle most of the problems that are present, and each patient must be taken individually as to what seems to give them the best chance for success.