Prostate Enlargement

Lower Urinary Tact Symptoms (LUTS) caused by an enlarged prostate gland is a common condition. 21% of men above age 50 have LUTS caused by Benign Prostate Enlargement (BPE) and this peaks as a problem over the age of 70.

TURP remains the most commonly used surgical procedure for BPE, utilised in 76% of men undergoing surgery for BPE in Australia.

A/Prof Peter Royce and Mr Dennis King perform the treatments for prostate enlargement (BPH) below at Cabrini Hospital Malvern, Cabrini Brighton, Epworth Eastern Hospital Box Hill and St. John of God Berwick, Melbourne Australia.

Pathology

• Benign Prostatic Hyperplasia (BPH) is a condition caused by an excessive growth of prostate gland tissue around the urethra. The prostate growth is influenced by the male hormone, testosterone, which causes the prostate to enlarge over many years.
• With the increased size of the prostate, the urethra is compressed causing decreased urinary flow and incomplete emptying of the bladder. The high pressure required to empty the bladder gives rise to an increased risk of urinary infection and bladder stones. Inflammation of the bladder and urethra may also cause blood in the urine.
• Because of the increased pressure on the bladder wall, the bladder may become overactive. This gives rise to the symptoms of urgency (feeling to urinate) and nocturia (the need to urinate at night). After years of sustained high pressure within the bladder, there may develop acute (sudden) or chronic (gradual) retention of urine, where the bladder is unable to function.
• Backpressure from the bladder may affect the kidneys causing the kidneys to swell (hydronephrosis) with eventual kidney failure.

Diagnostic Testing

• Urine analysis looks for blood and bacterial infection.
• Blood tests may include electrolytes, serum urea, creatinine and as a baseline of kidney function.
• A Prostate Specific Antigen (PSA) blood test. The PSA level may be raised with BPH due to increased size of the gland, but any increase suggests prostate cancer.
• Uroflowmetry (measurement of urine flow) is one of the simplest best diagnostic tests for bladder outlet obstruction. Men usually have urine flow rates between 12 - 20cc/sec. Flow rates of less than 10cc/sec are seen with bladder outlet obstruction.
• The residual urinary volume (volume remaining) after urinating can be measured either by catherization (catheter placed in the bladder) or ultrasound scan. Residual volumes greater than 100 - 150 cc are usually significant for obstruction.
• Ultrasound Scans do not require the placement of a catheter or other instrument in the bladder. Sound waves are bounced off the bladder back to a receiving unit that converts the waves into a picture. This test can detect urinary volume, stones in the bladder and evidence of back pressure on the kidneys. It can also measure the size and volume of the prostate and help in decision making on appropriate treatment.
• Cystoscopy (the use of a small diameter, lighted telescope) along with measurement of bladder pressures (cystometrogram) are sometimes performed if a there is a suspicion of neurologic dysfunction or urethral strictures (narrowing).

The symptoms of BPH may be mimicked by several conditions. These include: -

• Neurologic (related to the nervous system) dysfunction of the bladder can occur from diabetes, parkinsons, stroke, spinal cord, medications and sphincter dysfunction.
• Strictures of the urethra from trauma or infection.
• In young adults, the median (near the centre) lobe of the prostate can enlarge (called median lobe obstruction). This can mimic BPH. TURP will help this condition also.
• Prostatic Cancer is considered in all cases of enlarged prostate as the patient population is very similar.

Surgical Treatment (TURP)

Indications For Surgery

• Surgery is usually indicated for obstructive or irritative symptoms of BPH that may not be relieved by medical management.
• A significant decrease in urine flow rate (<10cc/sec) or significant residual volumes (>100 - 150cc). This includes men with acute or chronic urinary retention, who will usually have a catheter in situ due to inability to pass urine.
• Recurrent urinary infections, bladder stones, haematuria.
• BPH is a disease that is progressive. Surgery is advised before complications arise.

Transurethral Resection Of The Prostate (TURP)

• The procedure usually takes less than an hour to perform and is usually performed under spinal anaesthesia. General anaesthesia may be used, if necessary.
• The patient is placed in the lithotomy position (with the legs elevated and spread).
• The bladder is filled with a saline solution.
• A cystoscope, which is a special telescope, is inserted into the penis and passes up the urethra, until it reaches the prostatic portion of the urethra.
• A special wire loop, called the resectoscope, is then inserted into the urethra. The resectoscope has electrical current passing through the loop that acts to cut the prostate tissue. The resectoscope shaves off "chips" of the enlarged prostate gland. The shaving starts at the margin of the bladder outlet and progresses into the prostatic part of the urethra up to the verumontanum with careful preservation of the external urinary sphincter.
• The ejaculatory ducts that open on the verumontanum and carry spermatic secretions are preserved. The voluntary external sphincter lies below the verumontanum. This sphincter will also be preserved, to allow control of urination.
• At the end of the procedure, the bladder outlet remains open and unobstructed. The bladder is irrigated to flush out any blood clots and prostatic chips. The prostate chips are sent for histopathology to check for prostate cancer.
• A catheter is left in place to drain the bladder and a continuous bladder washout with saline fluids.
• The Gyrus bipolar TURP is a new technique which uses saline fluid irrigation which is safer and reduces risk of TUR syndrome.

Gyrus TURP

A newer technique currently being used by Urology Associates. This involves bipolar diathermy resection of the prostate which has the proven advantages of :-

1. Allowing the use of normal saline irrigation fluid during the prostate surgery, which is safer than the glycine irrigation used with standard TURP.
   This allows safer resection of larger prostates which may otherwise require open surgery, and avoids the TUR syndrome associated with glycine irrigation.
2. There is less bleeding both during and after the TURP surgery.
   Gyrus bipolar TURP forms a safer seal of bleeders than standard TURP.
3. It allows superficial vaporisation of the prostatic tissue, while shaving away prostate chips, thus leaving less tissue debris at the end of the procedure. Prostate tissue is available for histopathology testing.

Urology Associates now routinely use this technique for prostate resection, backed up by several meta-analyses which prove the advantages of Bipolar TURP with saline.

Postoperative Care (TURP)

• Blood tinged urine may be present at the end of the procedure. A continouous bladder washout with saline fluids is routine after TURP surgery to prevent blood clots forming in the bladder.
• The catheter is kept in until the urine clears, which is usually 24 - 48 hours. Patients usually stay in the hospital during this time.
• Occasionally, patients who are unable to void postop TURP, will be discharged home with the bladder catheter attached to a leg bag, which is subsequently removed at Suite 51 by our Urology nurse.
• Men do not usually experience much pain after the operation and can usually commence walking and driving as soon as they leave hospital.
• Antibiotics are usually given for a several days to a week after the operation to prevent infection.
• Blood Thinning Medications (Anticoagulants) are routinely stopped prior to a TURP, and restarted after TURP, on the advice of the Urologist and Cardiologist. Please ask for specific instructions about any anticoagulation medications.
• About 8% of patients will require a repeat TURP or opening of a scar or stricture (narrowing) during the remainder of their lives. This will depend on the initial size of the prostate, the natural healing process and the skill of the surgeon performing TURP.

After The Operation

• You will be closely monitored for the first few hours.
• If you have had a spinal anaesthetic, your legs are likely to feel numb or heavy for up to 4 hours.
• If you have had a general anaesthetic you may experience drowsiness, which can take some hours to wear off.
• You will be staying in bed for the rest of the day.
• You will have a catheter draining urine from the bladder and from this a continuous bladder wash out will flush out any blood.
• You will have an intravenous drip to provide you with fluids until the next day.
• You can eat and drink when you feel up to it.
• Normal medications will resume (except for Aspirin, Warfarin and anti inflammatory drugs). In some cases it is necessary to have antibiotics.
• Your nurse will assist you with washing, cleaning your teeth and any other personal care needs you may have.
• Minimal discomfort is expected after this operation, so any pain or discomfort should be discussed with your nurse so she can assess the situation.

Post Operative Day 1

• The day following your surgery your bladder wash out system and intravenous drip will be removed after consultation with your surgeon.
• The surgeon may ask for you to have a follow-up blood test.
• Your catheter may be removed depending on the colour of your urine.
• You may shower sitting down with supervision; pay special attention to cleaning around the tip of your penis.
• At this stage it is very important to drink approximately 2-3 litres of fluid a day to flush any blood or debris out of your bladder. If you have been advised for medical reasons not to drink a lot of fluid, please discuss this with your surgeon.
• Gentle walking around the ward is encouraged, this helps prevent complications.

Post Operative Day 2

• Depending on the colour of your urine and after review by your surgeon, your catheter will be removed by your nurse.
• It may be some time before you pass urine but when you do you will find several things:
• • Some burning or stinging
  • Urgency - needing to pass urine in a hurry
  • Frequency - needing to pass urine often
  • Incontinence - loss of control of urine associated with needing to pass urine in a hurry and often
  • Blood in the urine and passing of small blood clots
  • These are normal and will gradually settle down.
• You will be instructed to pass urine into a jug in the bathroom so the nurses can measure volumes and observe the colour.
• You may eat and drink as normal. A high fibre diet is advised to prevent constipation and avoid straining.
• Continue drinking 2-3 litres a day.
• You may shower independently and be as mobile as possible.

Post Operative Day 3

• If you are passing urine without difficulty and following review by your surgeon, you may go home.
  Some people may need to stay for another day but this will be discussed at the time.
• Management of ongoing urgency, frequency and incontinence of urine will be discussed prior to discharge.
• If you were taking any aspirin or anti-inflammatory drugs before your surgery, you will need to ask your surgeon when these can be recommenced.
• Discharge time is usually between 8.00am - 10.00am, but other arrangements can be discussed with your nurse if required.
• You will be given written information regarding new medication and follow up appointments.

Alternative Prostate Procedures

• Transurethral Incision of the Prostate (TUIP)

  This technique involves making incisions through the bladder neck into the prostate gland, without resecting the prostate tissue. These incisions cut through the involuntary bladder neck sphincter and open the urinary tract. Results of this technique are almost as good as TURP and there is less risk of postoperative scar tissue formation. TUIP may be used for smaller prostates and in younger patients but can result in Retrograde Ejaculation.

• Greenlight Laser Ablation

  GLL is prostate laser surgery used to vaporise prostate using laser heat energy. GLL is utilised in 19% of men having surgery for BPH in Australia. There is less bleeding in this procedure and may be beneficial in men with bleeding disorders or on anticoagulation therapy. Long-term results of GLL are comparable to TURP, but large prostates do not do as well. The postop recovery is typically longer and more uncomfortable than with TURP.

• Open Prostatectomy

  Open surgery may be advisable in men with very large prostates as the outcome for TURP is often unsatisfactory with prostate volume larger than 100cc. Open Prostatectomy may also be necesary if additional procedures are needed such as simultaneous removal of bladder stones. An incision is made in the lower abdomen and the prostate is enucleated or ‘shelled out’ of the prostate capsule. The specimen is often the size of an orange!
  The postoperative recovery is longer than with a TURP, may need blood transfusion, and there is a higher risk of urinary incontinence.

• Transurethral Prostate Enucleation

  Enlarged prostate glands can be enucleated via a transurethral surgery using several types of energy including Holmium Laser (HoLEP) or Bipolar Electrical Energy.
  The prostate tissue is detached into the urinary bladder and removed with a surgical morcellator or resected similar to a TURP.
  This procedure requires considerable surgical experience to avoid the risk of urinary incontinence.

• Urolift^®

  Prostate Urethral Lift procedure involves the insertion of several, usually 4-6, permanent prostate retractors to create a channel in the urinary tract. The procedure is transurethral using video with placement of the retractors directly into the prostate tissue.
  The Urolift is regarded as safe and effective, with results indicating low risk for retrograde ejaculation or erectile dysfunction. Urolift is regarded as more effective than tablet medications, but there are no current studies to compare Urolift with TURP in terms of longterm outcomes. Urolift is covered by Medicare and Private Health Insurance.
  (see section below for more information)

• Rezum

  Water Vapour Thermal Therapy (Rezum) uses steam heat injected directly into the prostate to remove tissue and open the urinary tract.
  This procedure is regarded as safe and effective, with results indicating low risk for retrograde ejaculation or erectile dysfunction. Rezum is regarded as more effective than tablet medications, but there are no current studies to compare Rezum directly with TURP in terms of longterm outcomes. Rezum is not covered by Medicare or Private Health Insurance, so Rezum is a self funded procedure.

• Aquablation

  Aquablation is a surgical robotic system using high pressure water to remove prostate tissue. The procedure is transurethral, with prostate parameters set by the treating Urologist with an automated robot performing the surgery. The Procept Aquabeam is undergoing clinical evaluation.

Special Comment

The choice of procedure for benign prostate enlargement will be discussed with you keeping in mind that TURP is regarded as the Gold Standard by which all other procedures are compared.

Some men will be more concerned with preservation of ejaculatory and erectile function, while others will be more concerned to have urinary function restored and urinary symptoms reduced.

Some men are on anticoagulation drugs for their heart condition, and need to remain on these drugs during prostate surgery.

Some men have very large prostate glands and may even have a urinary catheter insitu, which will limit the surgical options, in order to achieve the best outcome.

All of these factors will be carefully considered and discussed with you before deciding on the best option. Please feel free to ask questions about any aspect of your prostate surgery.