BENIGN PROSTATIC HYPERPLASIA (BPH)
Introduction
Benign prostatic hyperplasia (BPH), often called simply “prostate enlargement” is a common condition in men of middle and advanced age. Studies demonstrates that the pathological process can start already between the ages of 30 and 40 years old and, finally, approximately 90% of elderly men suffer from BPH at the age of 80. Therefore, this condition increases with age resulting in a gradual progression and often leading to a worsening in micturition that can affect the quality of life.
Symptoms of BPH can develop gradually. They include:
– Frequency or frequent urination. It is one of the most common and bothers most of the patients. When it occurs at night is called nocturia.
– Reduction of the urine flow (force of urination). Typically, the patients observe that the urine flows near to the body so that, sometimes, the urination results in wetting their shoes. It is particularly troublesome because many men with BPH are forced to urinate sitting down in the basin in an attempt to avoid wetting themselves.
– Urgency or urgent urination. Many patients complain that they have an urgent desire to urinate that cannot be held and, sometimes, on the way to the toilet they may also lose some urine.
The emergence of the so-called teardrop bladder is usually a result of reduction of the urine flow. In healthy individuals the urination can be voluntary stopped without any loss of urine, thus remaining dry. On the contrary with a BPH, urination may continue for a few seconds forming drops of urine despite the will of the person to control the process.
– Urinary hesitation. Many patients describe struggling over the toilet to start urination that comes only after a long wait. Other patients use the sound of running water, for example opening the tap, in order to relax and urinate. Sometimes they complain pain and can see also some blood colouring the urine.
– Feeling of incomplete emptying of the bladder. Many people feel that after urination their bladder is not empty and there is residual urine in it.
– Acute urinary retention. It is a dangerous and dramatic symptom of hyperplasia, resulting in an inability to void despite the full bladder. The patient feels great discomfort and pain in the lower abdomen. The condition requires immediate treatment by a medical specialist with the placement into the bladder of a transurethral catheter or a suprapubic drainage of urine.
Apart from the symptoms, there are significant risks, not always visible, that can seriously jeopardize the health of unsuspecting men. It should be emphasized that the disease is not dangerous at its early stages. Nevertheless, its final evolution can include serious complications.
The obstruction caused by the prostatic hyperplasia prevents urine to find a natural way out, so there is always an amount of urine remaining into the bladder. This “trapped” urine is the source of many problems such as the formation of bladder stones.
Moreover, serious complications such as hydronephrosis, pyelonephritis, and eventually renal failure are also possible. The term hydronephrosis describes the pathological dilatation of the kidney that “swells” due to its inability to expel urine over the prostatic obstruction. This creates a vicious circle in the urinary system. The stagnant urine can become infected and ultimately cause a renal infection called pyelonephritis. Eventually, kidney failure is the most unfortunate but rare condition of the benign prostatic hyperplasia.
Close collaboration with a urologist is necessary in order to early diagnose and treat prostatic hyperplasia, avoiding the above complications.
BPH can be treated either conservatively or surgically. In most patients the initial treatment proceeds conservatively with the administration of drugs. Surgical treatment follows when the conservative treatment fails. Only the urologist is able to set the appropriate “indication” for each case.
The surgery includes the excision, or rather, the removal of the obstructive central part of the prostate (the prostatic adenoma) and it is called prostatectomy. With this purpose, our department offers 3 different techniques to the patient: transurethral resection of the prostate (TURP), laser treatment and laparoscopic simple prostatectomy.
The TURP is the current gold standard for the treatment of medium size (up to 80g) prostate. This endoscopic procedure is performed by the use of a special tool called resectoscope under control vision and inserted through the urethra till the prostate that can be resected. The surgery is performed under general or spinal anesthesia. Urinary catheter is placed after the surgery and removed on 2-3 day postoperatively. Normally the patients can be discharged from the hospital and return home after approximately 3-4 days.
The photoselective vaporization of the prostate (PVP) with greenlight laser or the vapo-resection with thulium laser are recently advanced methods of prostatectomy for the treatment of BPH. Similarly to TURP, these endoscopic methods does not require any skin incision and the introduction of the tools is done through the urethra. The difference is in the removal of the prostatic adenoma with a different type of energy using a laser. An important advantage of this method is the increased potential for intraoperative hemostasis, which is useful especially in patients receiving anticoagulant therapy with an increased risk for bleeding. In addition, the inserted catheter can be removed on the first day after the surgery.
Laparoscopic simple prostatectomy is an advanced approach for bigger size prostates. It replaces open prostatectomy surgery which has represented the basis for the surgical treatment of BPH for decades. In the case of laparoscopic simple prostatectomy, the surgical incision in the lower part of the abdomen of the patient (unlike open prostatectomy) is avoided: surgery is performed using laparoscopic instruments placed through small 5-10mm incisions. In the end, one of the incisions is enlarged (about 5cm) in order to get out the removed prostatic tissue. During the surgery a bladder catheter is placed. Usually after 5 days, the catheter is removed and the patient returns back home. The method has significant advantages compared to the open prostatectomy in terms of blood loss, post-operative pain and mobilization of the patient. It should be noted that this method is indicated to patients with very large prostates in which the performance of the transurethral methods is difficult or impossible.
As for any surgical procedure, there is a possibility of adverse situations after prostatectomy. In some cases, sudden bleeding may appear even after discharge of the patent. If the bleeding does not stop immediate, the consultation with the treating doctor or a urologist is required. However, the patient should avoid to panic. Usually such bleeding can be controlled conservatively or with the insertion of urethral catheter. In rare cases surgical coagulation of the bleeding vessel may be required.
Another complication is the infection of the urinary tract. It can result in painful urination, sometimes fever and infection of the testicles. Also in this case the patient should contact the treating urologist to receive the appropriate treatment, usually pharmacological.
Some patients (up to 30%) may experience urinary incontinence in the early postoperative period; however, the incidence of late incontinence that persists for more than 6 months is only 0.5%–1%.
Of crucial importance is the question of sexual potency after prostatectomy for BPH. The answer is that the surgery does not affect the potency unless the patient has erectile dysfunction preoperatively. Nevertheless, it should be emphasized that there is the possibility not to see the sperm with the ejaculation: this is associated with the release of the sperm in the bladder where it is mixed with the urine. In short, the sperm comes out together with the urine. This situation is called “retrograde ejaculation” and there is no reason to believe that the operation has not succeeded.