His and Her Health

Myron Murdock, MD, Medical Director, Vibrance Associates

So your doctor told you the reason for your nighttime urine frequency was this strange sounding ailment. Then the doctor said it was BPH. Benign prostatic hypertrophy, or BPH, will affect 50% of all American males with urinary symptoms. Many will respond to a medicine called alpha-blockers, often used to treat high blood pressure, which relax the fibromuscular tissue of the prostate, or what we call “5-alpha reductase inhibitors,” which actually shrink the prostate, or combinations of both.

Men who do not respond, who develop side effects from drug therapy or who no longer wish to take drug therapy can opt for an effective procedures to reduce the obstruction of the prostate, many of which are minimally invasive, involve minimal or no anesthesia and require no hospital stay, blood loss or post-procedural catheterization.

Some men select these procedures because their insurance companies will not pay for the appropriate medications, in the long term the medications are more expensive than the procedures themselves, concern about drug-drug interactions or the complications of many of the drugs are no longer of concern to the patient.

The least invasive and simplest procedure is the transurethral microwave therapy, otherwise known as TUMT. It involves placing a specially designed catheter into the penis and bladder. A balloon is inflated in the bladder, and that segment of the catheter nearest to the balloon has wires embedded in its wall which emit microwaves. Each catheter is specific for the patient based on the length of the prostate itself, which can be gauged by the surgeon through cystoscopy or by doing a prostate ultrasound.

Once the catheter is positioned the balloon is inflated, the catheter is attached to a drainage bag and the microwave portion of the catheter is attached to a computerized microwave generator. Prior to the procedure, the patient is frequently given an antibiotic, a short-term bladder relaxant, minor pain medications and an alpha-blocker. The procedure takes approximately 30 minutes.

The prostate is microwave heated destroying the sympathetic nerves going to the prostate. In addition, the prostate is “coagulated” and over time, usually 6-8 weeks, the prostate may shrink as well. Approximately 50% of the patients do not need a catheter and are successful post procedure in a trial of voiding. The bladder is filled, the catheter is removed and the patient voids, and if successful, a catheter may not be placed. Some feel a catheter should remain for 24 hours at a minimum.

After the procedure, the patient may maintain an alpha-blocker for a 6-8 week period, at which point most patients get improvement in their voiding symptoms. In general, 70% of the patients will be happy with the procedure, even patients who have been in urinary retention. My own personal opinion is that this procedure, which I felt would not be an effective tool, has turned out to be a tremendously effective tool working in most of the patients and allowing the most minimal invasive procedure to be utilized in those men who no longer wish to take oral drug therapy for BPH.

GreenLight, or PVP laser of the prostate, is the second-least invasive procedure. It does require, in most cases, an in-and-out hospitalization with some form of anesthesia, sedation plus local or general anesthesia.  The patients are given a preoperative antibiotic and a cystoscopy is placed in the penis. Monitoring is done through a television screen, and a GreenLight laser probe is placed through the cystoscope under direct vision into the area of the prostate.

The procedure is similar to painting the lining of the prostate with high-intensity laser light that heats the prostate tissues and vaporizes and obliterates the obstructing tissue. The GreenLight wavelength has a propensity for hemoglobin in the red blood cells, and therefore, the vascular lining of an enlarged prostate absorbs this light more readily than the nonvascular capsule of the prostate. The more vascular the prostate, the easier the vaporization and destruction of the prostate tissue occurs. The vascular capsule is very difficult to penetrate because of its lack of hemoglobin.

After the patient awakens from his anesthetic, a trial of voiding can ensue, and the patient may go home without a catheter. Bleeding is minimal because of the intense heat and coagulation effect of the GreenLight laser, particularly since it tends to attract to the hemoglobin of the red blood cells and blood vessels. The limiting factor in PVP laser is the length of the prostate and, probably more importantly, the skill of the surgeon.  Some surgeons can do very large, long glands and others can only do short glands, and so, the decision to do a PVP laser is really based upon the skill of the urologic surgeon.

GreenLight laser should obviously be considered in those patients who fail microwave therapy. However, in very long prostates, greater than 4.5 cm, GreenLight laser may be the treatment of choice. Microwave therapy is not indicated for patients who have obstruction basically at the posterior bladder neck with a subcervical or subtrigonal prostate enlargement and also not in patients who have an intravesical component. PVP laser can be used in some of these circumstances. However, when these circumstances are a dominant factor, the gold-standard, traditional transurethral resection of the prostate may be necessary.

In those circumstances in which the prostate is very long and very large or where the major obstructing component is at the bladder neck or in circumstances in which the surgeon feels uncomfortable with microwave therapy or PVP GreenLight laser, a transurethral resection could be done. The procedure involves cutting strips of prostate tissue from the prostatic urethra, opening the urethra, decreasing resistance and allowing for better voiding.

The procedure usually requires at least a 24-hour hospitalization.  There may be bleeding and, in rare cases, the need for transfusion. A catheter is almost always necessary post procedure and, with it, the associated discomfort. The major advantage of a transurethral resection of the prostate, or TURP, is that the obstructing tissue is definitely removed and tissue can be evaluated by a pathologist under the microscope to rule out carcinoma of the prostate. Obviously, microwave therapy does not remove any tissue for pathological purposes, and PVP GreenLight laser completely vaporizes and destroys the tissue so that evaluation cannot be done. In those two procedures, preoperative evaluation for cancer is necessary with digital rectal exam and PSA testing, and if suspicious for cancer, transrectal ultrasound with ultrasound-guided biopsy of the prostate should be performed.

Prostate enlargement is a common problem among men, affecting 50% of us with obstructive and/or irritative symptoms; decreased stream, frequency, urgency, urgency control, awakening multiple times at night, intermittent urination and a tremendous amount of bother. It would be certainly nice if we could resolve this mechanical problem with drug therapy all the time.

Unfortunately, this is not the case.  Surgical procedures to remove the mechanical obstruction will be needed in a significant number of patients, and the newer, minimally invasive techniques, including microwave therapy and GreenLight PVP laser ablation of the prostate, certainly minimize anesthesia, hospitalization, postoperative catheterization and the complications normally associated with more invasive prostate procedures.  The urological surgeon’s skills, experience and technical prowess frequently is a major factor as to which procedure should be performed. Local anatomy and patient input may play a role. Financial costs and insurance coverage is becoming more important. (July, 2008)