A New Era in Benign Prostatic Hyperplasia (BPH) Surgical Approach

Many men above age 50 develop urinary symptoms which gradually worsen over time.

 (photo credit: RF123)
(photo credit: RF123)
The cause is most frequently a common medical condition called Benign Prostatic Hyperplasia or BPH. Hyperplasia means increased cell formation causing the prostate gland to get bigger, blocking urine from exiting the urinary bladder during urination.

In recent years, many new surgical treatments have emerged, which could cause confusion as to what is actually the best way to treat this condition. 

"No treatment is perfect, and therapy will always partly consist of lifestyle modifications and proper pharmacological treatment when possible" Dr. Assaf Bar El, Urology Specialist, Senior urologist at the screening institute at Sheba Medical Center told the Jerusalem Post. 

This article should help you better understand BPH, including investigational tests for diagnosis, and information to guide you on what might be the best surgical option for you. 

“Why do I wake up at night so often?”, “I have noticed that I go many times to urinate during the day”. “My urinary stream got weaker in the past months”. “I can’t “hold it” as I used to before…”. These are some common complaints of patients seeking relief for their urological symptoms, Most often, their problem is due to an enlarged prostate.  

Common symptoms of an enlarged prostate include:

• Hesitancy of urination

• Urgency and/or frequency in urination

• Weak urinary stream

• Waking multiple times at night to urinate

• A feeling of not emptying yourself completely

• Extra effort is needed to complete the urination

• Dribbling of urine, often leading to wet underwear

• Leak of urine before managing to arrive the toilet

“What kind of investigations should the doctor recommend for me?” 

After a thorough physical examination (including a digital rectal examination) and comprehensive medical history taking, your doctor might order additional tests by sending you to one or more of the following:

1. Blood and urine lab tests such as kidney function, PSA (prostate specific antigen), and urinalysis including urine culture.

2. KUB (Kidney-Ureter-Bladder) ultrasonography, to evaluate the urinary system including the prostate size and your urinary bladder residual volume after urination. 

3. Voiding diary – a very primitive evaluation but could give your doctor a great deal of insight regarding your urination habits.

4. Uroflowmetry tests which help the urologist to evaluate the severity of your symptoms (more objectively) by assessing your urine volume and flow rates. 

5. Prostate symptom score questionnaire – a validated form that could help your urologist to understand better the severity of your symptoms. 

“I have taken medications for several years and my symptoms have only gotten worse!”, “the medications make me feel dizzy” or “I’m not able to ejaculate since starting my prostate meds”, “Doctor I’m suffering from multiple urinary tract infections in the past several months”. These are the more common complaints leading the patient towards a surgical solution. However, in recent years many new emerging surgical options are available, so, “what are the best BPH surgical options suited for me?”

Minimally invasive -Minimal hospital stay:

- iTIND – Temporary implantable Nitinol Device. This is one of the newest and most promising approaches for BPH treatments in the future. The device is implanted for 5-7 days and situated at the bladder neck and prostatic urethra. During that time the device form tissue compression on three different locations leading to a better opening of the bladder outlet and gradually improve urination. This is truly minimally invasive, short, safe procedure without the need for hospitalization, and minimal risk of complications.
* Dr. A. Bar El is the first and most experienced urologist in Israel to perform iTIND procedures.

- Urolift - in this case the urologist places several permanent implants that lift and hold the enlarged prostate tissue out of the way and improve the opening of the urethra. * The procedure isn’t yet available in Israel.

- ReZum – this method uses heat energy to “detach” the enlarged obstructed area of the prostate and eventually leads to it’s shrinkage.

- Embolization – This procedure is done mostly by invasive radiologists by blocking the arteries supplying the prostate. Blockage of the arteries leads to shrinkage of the tissue over time. This procedure is reserved for few selective patients. 

Less invasive –Short hospital stay:

- TURP – Trans Urethral Resection of prostate, this has been the gold standard procedure for prostate surgery for decades, and the most common procedure even today. In the past several years we see a gradual decline in the number of TURP’s due to new innovative techniques and devices available. During this procedure, the surgeon will place a small working sheath through the urethra and will remove the blocking tissue which prevents urine from flowing properly by electrical loop.
 
- Photoselective vaporization of the prostate (PVP) – this procedure is very similar to TURP, with the difference being a different energy method to remove the excess tissue. In this case the surgeon uses a laser, most often Green-Light laser. The laser uses high energy to vaporize the tissue. Suitable for patients who can’t stop taking blood thinners. It’s less beneficial for patients with a very large prostate which may lead to an onerously long surgical procedure.

- HOLEP – Holmium laser enucleation of prostate. With this new approach, the surgeon uses Holmium laser in order to separate the obstructed tissue in hole. The obstructed tissue is detached and removed through the urinary bladder where it is extracted by special device. 

In order to choose which procedure is best for you, your urologist will need to know several points.  How big is your prostate? How significant are your symptoms?  How concerned are you about potential surgical complications? Is preserving your ability to ejaculate important to you?  Are you on blood thinners that cannot be stopped? Regardless of your decision, proper communication and follow up with your trusted and experienced urologist is a must!

Written in Association with Dr. Assaf Bar El