Benign Prostatic Hyperplasia (BPH), or prostate gland enlargement, is common in males over 50. Over half of men older than 50 years old have this condition. Enlargement of the prostate gland may obstruct the bladder neck and section of the urethra that traverses the prostate. Men with BPH may experience symptoms such as a weak urinary stream, incomplete bladder emptying, or post-micturition urinary dribbling, among others. However, keep in mind that some may have other symptoms.
Treatment of symptomatic BPH usually starts with medications, but sooner or later may require prostate surgery due to progressive severe obstructive symptoms affecting the quality of life.
Urological testing to confirm the diagnosis and evaluate the severity of BPH includes post-void residual urine volume to assess the ability of the bladder to empty; uroflowmetry to measure the average urine flow rate, the shape of the voiding curve, duration of micturition, and maximum flow rates; pressure flow studies in some patients; and prostatic imaging to determine the size and shape of the gland that helps with choosing the optimal treatment approach.
Cystoscopy, an endoscopic examination, may be needed to confirm if the prostatic blockade causes the voiding problem.
Indications for surgical treatment
- Moderate to severe voiding symptoms due to BPH are refractory to medical treatment, or those who do not want to continue medication.
- Refractory acute urinary retention and recurrent urinary tract infection are attributed to BPH.
- Bilateral hydronephrosis with renal function impairment.
- Recurrent gross haematuria.
- Bladder calculi.
The prostate gland is an organ that is comparatively hard to access for surgery. In the past, open operations with large incisions were commonly performed through various approaches such as perineal, sacral, and retropubic, which can cause considerable bleeding complications, mineral-salt disturbance, impotence, and scarring. These make many patients reluctant to go for surgery. Traditionally, for BPH, a benign prostate condition, the operations are performed via transurethral endoscopy with electrocautery wire loop cutting of prostatic tissue. The procedure can be complicated by prolonged bleeding, requiring continuous bladder irrigation through an indwelling catheter to prevent blood clot accumulation.
One of the newer non-evasive procedures is to use a green light laser called photo-selective vaporisation of the prostate (“PVP Green Light.”). This procedure is done via cystoscopy with a side-channel for fibre optic bundles to deliver a green light laser to make part of the obstructed prostate tissue disappear by vaporising. There is no need to cut or remove the tissue from the bladder. This procedure is preferred because of the lower risk of bleeding and the need for transfusion. Some patients taking anticoagulation or antiplatelet therapy may not need to interrupt their treatment for the procedure.
The PVP technique diminished the complications that happened with previous prostate surgery, such as:
- Minimal bleeding obviating the need for a blood transfusion.
- No mineral-salt disturbance (“TUR syndrome”).
- Less scarring.
- No erectile dysfunction problems.
- Less catheter time (usually one day).
- Shorter hospitalisation (just a one-night hospital stay).
- Less pain (postoperative pain killers are rarely needed).
- Can be done as an outpatient.
Early prostate cancer has been treated with open radical prostatectomy for decades. Through advancements in surgical instrumentation and equipment, less invasive operations are now the norm with keyhole (laparoscopic) or robotic (Da Vinci) surgery. However, side effects and complications such as incontinence, erectile dysfunction, scarring, bleeding, and lengthy hospitalisation with a catheter remain a possibility in half of the patients. This can adversely affect their quality of life.
Nowadays, another treatment modality with an internal source of radiation called ‘’Brachytherapy’’ or ‘’Radioactive Seed Implants’’ affords the patient another option of a minimally invasive procedure with a treatment success rate as high as radical prostatectomy surgery, but with far fewer side effects.
The Brachytherapy procedure involves the placement of radioactive needles into the prostate tissue according to a computerised treatment plan. The needles deliver short-range, differential high-dose radiation to kill the cancer cells while minimising radiation and sparing the damage to adjacent healthy tissue. The patients only need a one-night hospital stay, or they can go home on the same day and resume their daily activities, including sexual activity, on the next day.
The advantages of Brachytherapy include:
- No incontinence.
- Shorter hospital admission (up to 1 night or outpatient surgical procedure).
- No bleeding. No blood transfusion is required.
- No immediate erectile dysfunction.
- There is less discomfort and pain.
Current technological and equipment advances supplant previous treatments of benign and malignant prostate issues with less invasive methods that better meet the patient’s preferences by virtue of having fewer side effects and long-term morbidities. Most importantly, they help maintain a good quality of life.
Author: Dr. Paibul Boonyapanichskul, Urologist Surgeon, Urology Clinic, Medpark Hospital
Series Editor: Katalya Bruton, Healthcare Content Editor and Director, Dataconsult Ltd, Dataconsult’s Thailand Regional Forum provides seminars and extensive documentation to update business on future trends in Thailand and in the Mekong Region.