What is prostate?
The prostate is part of a man’s reproductive system. It is a walnut-sized gland that lies at the base of the bladder and surrounds your urethra (tube that takes urine from the bladder, along the penis and out of your body). The main function of the prostate is to produce fluid which provides nutrition to the sperm.
What is enlarged prostate?
As men get older, the cells of the prostate begin to swell, which increases the size of the prostate. This is non-cancerous and is called benign prostatic hyperplasia (BPH). The enlarged puts pressure on the urethra (the tube through which you pass urine). This can make it difficult to pass urine and may cause urinary symptoms such as hesitancy, straining, weak stream, dribbling, incomplete emptying, frequency, urgency and nighttime urination. The enlargement can also lead to complications like retention (inability to urinate), urinary tract infections, hematuria (blood in urine), epididymorchitis (infection of testicle) and in rare cases, bladder damage and kidney failure.
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How do you treat enlarged prostate?
Not everyone who develops an enlarged prostate will need treatment. Only patients have complications from prostate enlargement and who have bother from their urinary symptoms require treatment.
The first line treatment is medical therapy or minimally invasive therapy (UROLIFT or REZUM). Medical therapy includes use of alpha blocker, 5-alpha reductase inhibitor, phosphodiestrace inhibitor and anticholinergic medications. In some patients, combination therapy may be utilized. Medical therapy is half as effective as minimaly invasive therapy and 25% as effective as surgical therapy.
Patients not responding to medical therapy or patients having complications from BPH usually require minimally invasive (UROLIFT or REZUM) or surgical therapy ( HOLEP, TURP, PVP, Aquablation, simple prostatectomy). The type of therapy depends on the prostate size, prostate anatomy and patient factors (comorbidties and use of blood thinners). The urologist may perform additional studies like cystoscopy, transrectal prostate ultrasound and urodynamic study to decide the best procedure for the patient.
The main complications of prostate procedures include bleeding, urinary tract infection, retrograde ejaculation, urinary incontinence, urinary frequency, need for post-operative catheterization and need for reoperation.
Below are a list of some of the treatment options for an enlarged prostate.
- UroLift ® System
- Transurethral resection of prostate (TURP)
- Holmium laser enucleation of prostate (HOLEP)
- Green light vaporization of prostate (PVP)
- Simple prostatectomy (open or robotic)
- Prostate artery emolization
The Urolift System is an FDA-approved, minimally invasive procedure that involves inserting implants in the prostate that lift and secure the prostate so it no longer blocks the urethra. There is no cutting or heating during this procedure so there is minimal post-procedure bleeding and pain. There are no sexual side effects and symptom relief extends up to five years following treatment. MedStar Georgetown was the first site in Washington, D.C., to offer the UroLift System. The procedure is appropriate for patients with a prostate size up to 100cc and can be performed on patients who are on blood thinners.
TURP involves resection (cutting) of the inner part of the prostate using electrocautery. The procedure is performed using a telescope inserted through the penis. It can be done utilizing monopolar or bipolar electrocautery. Most patients require overnight catheterization and hospitalization. Retreatment rates are low (<10%). The main complications include retrograde ejaculation (>75%), urinary incontinence (<5%). TURP can cause post-operative bleeding and is not recommended in patients with large prostates (>100gm) and where the bleeding risk is high. This procedure is considered the gold standard for surgical treatment for BPH.
Holep involves enucleation of the inner part of the prostate using a laser. The procedure is performed using a telescope inserted through the penis. The enucleated tissue is morcellated and removed from the bladder. Most patients require overnight catheterization and hospitalization. Retreatment rates are very low (<5%). The main complications include retrograde ejaculation (>75%) and urinary incontinence (<5%). It can be performed in patients with large prostates (>100gm) and in patients where the bleeding risk is high. This procedure is considered the ‘new’ gold standard for treatment of BPH as it is minimally invasive and can be performed in all patients with BPH.
PVP involves vaporization (evaporation) of the inner part of the prostate using a laser. The procedure is performed using a telescope inserted through the penis. No tissue is obtained for pathologic examination. Most patients require overnight catheterization and it can be performed in an outpatient setting. Retreatment rates are higher than TURP and HOLEP (10-20%) and some patients may have worsening of their urinary frequency and urgency. The main complications include retrograde ejaculation (>75%) and urinary incontinence (<5%). It cannot be performed in patients with large prostates (>100gm); however, it is safe to perform in patients where the bleeding risk is high.
Simple prostatectomy involves enucleation of the inner part of the prostate using an abdominal approach. This can be performed using an incision (open surgery) or using laparoscopic surgery. Most patients require prolonged catheterization (5-10 days) and hospitalization (2-3days). Retreatment rates are very low (<5%). The main complications include retrograde ejaculation (>75%), blood transfusion (<10%) and urinary incontinence (<5%). It is only performed in patients with large prostates (>100gm).
In this new procedure, the interventional radiologist will thread a tiny catheter through the artery in the groin to the arteries supplying blood to the prostate gland. The radiologist will then embolize (cut off the blood flow) to the prostate gland. The decreased blood flow causes the prostate gland to shrink. The procedure is investigational and is best suited for patients who are not the best candidates for other surgical therapies.
The Rezūm treatment involves injection of water vapor (steam) therapy to create necrosis within the transitional zone, which eventually shrinks the prostate, thereby improving urinary symptoms. The procedure is done in the office under local anesthesia using a telescope. The patients need a catheter for 3-7 days and it may take 4-6 weeks to see symptoms improvement. The risk of erectile and ejaculatory dysfunction is rare. The symptoms remained significantly improved over 60 months and the retreatment rate was 4.4% at 5 years.
The Aquablation procedure uses a targeted high velocity saline stream to ablate prostatic tissue using a robot without generation of thermal energy under real-time ultrasound guidance. The procedure is an alternative to TURP in patients with prostate volume between 30-100g. The procedure typically takes less than 45 minutes. Most patients require overnight catheterization and hospitalization. Long-term evidence of efficacy and retreatment rates are unknown.
The urologists at MedStar Georgetown University Hospital provide the whole range of medical and surgical therapies for treatment of enlarged prostate.