Benign enlargement of prostate (BPH) affects men above age 50. Why prostate gland increase in size beyond 50 years is still unclear & role of male sexual hormone, testosterone as a causative agent is debatable.
Whatever may be the cause, symptoms arising due to enlargement of prostate is quite bothersome for men. Usual symptoms are weak stream, taking longer time to urinate & empty the bladder, frequent urination, getting up many times at night. Sometimes patient experiences passing blood in urine or even may develop acute urinary retention requiring catheterization. Untreated men may develop recurrent urinary tract infection, formation of stone in urinary bladder, damage to the kidney due to backpressure. Loss of bladder control & loss of bladder tone or contractility are other seriouenign enlargement of prostate (BPH) affects men above age 50.
Why prostate gland increase in size beyond 50 years is still unclear & role of male sexual hormone, testosterone as a causative agent is debatable.
Whatever may be the cause, symptoms arising due to enlargement of prostate is quite bothersome for men. Usual symptoms are weak stream, taking longer time to urinate & empty the bladder, frequent urination, getting up many times at night. Sometimes patient experiences passing blood in urine or even may develop acute urinary rs complications of untreated BPH with serious long term consequences.
Treatment of BPH is mainly medical or surgical. All patients should be given trial with medicine initially once it is decided that he needs treatment to control symptoms due to BPH.
Medical treatment: usually two type of medicines are available
1) Alpha blockers: Tamsulosin (Urimax), Alfuzosin (Alfusin or Alfoo) & Silodosin (Sildoo or Silodal). All are quite effective; side effects like palpitation, giddiness and uneasiness may occur & may necessitate stoppage of treatment. Newer generation of drugs like Silodosin causes less of side effects & may be more effective, but causes retrograde ejaculation or failure to discharge semen following coitus.
2) 5 alpha – reductase inhibitors (Finesteride / Dutasteride) They act by reducing the size of the prostate. Combination of alpha blocker & Dutasteride are better especially for large glands, when used for a period of more than 6 months.
Surgery for prostate is indicated when
1). Medical treatment fails.
2). Complications due to BPH develops like bladder stone, recurrent infection, repeated passage of blood in urine, backpressure changes, acute urinary retention, progressively decreasing bladder capacity (as this may cause loss of bladder control) or progressively increasing bladder capacity (as this may cause of loss of bladder muscle tone or contractility).
Till few years ago TUR-‘P’ (Transurethral resection of prostate) was the sole option available all over; But TUR‘P’ involves more of complications as tissues are cut using electric current. Almost 20% – 30% patient develop complications like bleeding, decrease in sodium level in blood immediate post surgery, septicemia etc. Most of them will need multiple blood transfusion, admission in ICU & very high level of antibiotics. Long term complications like stricture urethra (narrowing of urine pipe) & erectile dysfunction are also more with TUR‘P’; Recurrence of prostate following TURP also high as complete removal of prostate most of the time may not be possible due to bleeding especially for large gland.
Introduction or HoLEP (holmium laser enucleation of prostate) is a boon to the mankind. As cutting modality uses laser there is very minimal bleeding during or after surgery, requirement of blood transfusion is very rare & consequently patients are discharged from the hospital within 24 – 36 hrs. Moreover, HoLEP technique is such that almost entire prostate is enucleated or removed from the fossa, thus future recurrence of prostate following a nicely done HoLEP is also rare.
So laser prostate surgery or HoLEP is a blood less & painless procedure & patient has fast recovery. And sooner or later HoLEP will be the gold standard surgical treatment option for enlarged prostate.
Institute of urology introduced 100 watt holmium laser machine from lumenis, USA in 2007. Since then our journey continues & more than 3000 laser prostate surgery has been performed with remarkably high success rate & greater patient satisfaction.
Other advantages of holmium laser prostate surgery.
1) Any size of the gland can be subjected to laser prostate surgery. Gland size >200 gms can be easily done without requiring blood transfusion. We have done quite a few gland weighting >250 – 300 gms; whereas with TUR‘P’ removal of more than 100 gms of prostate can be quite challenging.
2) Ideal for patients with cardiac pacemaker. Electric current usage during TUR‘P’ causes disturbances or malfunctioning of the pacemaker where as no such things happen during HoLEP.
3) As it is a blood less surgery, bacteria / toxins form the bladder and prostatic fossa less likely to enter the blood stream, thus reducing the chance of septicemia significantly. Whereas during TUR‘P’, because of bleeding & opening up of blood vessels, toxins enter the blood stream quite frequently thereby chance of septicemia is high. Thereby HoLEP is ideal for diabetic or immuno compromised patients.
4) Due to blood less / painless technique older people tolerate the procedure much better compared to TUR‘P’. Institute of urology has quite a few patients above 90 years of aged treated successfully using laser machine.
5) Less chance of postoperative stricture formation (narrowing of urine pipe). Incidence of erectile dysfunction is also less with HoLEP.
How to go about the procedure of “HoLEP”.
Once it is decided to operate upon a patient of BPH, first patients are investigated properly for anesthesia & surgical fitness. This involves routine blood & urine tests, x-ray chest, ECG & 2D echo. Patients are examined by physician, cardiologist & anesthesiologist. Patients are counselled & pros & cons of the procedure are explained to him & his relatives. Preoperative urinary infection if any is controlled by antibiotics prior to surgery. Patient taking ecosprin need not stop the medicine prior to HoLEP, but clopidegrol has to be stopped 05 days before surgery.-
Single most important investigation to select a patient for HoLEP is to rule out malignancy or cancer in the prostate; Institute of urology routinely performs DRE (digital rectal examination or finger palpable of prostate by urologist through rectum to rule out any hard areas in the prostate which may indicate cancerous growth in the gland), TRUS (transrectal sonography to rule out any abnormal looking areas) & S. PSA level. Suspicious cases of cancer prostate are subjected to MRI scan to rule out malignancy. Suspicious cases at our center further subjected to needle biopsy of prostate & managed accordingly.
Routinely patients are admitted on the day of surgery. Same patients are admitted overnight if situation demands.
The procedure of HoLEP is carried out in OT under spinal anesthesia. Patient remain awake during the procedure and may observe the operation in large monitor it he wishes to do so. Usually 100 gms prostate requires 1 hour of operating time. An endoscope or telescope with camera is passed into the bladder through the urethra & using laser prostatic tissue is enucleated from its bed & delivered to the bladder. Then tissue are fragmented using morcellator blade & sucked out. Removed tissues are sent for histopathology examination routinely to rule out existing malignant focus. At the end of the procedure a catheter is left in the bladder for 1 – 2 days.
Mild blood tinged urine is common after the procedure for a day or two. Usually patients remain very comfortable during next 24 – 36 hrs. Upon removal of catheter patient passes urine with very good flow. Transient urinary leakage may occur but usually subsides within a few days.
Institute of urology over the years developed wonderful HoLEP techniques where almost all patients are continent immediately after catheter removal.
Team of urologists at institute of urology headed by Dr. M. Roychowdhury performs HoLEP after strict patient selection and uses meticulous & diligent technique. Excellent patient counseling & support system also available post surgery.
At out institute usually patients are followed up after 7 days, after 6 weeks & 3 months; At every visit uroflometry & urine examination are carried out to see that patients are doing well.
Points to ponder
Patient with BPH often develop overactive bladder where because of small capacity of bladder there is loss of bladder control before & after surgery. Patients complaints of increased urinary frequency, urgency & urge incontinence following surgery & remain dissatisfied. But many of them show significant improvement in bladder control 3 – 6 months after surgery. So, HoLEP in an overactive bladder should be done after thoroughly explaining the patients about the consequences & counseling about slow recovery of bladder control (often taking 6 months to one year) following surgery.
In another scenario if bladder muscle gets weakened due to BPH they are not able to void following successful HoLEP; Due to lack bladder muscle power or strength patients are not able to void after surgery. So at our center hypotonic bladders are not operated upon until tone returns.