When the prostate is very large, usually much greater than 100 grams as measured by a prostate ultrasound and the patient needs surgery, many urologists prefer an open or robotically assisted prostatectomy because it is safer and more effective. In this surgery the core(Transition Zone) of the prostate is removed after opening the bladder and/ or prostate. The peripheral zone is left behind. The recovery and bladder catheterization is typically much longer than TURP. It is important not to confuse this surgery with complete removal of the prostate performed for prostate cancer. In other words -Open prostatectomy is performed for benign prostatic hyperplasia (BPH) while Radical Prostatectomy is only recommended for prostate Cancer.
Benign Prostatic Hyperplasia-BPH
Not to be confused with prostate cancer, benign prostatic hyperplasia (BPH) is essentially a normal part of male aging. Most men with benign prostatic hyperplasia BPH will never develop clinical prostate cancer. While prostate cancer typically grows in the peripheral zone of the prostate, BPH is found in the transition zone which is more toward the center (the core) of the prostate gland.
After the age of 40 the prostate progressively enlarges (from size 15 grams to approximately 50 grams – rarely up to 250 grams or more) to the point where urination starts becoming more difficult. Typical symptoms include needing to urinate very often (frequency) during the day or during the night (nocturia). Some patients start taking a while to get started (urinary hesitancy). Other patients start to strain or push to urinate (straining). If the prostate grows too large or the tension of the prostate muscles increases, it may constrict the urethra, block the bladder neck (outlet) and impede the flow of urine, making urination difficult and painful. In severe cases, the patient may not be able to urinate at all. The bladder remains full, the patient has the desire to void, yet no urine comes out of the urinary bladder. This condition called acute urination retention is very painful and considered a medical emergency. In cases of urinary retention, a urethral Foley catheter (a straw) is typically inserted to drain the urine out of the urinary bladder. If urinary retention remains untreated, it will cause kidney damage (hydronephrosis) and / or infection or even renal failure.
The cause of urinary retention needs to be determined since other medical and neurologic conditions can cause inability to urinate or adequately empty the urinary bladder. A bladder test (Urodynamics) can determine that the bladder pressure is high while the urine flow is low. Cystoscopy and ultrasound of the prostate may be indicated in select cases.
Once prostate cancer has been ruled out by PSA blood test and digital rectal examination, a treatment plan can be determined.
Medication is the most common treatment for mild to moderate symptoms of prostate enlargement. The options include:
Alpha blockers. These medications relax bladder neck muscles and smooth muscle fibers in the prostate, making urination easier. Alpha blockers — which include alfuzosin (Uroxatral), doxazosin (Cardura), tamsulosin (Flomax), and silodosin (Rapaflo). In general these medications usually work quickly in men with relatively small prostates and mild to moderate prostate. Side effects might include dizziness and a harmless condition in which the semen quantity diminishes (low ejaculate volume or anejaculation). These medications are not known to cause erectile dysfunction.
5-alpha reductase inhibitors. These medications progressively shrink the prostate by preventing hormonal changes that cause prostate growth. These medications which include finasteride (Proscar) and dutasteride (Avodart) typically take up to six months to be effective. Side effects include retrograde ejaculation or rarely breast enlargement.
Combination drug therapy. Your doctor might recommend taking an alpha blocker and a 5-alpha reductase inhibitor at the same time if either medication alone isn’t effective.
Tadalafil (Cialis). Recent studies have shown that Cialis 5 mg by mouth once a day, which is often used to treat erectile dysfunction, might help urinary symptoms associated with prostate enlargement. However, Cialis is not routinely used for BPH and is usually prescribed in men who also experience erectile dysfunction.
When Is Minimally invasive or surgical therapy Indicated?
Minimally invasive or surgical therapy might be recommended if your symptoms are moderate to severe or medication hasn’t relieved your symptoms. Other strong indications include severe urinary tract obstruction, bladder stones, gross blood in your urine or kidney problems. Other patients prefer surgical treatment instead of medications.
Any type of prostate procedure can cause side effects. Depending on the procedure you choose, complications might include:
Semen flowing backward into the bladder instead of out through the penis during ejaculation
Temporary difficulty with urination
Urinary tract infection
Very rarely, loss of bladder control (incontinence)
There are several types of minimally invasive or surgical therapy.
Transurethral resection of the prostate (TURP)
A lighted rigid scope is inserted into your urethra, and the surgeon removes the central part (transition zone) of the prostate. It is still possible to develop prostate cancer after a TURP. Therefore, the patients need continued monitoring using PSA and rectal examination. TURP generally relieves symptoms quickly, and most men have a stronger urine flow soon after the procedure. After TURP you might temporarily need a catheter to drain your bladder, and you’ll be able to do only light activity until you’ve healed. Usually erectile dysfunction is not noted after a TURP. Transurethral microwave thermotherapy (TUMT)
Your doctor inserts a special electrode through your urethra into your prostate area. Microwave energy from the electrode destroys the inner portion of the enlarged prostate gland, shrinking it and easing urine flow. This surgery is generally used only on small prostates in special circumstances because re-treatment might be necessary.
In this outpatient procedure, a scope is passed into your urethra, allowing your doctor to place needles into your prostate gland. Radio waves pass through the needles, heating and destroying excess prostate tissue that’s blocking urine flow.
This procedure might be a good choice if you bleed easily or have certain other health problems. However, like TUMT, TUNA might only partially relieve your symptoms and it might take some time before you notice results.
A high-energy laser destroys or removes overgrown prostate tissue. Laser therapy generally relieves symptoms right away and has a lower risk of side effects than does nonlaser surgery. Laser therapy might be used in men who shouldn’t have other prostate procedures because they take blood-thinning medications. There is no evidence that Laser prostate surgery is superior to TURP.
In this newly FDA approved transurethral procedure, special tags (like staples) are deployed through the urethra to compress the sides of the prostate to increase the flow of urine by retracting the lateral obstructing lobes of the prostate. Long-term data on the effectiveness of this procedure aren’t yet available.