Prostate

Prostate Enlargement

Obstruction of urine flow by an enlarged prostate gland is a common condition. Almost 50% of the male population above age 50 will have some clinical evidence of prostate enlargement.

TURP (prostate operation to relieve obstruction) procedures are one of the most commonly performed operations in men over the age of 70.

Surgery to relieve the prostatic enlargment has been described since the early 19th century, but the development of fibreoptic telescopes and videocamera imaging has greatly enhanced the success rate of TURP.

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.

Anatomy & Physiology

  • The prostate gland is shaped like an inverted pear and lies just below the neck of the urinary bladder. It is about 5cm (3 inches) long and 3-4cm wide. The urethra, which runs from the bladder through the middle of the prostate gland and through the penis, carries urine from the bladder.
  • The smooth muscle of the urethra is the internal urinary sphincter. Just below the prostate gland is a muscular diaphragm that acts as the external urinary sphincter. This sphincter, which encircles the urethra, is under both reflex and voluntary control.
  • Along the back wall of the urethra in the prostate, there is an elevation called the verumontanum, and it is into this elevation that sperm (through the ejaculatory ducts) and spermatic secretions from the seminal vesicles and prostate enter the urethra.
Benign Prostate Hyperplasia

Pathology

History & Examination

  • A patient with an enlarged prostate complains of symptoms that are related to obstruction of urine flow, irritation and symptoms that occur later.
  • Obstructive symptoms: -
    1. Hesitancy or delay in urine flow during attempted urination. There is a decrease in force and size of the urinary stream. There may be intermittency (pauses in flow of stream), dribbling of urine at the end of urination and a feeling of incomplete emptying of the bladder.
    2. Irritative symptoms include increased frequency and urgency of urination, nocturia, pain on urination from bladder stones, infection or muscle spasms and blood in the urine from infection, inflammation or bleeding veins at the surface of the prostate.
    3. Delayed symptoms are those of renal failure due to kidney involvement and the development of a hernia or haemorrhoids from constant straining during urination.
  • During the physical examination, the prostate gland is examined. Digital rectal exam (DRE) is carried out by inserting a finger into the rectum. The prostate gland lies just in front of the rectum and can be felt for size and nodules. It is important to rule out a cancer of the prostate.

Diagnostic Testing

Medical Treatment

  • Medical therapy is appropriate for patients who have mild symptoms of urinary obstruction or are too old or unwell to undergo a surgical procedure.
  • Relief from obstruction may not be immediate and usually necessitates life long medical treatment. Medical treatment may be ineffective with high grade obstruction.
  • There are two main drug groups that are used to treat BPH: -
    1. Muscle Relaxants - This group of drugs blocks nerve impulses going to the muscles of the involuntary internal sphincter thus easing urinary flow. Side affects of these medications include low blood pressure, dizziness, fast heart rate, tiredness, nasal congestion and retrograde ejaculation (sperm goes into the bladder).
    2. Hormonal Agents - These drugs attempt to reverse the effect of testosterone on the prostate causing a decrease in size. This is accomplished by blocking the effect of testosterone on the prostate. Side effects of these drugs may include impotence and a loss of libido.

Surgical Treatment (TURP)

Indications For Surgery

Transurethral Resection Of The Prostate (TURP)

Transurethral Resection Prostate (TURP)

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 advanatages of Bipolar TURP with saline.

Complications

Complications seen with TURP and their approximate rates of occurrence are: -

  • Bleeding (<5%).
  • Infection (<2%).
  • Perforation of the bladder (<1%).
  • Inability to pass urine, usually due to muscle dysfunction with longstanding BPH (5%).
  • Stricture of the urethra from scarring (2.5%).
  • Urinary incontinence from damage to the sphincter (<2%).
  • Impotence (5% dependent on patient age).
  • Retrograde ejaculation (passage of sperm) (50%) - because of the loss of the internal sphincter, spermatic secretions may go upwards into the bladder rather than down through the penis during ejaculation. These secretions will pass out later during urination. This may give rise to sterility due to reduced sperm count.
  • TUR Syndrome (<2%) - Extensive TURP, especially with very large prostates, may open up venous blood vessels during surgery. Fluid in the bladder may get absorbed into the blood causing fluid overload and electrolyte (salt) imbalance in the body. Fluid overload may be particularly a problem in a patient with heart or lung disease. Electrolyte imbalance may cause neurologic symptoms, including seizures and coma. This syndrome is now preventable with the use of the new bipolar resectoscope (GYRUS TURP).

Postoperative Care (TURP)

Alternative Therapies

  • Transurethral Incision of the Prostate (TUIP) - This technique involves making incisions from the bladder down to the veru montanum in the prostate. These incisions cut through the involuntary internal sphincter and open the urinary tract. Results of this technique are almost as good as TURP and there is less chance of complications. This technique may be used for smaller prostates and in younger patients.
  • Greenlight Laser Ablation - This technique is newer and involves use of a probe which fires a laser to evaporate prostatic tissue. There is less bleeding in this procedure and may be beneficial in patients with bleeding disorders. Long term results of this technique are reasonable but large glands do not do as well.
  • Open Prostatectomy - An open procedure may be advisable in-patients with extremely large prostates as the risk of complications from TURP increases with increasing size of the prostate. This procedure may also be necessary if additional procedures are needed (e.g. removal of a bladder stone). An incision is made in the lower abdomen and the prostate is "shelled" out of it's capsule. Although the risk of many of the complications or TURP is reduced, recovery time is longer.
  • Balloon Dilation/Stenting - These techniques have not demonstrated good long term results but are considered in patients too sick to undergo a formal surgical procedure.
  • TUMT - TransUrethral Microwave Therapy may be successful but is not as well controlled as laser or TURP.
  • UroLift® - Minimally invasive treatment for BPH (see section below for more information).

UroLift®

UroLift is a newer minimally invasive procedure suitable for treating BPH in some patients. It has been trialled since 2005 and been approved for use since 2013.

A cystoscope (small telescopic tube which allows visualisation of the urethra and bladder) is passed into the urethra under an anaesthetic. Small implants are used to tether the enlarged prostate tissue, holding it and therefore increase the bore of the urethra. The implants are left in place permanently but can be removed if required. The procedure takes about 30 minutes.

Enlarged Prostate

An enlarged prosate can narrow or even block the urethra.

Step 1

The UroLift Delivery Device is placed through the obstructed urethra to access the enlarged prostate.

Step 2

Small UroLift Implants are permanently placed to lift or hold the enlarged prostate tissue out of the way and increase the opening of the urethra. The permanent Implants are delivered through a small needle that comes out of the UroLift Delivery Device and into the prostate.

Step 3

The UroLift Delivery Device is removed, leaving an open urethra designed to provide symptom relief.

Advantages

Side Effects

There may be pain or burning wih urination, blood in the urine and frequency of urination and pelvic pain for 2-4 weeks after the procedure.

Follow Up

Review of prostate symptoms score and uroflow testing will confirm the success of UroLift procedure.