BPH

WHAT IS THE PROSTATE GLAND? WHERE IT IS LOCATED?

The prostate gland is a chestnut sized organ which is located below the urinary bladder and surrounds the external urinary tract.

WHAT IS THE FUNCTION OF THE PROSTATE GLAND?

Prostate is a secondary sex organ which is present in men only.

It participates into formation of liquid part of the ejaculate and provides liquidation of the ejaculate.

This liquid includes substances required for vitality of the sperms.

It corresponds to the uterus in women.

BPH (BENIGN PROSTATIC HYPERPLASIA)

A normal prostate weighs about 18 to 20 grams. This may reach to 200 even 250 grams for a hyperplasic prostate. The prostate gland starts to enlarge due to hormonal modifications within the body of men over 40. 50% of the men over 60 and 80% of the men on 70-80 years have a problem of non-cancerous enlargement of the prostate, namely “Benign Prostatic Hyperplasia” (BPH). Actually, the enlarged part is not the prostate, it is a cell group called “adenoma”. All treatment methods are devoted to decrease or remove the pressure onto the urinary tract caused by this adenoma tissue.

SYMPTOMS

Enlargement of the prostate gland and initiation of the compression onto the urinary tract causes different complaints.

• Prostate enlargement presents the following symptoms;
• Frequent urination,
• Waking up with a urination sense at nights,
• Waiting for a while to start the urination,
• To discharge the urine intermittently,
• Difficult urination,
• Bifurcated discharge of the urine,
• Inability to discharge the urinary bladder completely,
• Having the sense to urinate just after the urination,
• Feeling sudden urination needs,
• Sometimes, urinary incontinence.

Many men are forced to change their life styles because of these complaints. Such as forced to urinate while sitting, not being able to have long travel, not being able to wear light colored pants, sleeping trouble because of frequent urination at nights.

These symptoms may also increase with constipation, sitting stable for a long time. The urinary bladder slogs to discharge the urine from the narrowed urinary tract and starts to loose its contraction power. In time, it can not discharge the urine within. If the disease is not treated on time, kidneys also are damaged and kidney failure may occur.

DIAGNOSIS

The most important point at the medical examination is to make a well differential diagnosis of the benign prostatic hyperplasia with the prostate cancer. Ultrasonography and PSA tests provide more significant results when combined with rectal palpation.

A differentiation is tried to be done between BPH and the prostate cancer via a blood test called PSA (Prostate Specific Antigen). This test is diagnostic and provides information about progression of the treatment for the prostate cancer as well. PSA is a protein produced by prostate gland cells. PSA level within the blood may increase in cases with prostate cancer. Higher blood PSA level, higher possibility to have prostate cancer. On normal conditions, total PSA should be below 4 ng/ml.

Although PSA elevation is a valuable diagnosis method, it may be insufficient solely for diagnosis of cancer and it should be coordinated with other diagnosis methods. Beyond total PSA value, Free PSA value and free/total PSA values (<22%) and annual velocity of PSA (<0.8) may provide more information than a single value.

Ultrasonography is a very important test for the diagnosis. It is possible to understand the prostate volume and residual urine in the bladder after the urination by this test. Furthermore, it reveals the difference between cancer and normal enlargement of the prostate. The following illustrations show the prostate and residual urine in the bladder after the urination.

Uroflowmetry is a valuable test where urine flow is imaged as a graphic.

Cystoscopy may also be performed when required. Urinary tract and bladder inside are imaged by an illuminated device inserted from the urinary tract in cystoscopy. This test must be performed for the patients who are planned to be operated before the operation in particular to search if there is any other disease besides prostatic hyperplasia in the urinary tract and bladder.

MEDICAL TREATMENT

Medical treatment is the first option for disturbing symptoms created by the hyperplasic prostate within the early period. However, it has some disadvantages which are requirement to be used for lifetime as medical treatment is not therapeutic and effective when drug is taken and expensiveness of such drugs. Also, it is noticeable that they may become ineffective within time.

Drugs used in general are;

• Alpha-1 blcokers (alfuzosin-doxazosin-tamsulsoin-terazosin); these are drugs for hypertension actually. Some of important side effects of these drugs are hypotension, dizziness, headache, fatigue and absence of sexual appetite and reduction in sexual potency.
• 5- alpha reductase inhibitors (finasteride- dutasteride); they function by decreasing the prostate volume in general. However, single use of these drugs is not recommended today.
• Combined therapies: (alpha blockers + 5- alpha reductase inhibitors)
• Herbal remedies (phytotherapy); it is known that efficacy of these drugs are not different from the placebo, but they may be used as well. It has been observed that they have provided benefit for some patients psychologically.

SURGICAL TREATMENT

OPEN PROSTATE OPERATIONS

TVP (Transvesical Prostatectomy)

It an operation that “adenoma” part of the enlarged prostate tissue is removed by an operation with a cut from the abdomen. It is generally preferred to remove prostates bigger than 100 grams which can not be treated with the closed method (TUR) or for presence of other conditions in the bladder that can not be treated with closed (endoscopic) methods.

In this method, the patients should be hospitalized about 1 week with a catheter to allow recovery of the bladder and other tissues after the operation.

Some complaints that may be seen include blodd transplantation as a result of blood losses, burning and stinging sense while urinating, retrograde ejaculation and sometimes urinary incontinence. Complete recovery is provided within 8 weeks approximately after the operation.

CLOSED PROSTATE OPERATIONS

Transurethral Prostate Resection: TURP

Transurethral Prostate Resection: TURP It is the most effective and gold standard treatment method which have been used for the treatment of BPH as yet. The enlarged prostate tissue is cut and removed by an electro-cautery endoscopically and healthy urine flow is provided again. However, as TURP is an operation, it may include some risks such as blood loss, requirement of blood transplantation, pain while urinating, urinary incontinence at intervals and high risk of retrograde ejaculation. TURP treatment method requires catheter for 1 to 4 days according to the experience of the applier. Complete recovery of the patient may last 6 to 8 weeks in average.

GREENLIGHT PVP LASER PROSTATECTOMY

SELECTIVE VAPORIZATION METHOD OF THE PROSTATE

(potassium titanyl phosphate laser KTP LASER)

Vaporization:

It is a vaporization method of the enlarged prostate tissue with a specialized laser beam under the control on 1 to 2 mm depth.

Selective:

During this procedure, parts of the prostate tissue which are desired to be protected and surrounding tissues; especially nerves that provide erection and muscle groups that prevent urine incontinence are not damaged at all.

Effective Treatment:

It is a vaporization method of the prostate tissue with an effect equivalent to a high heat effect of 95 degrees Celsius within a special fluid.

How is PVP procedure applied ?

GreenLight PVP procedure is performed with a laser system called KTP. GreenLight PVP procedure combines two positive characteristics; it is a minimally invasive and it provides an effective solution within a short period. It presents effective solutions within a shorter period than treatment methods such as TURP, TUIP or open surgical operation.

What makes this laser wave so special is being absorbed within hemoglobin (blood). Due to rapid absorption, it vaporizes the enlarged prostate tissue immediately and repairs the thin area surrounding the prostate (with a depth of 1 to 2 mm) by preventing the bleeding. Benefit of the immediate vaporization is not to leave any tissue residue or space. Because to repair an important small area only will be in a short time and painful, it provides recovery somehow. Laser is placed into the cavity with a very thin wire and pushed into the urinary tract by an endoscope.

In Nd: YAG laser, a pervious laser method; a tissue coagulation was used to be created with a depth of 10 mm and this was used to cause many adverse events. As a result of passing Nd:YAG laser from a special crystal, wavelength is reduced into the half and KTP laser with a wavelength of 532 nm is created; it is absorbed by oxyhemoglobin highly through this and it becomes to affect to the prostatic tissue on a 1 to 2 mm depth. Through this characteristics, laser energy effect the tissue on a less depth without causing any excessive coagulation and eliminated risks without leaving any carbonization and residual tissue. PVP procedure lasts between 40 and 120 minutes depending on the size of the prostate.

What are superiorities of PVP method when compared with other methods?

When each surgical procedure is considered as a controlled trauma, PVP is a surgical procedures which will be performed for BPH and cause the least trauma. Other non-invasive procedures such as TUNA and microwave decrease the complaints by damaging the nerves. Therefore, recovery is temporary and complaints may repeat after months. In addition, sufficient tissue to open the prostatic channel can not be eliminated in these procedures. Flow rate may recover temporarily and may return to first values on time. Urinary obstruction may develop in many patients who had these procedures, catheter application may require during weeks even months.

PVP method may only be compared with TUR-P method which is referred as a gold standard. Current findings indicate that PVP has advantages according to TUR-P. Hospitalization period is shorter in PVP method. Also it has a positive effect on increase of the life quality. The patient is discharged on the next day even at the same day in some cases, may perform daily activities which are not forcing; single session is enough when compared with other non-invasive methods. One of the most important issues for the patients with hyperplasic prostate is requirement of anticoagulant drugs for those who use these drugs before TURP. Discontinuation of aspirin is not necessary for PVP, also PVP may be applied without discontinuation of oral anticoagulants if discontinuation of them creates a problem.

What are disadvantages?

Common opinion of many urologists who apply this procedure is absence of a significant disadvantage. It is more expensive than traditional methods due to materials used and cost of the device.

Which patients are eligible for PVP?

Every patient with hyperplasic prostate which cause obstruction in the urinary tract, namely;

All BPH patients who need surgical treatment,

Patients who have narrowing on bladder collum or urethra,

Patients whom medical or other treatments have been unsuccessful.

There is not any age limitation.

PVP is an ideal method for patients who had BY-PASS or cardiovascular system operation where operation period or blood loss is very important in particular; patients with heart failure, diabetes, hypertension, asthma and some chronic pulmonary diseases; those with BLEEDING TENDENCY or patients who use anticoagulant agents; patients who may need INTENSIVE CARE on surgical procedures; those with operation fear due to the age; patients who desire to continue on sexual activity just as before and patients who abstain from other operations and do not want these methods.

WHICH PATIENTS ARE INELIGIBLE?

This method should not be applied to patients who have current acute prostatitis and severe urinary tract infection before they are treated. It may be used to provide urination of the patient only for those who have been diagnosed with prostate cancer.

WHICH ANESTHESIA METHOD IS APPROPRIATE?

PVP may be performed by local, spinal or general anesthesia. Patients who have an irregular general medical condition preventing them to receive general anesthesia may have this procedure with local anesthesia, and this provides an additional advantage for such patients.

GREENLIGHT PVP SYSTEM IN SUMMARY

It is a treatment method which does not create severe EDEMA, does not nearly require HOSPITALIZATION, recovers URINATION COMPLAINTS IMMEDIATELY and has a low surgical risk!!! This new system vaporizes the enlarged prostate tissue and removes completely within quite shorter operation periods. Reduction on all complaints is observed within a short period! It is a method where almost no bleeding is present. Therefore, even patients who receive drugs that increase the blood flow because of cardiovascular diseases may be treated successfully. It is on the way to be a new gold standard for BPH treatment in developed countries. It is a treatment method which provides recovery within a shorter period than TURP and other treatment methods. In general, placement of a catheter into the patient is required for 1 day at most. It is a daily (outpatient) procedure in general. Generally, it requires to be hospitalized for 1 day at most. Erection problem (Impotence) and Urinary Incontinence are not seen after the procedure. It definitely protects the life quality.

OTHER TREATMENT METHODS

• Watchful waiting
• Transurethral incision of the prostate (TUIP)
• Transurethral microwave thermal therapy (TUMT)
• Transurethral needle ablation (TUNA)
• High intensity focused ultrasound (HIFU)
• Water induced thermo therapy (WIT)
• Transurethral ultrasonic aspiration of the prostate
• Visual laser ablation of the prostate (VLAP)
• Holmium: YAG laser (HoLEPve HoLAP)
• Interstitial laser coagulation of the prostate (ILC)
• Cryotherapy
• Balloon dilatation
• Intraurethral stents