Benign Prostatic Hyperplasia

When does Benign Prostatic Hyperplasia (BPH) begin?

BPH usually begins at 30s and progresses gradually. Initial symptoms emerge at 50 years of age and later on. Most of men aged 60 have minimal BPH. The probability of the inability to urinate and difficulty urinating secondary to BPH is 90% in men aged 85.

What are symptoms of BPH?

The prostate gland enlarges in BPH. The urethra, the urinary canal that lies in the middle of the prostate gland, is compressed and it narrows due to the enlargement. This condition prevents or challenges outflow of the urine from the bladder. Abnormal urinary frequency occurs in daytime and at night due to difficulty urinating (Pollakiuria and nocturia). Other common symptoms include urinary urgency and weak and slow urine flow, secondary to blocked outflow of urine from the bladder. Urinary tract infections, secondary to inability to empty the bladder completely, and kidney damage and kidney failure, secondary to blocked urinary tracts, may develop.

Signs and symptoms of BPH:

Symptoms may include:

Urinary frequency (pollakiuria)
Difficulty starting urination
Frequent urination at night (nocturia)
Leaking after voiding
The inability to empty the bladder completely
Blood in the urine (BPH may result in damage to capillaries).
Recurrent urinary tract infections

TREATMENT OF BPH:

A) Non-surgical treatments:
Follow-up:
Not all BPH patients require treatment. Patients without difficulty urinating and resultant signs and symptoms can be followed up, if damage to the kidneys or urinary bladder is not detected on urologic examination and tests. Follow-up is planned at recommended intervals, including the longest one on annual basis.
Medication therapy: 
Treatment is started when BPH-related complaints hinder daily life activities and impair quality of life. Medications are usually the first option.
5-Alpha reductase inhibitors: These medications include Finasteride (Prosterid®, Proscar®, Dilaprost®) and Dutasteride (Avodart®) Such medications prevent transformation of testosterone into dihydrotestosterone (DHT), the active form of testosterone. It is reported that size of the prostate is reduced to a certain extent in this way. Side effects include loss of libido, impotence (erectile dysfunction), enlargement and tenderness of breasts and low sperm count.
Alpha-blockers: These medications relax smooth muscles of the bladder neck and prostate, resulting in enlargement of the urethra. The medications are taken by mouth once a day. The most common ones are Alfuzosin (Xatral®), Doxazosin (Cardura®), Terazosin (Hytrin®) and Tamsulosin (Flomax®). Side effects may include headache, dizziness, tiredness, fatigue and low blood pressure.
B) Minimally invasive treatments:
Implantation of prostatic stent:
The procedure can be performed for patients who do not respond to medication therapy and who are inoperable due to impaired overall health. It is a coil spring that is placed through a fine tube and enlarges the urethra when released. Urolume® and Memotherm® are the most common stents. The procedure does not require general anesthesia or hospital stay, the risk of bleeding is very low and these stents can be implanted in a short time. Major disadvantages may include improper placement of the stent, displacement of stent, irritation and resultant frequent urination, urinary incontinence and pain.

C) Invasive Treatments:

They are classified into open or closed prostate surgeries.
TRANSURETHRAL RESECTION of the PROSTATE (TURP):
Transurethral Resection of the Prostate is the most common technique in surgical treatment of benign prostatic hyperplasia (BPH). In this method, general or lumbar (spinal or epidural ) anesthesia is induced and a special device, namely resectoscope, is inserted through the urethra. The prostatic tissues are cut with electric current. Images magnified up to 10-12x are transferred to a monitor by an optic device. During the procedure, it is required to use irrigation fluid continuously. The electric current is delivered to the tissues over a semi-circular wire, namely “loop”, and bleeding is stopped with the loop, while the prostatic tissues are cut in the form of small chips. Then, the prostatic tissues that accumulate in the urinary bladder are removed with vacuum. A catheter is postoperatively placed through the urethra and the catheter is removed 2 days later.

The most important advantages of transurethral resection of the prostate include creation of a cavity by removing the obstructing part of the prostate and pathological examination of the surgical specimens. Intra-or post-operative bleeding may rarely occur that requires no blood transfusion in most cases. Rarely, urinary tract stenoses may develop in the postoperative course.

Greenlight Laser therapy for enlargement of the prostate
The use of laser is becoming increasingly popular in many fields of medicine and many laser types have been used in prostate surgeries until now. For this purpose, the most recent method is Greenlight laser. The KTP laser used in Greenlight laser prostatectomy, also called PVP (photoselective vaporization of the prostate) in medical terminology, generates a green light and accordingly, this method is called “Greenlight Prostatectomy”. KTP laser is selectively absorbed by the prostatic tissue or in other words, it has an affinity for the prostate. Actually, Greenlight laser energy is absorbed by hemoglobin and blood vessels are vaporized together with the prostatic tissue. Thus, the procedure is associated with very minimal bleeding.

Greenlight Laser Surgery

The surgery can be performed under general anesthesia or lumbar anesthesia (involving the injection of an anesthetic agent into lumbar spine). For high-risk patients, local anesthesia can be used as well. A cystoscope is inserted into the urethra and the bladder and prostate are visualized and the prostate is evaporated through lights generated by a laser probe advanced via cystoscope. When the prostatic tissue is evaporated with laser beams, a cavity is formed that allows the urine to pass smoothly. As no tissue is excised for postoperative pathological exam, investigations regarding prostate cancer should necessarily be done for all patients before the procedure.

Advantages of Greenlight Laser:

For patients who take anticoagulants, such as Coumadin and Aspirin, the procedure can be performed without any need to stop these medications. It is required to stop anticoagulants before open prostatic surgery and closed surgery, such as TUR-P, to prevent the risk of bleeding. It is not required to stop these medications for Greenlight laser procedure. Because Greenlight laser energy is absorbed by hemoglobin and evaporates blood vessels together with the prostatic tissues. Thus, the procedure is associated with very minimal bleeding.

There is no or very minimal bleeding. During a Greenlight laser procedure, a coagulation zone occurs beneath the vaporized prostatic segment. Therefore, almost no bleeding occurs during or after the procedure.

Short-term catheterization: Compared to other surgical techniques, Greenlight laser procedure is associated with shorter duration of catheterization and hospital stay (24 hours).

The length of hospital stay is very short. Greenlight laser procedure is performed as a day surgery at many centers in the U.S. The patient can be discharged on the same day.

There is no risk of TUR syndrome. During Greenlight procedure, isotonic solution is used and thus, “TUR syndrome”, secondary to absorption of fluids used during TUR-P, does not occur.

Greenlight laser was first introduced in early 2000s, after devices with 60-80 watts of power were started to be used. Recently, parallel to technological advancements, devices with 120 watts of power (HPS) were developed and introduced to the practice. These devices have more power than the previous models and they are advantageous by evaporating far more tissues in a short time. In this way, patients with severely enlarged prostate can be treated.

With Plasma Kinetic method, tissues excised during the surgery can be sent to pathological exam. This method accurately clarifies whether the prostatic enlargement is benign or not. As no tissue is excised in laser method (Greenlight), no pathological exam can be made.
Enlargement of the prostate poses no obstacle, since Plasma Kinetic method uses isotonic saline. The duration of surgery is shorter and the risk of bleeding is lower. The procedure can be performed under local anesthesia. Thus, it can be performed for patients with cardiac and pulmonary problems.

Plasma Kinetic is the safest treatment modality for the prostate.

Superiorities of plasma kinetics

The risk of fatal water intoxication is not present due to use of isotonic sodium chloride.
The specimens are examined in pathology laboratory and cancer can be diagnosed and treated, if present.
The risk of bleeding is very low – images are more clear which ensures working more comfortably.
The duration of surgery is shorter. It uses low energy; the energy affects only the areas where it contacts the prostate and thus, peripheral tissues are not harmed. Therefore, it can even be performed for the patients with pacemaker.
Duration of catheterization is short.
Professor Biri says “In “TUR” surgeries, access is made from urethra with laparoscopic method and the prostate is removed after being excised into pieces with special devices using an energy source. The energy source can be monopolar or bipolar. Monopolar systems require electric currents that flow through patient’s body.
However, this is unnecessary in bipolar systems. The bipolar TUR system that we currently use is the Plasma Kinetic TUR system.". Stating that the system is recently used in urology, Professor Biri adds;
“The system uses a plasma kinetic energy source and this system has many advantages in comparison to conventional monopolar systems. The most critical advantage is the fact that the electric current does not flow through the patient's body.
It can be, therefore, preferred even for patients with pacemaker without facing a problem, such as effects of the electric current on the pacemaker. The duration of surgery is quite short, as this system allows safer and quicker excision of the prostate during the surgery. This also means milder bleeding and shorter hospital stay. The urinary catheter is removed within a shorter period after the surgery.
With Plasma Kinetic method, the tissues extracted during the surgery may be sent for tissue examination. As the tissues are not removed during laser assisted surgeries, plasma kinetic treatment is also advantageous regarding this aspect. TUR syndrome secondary to the fluid used to obtain images during conventional TUR surgeries develops by 1 to 2 percent. TUR syndrome is the decline of sodium levels in body due to leakage of the fluid into the body.
Plasma kinetic method uses saline to obtain images. This fluid does not cause TUR syndrome even if it is absorbed to the body. There is risk of stenosis in urethra or urinary bladder following conventional TUR surgeries. Possibility of stenosis is very low in Plasma kinetic TUR surgeries. Professor Biri, who emphasized that the plasma kinetic method is not solely used for prostate surgeries, but it is also possible to perform laparoscopic treatment of urinary bladder cancers, expressed that the laparoscopic treatment of urinary bladder cancers is more difficult. Stating that this method allows quick and proper excisions, Professor Biri says “Plasma kinetic system is also the optimal method for treatment of stenosis in the urethra”.
Plasma vaporisation

This is an endoscopic (closed) prostate surgery technique. When patients are operated on with this technique, the prostatic tissue is vaporized with high electric energy. Therefore, bleeding is very minimal, if any, during and after surgery with plasma vaporization technique. This surgical technique ensures patient’s comfort during and after the surgery. Contrary to the other closed surgery technique, TURP, special fluids are not used in surgeries performed with plasma vaporization technique. The problems caused by these special fluids do not occur in surgeries performed with plasma vaporization technique. Unlike TURP surgery, this surgical technique does not require excision of prostatic capsule and thus, potential resultant complications are eliminated.

Open or laparoscopic surgery should be considered as an option in cases where the prostate weight above 100-120 gram.

Other than two prostatic diseases (benign prostatic hyperplasia and prostate cancer), there is another disease of prostate gland that is more common in young men, called chronic prostatitis (chronic inflammation of the prostate). Symptoms of above mentioned chronic prostatitis include urinary frequency, sense of stasis or blunt pain that radiates to rectum from testicles or penile base, aching and sense of burn during ejaculation. While this chronic infection that occurs due to microorganisms can be managed with anti-biotherapy, treatment of inflammation that is unrelated to microorganisms may last longer.

In some cases, BPH may be associated with prostatitis and the inflammation aggravates symptoms of the prostate. Long-term antibiotic and anti-inflammatory agents may, therefore, be added to above mentioned medical treatment.

Open Prostate Surgery 

In open prostatectomy; a 10-cm horizontal incision is made 5-6 cm below the umbilicus. The urinary bladder is accessed through this incision, it is opened and the enlarged parts of the prostate are extracted. A catheter is placed to the urinary bladder from the urethra. This catheter is removed on postoperative day 6 or 7, if no problems occur. A drain, which will be removed two or three days after the surgery, is placed to the surgical site (a drain looks like a thin hose and it is removed at the point of care (in patient’s room). The removal process is completely painless and easy for the patient; it does not require anesthesia etc.). Next, all manipulated tissues are stitched and closed. General, spinal or another anesthesia method can be used during this surgery, depending on decision of the anesthesiologist.

Alternatives to open prostatectomy: 

Medical treatments can be considered in early stages of the disease. Medical treatments cannot cure the condition definitively; most of them only dilate the urethra to facilitate outflow of the urine, but this effect disappears, when the medicine is stopped.

Enlarged prostatic tissues can be reduced without requiring an open surgery with therapeutic methods, such as electric current, laser, high intensity focused ultrasound, cryotherapy etc.

Why this method is preferred in your surgery: 

The most common method for surgical treatment of benign prostatic hyperplasia is the laparoscopic surgery (TUR.P, reduction of the prostate by excising enlarged prostatic tissues into small pieces with special equipment and electric current). However, open prostate surgery is preferred for your condition. Because;

Volume of the prostate is high and if you are operated on with one of other methods, duration of the surgery may prolong significantly, bleeding may extend beyond the acceptable limits and prostatic tissue residue is likely that may lead to potential future problems.

There is/are stone/stones in your urinary bladder, which cannot be treated with endoscopic (closed) method.

Another condition in your body prevents you being positioned properly for laparoscopic surgery.