When bladder outlet obstruction due to an enlarged prostate becomes symptomatic, it still requires expert operative intervention by urologists. Operative intervention is also indicated for persistent bleeding from the prostate, persistent urinary tract infections that will not clear with antibiotics, weakening of the bladder, worsening kidney function, and bladder stones. Medications do not always work, and at that point, surgery can provide excellent results. Today, there are many types of invasive therapies available.
Indications for surgical treatment
Enlarged prostate tissue can be removed by making a small incision through the lower abdomen, and then removing the enlarged portion of the prostate by going through the bladder. The whole prostate is not removed, but only the enlarged growth in the middle of the prostate is removed. This form of prostate surgery was developed 100 years ago, and is still the most effective treatment for an enlarged prostate. There is a 98% chance that a man will see improvement in his voiding symptoms after this procedure. However, open prostatectomy requires general anesthesia, catheters draining the bladder for about one week, and hospitalization for about one week. This procedure is usually used for an extremely enlarged prostate or a prostate that grows primarily back into the bladder.
This procedure, commonly known as a "prostate scraping" or "roto-rooter" operation, was first described back in 1913, and has steadily gained in popularity as the instrumentation for the procedure has improved. A TURP involves using a telescope-like instrument inserted into the urethra to shave off the portion of the prostate that is blocking the bladder. No surgical incision is necessary. If the prostate can be thought of as a doughnut, this operation involves making the hole in the middle of the doughnut wider. A TURP is an effective treatment for an enlarged prostate. There is an 88% chance that a man will see improvement in his voiding symptoms following this procedure. A catheter is usually required for only one to two days, and many patients leave the hospital after just on overnight stay.
This procedure has been in common use since the 1970's. A TUIP involves using a telescop-like instrument inserted into the urethra to incise, or cut, the opening of the bladder and the prostate. The prostate then springs open, resulting in less blockage to the flow of urine coming from the bladder. If we think of the prostate as a doughnut again, this procedure enlarges the hole in the middle of the doughnut by cutting it, not removing any portion of the doughnut. This procedure is ideally suited for men with small prostates that are obstructing the bladder outlet. It requires general anesthesia and the patient will have a catheter in his bladder for one to two days. However, for small prostates, a TUIP gives results as good as the more commonly used TURP, and has fewer complications. There is a lower incidence of scar tissue forming at the opening of the bladder and less bleeding after a TUIP compared to a TURP.
The idea behind a prostatic stent is a simple one. A man-made device in the shape of a hollow tube is placed within the prostate to hold it open, or keep the passageway open. This relieves the blockage and allows a man to void easily.
The UroLume® stent* is such a device. It consists of braided wires and is inert, nonreactive, in the human body. This device is inserted within the prostate by using a telescope-like instrument. No incisions are necessary. The UroLume® stent expands when it is released within the prostate, and presses against the walls of the passageway within the prostate. By pushing the walls of the prostate apart, the UroLume® stent gets rid of the obstruction to the bladder.
The UroLume® stent has proven to be an effective means of relieving blockage to the bladder due to an enlarged prostate. There is a marked improvement in a man's flow rate (how fast the urine comes out of the bladder) as well as a man's symptoms. These improvements have been shown to be long lasting, with studies showing sustained improvement up to seven years after stent placement.
Stents offer a safe option and can be placed with minimal anesthesia and few risks. When compared to the more common TURP procedure, the UroLume® stent has a lower incidence of complications, less blood loss, and provides immediate relief. Almost all patients will be able to urinate immediately after the procedure, even those patients who had been in urinary retention (completely unable to urinate) prior to the procedure. The UroLume® stent can also be placed as an outpatient procedure. Men who are too sick to undergo the longer TURP procedure can usually undergo the shorter, effective UroLume® stent procedure.
This photograph shows a UroLume® stent in place within the prostate. The passageway within the prostate is now wide open and the lumen of the bladder can be clearly seen (black space in the center).
There are other treatments for bladder outlet obstruction due to an enlarged prostate. They are less commonly performed than the other procedures discussed above.
Transurethral electrovaporization of the prostate (TUEVP)--This procedure uses a roller electrode to vaporize prostate tissue via a cystoscope.
Contact laser prostatectomy--This procedure uses a Neodynium:Yttrium-Aluminum-Garnet (Nd:YAG) laser to incise or vaporize the prostate via a cystoscope.
Free beam laser prostatectomy procedures--These procedures employ laser energy to treat prostate tissue.
Nd:YAG laser prostatectomy--In this procedure, laser light produces coagulation necrosis of prostate tissue. The treated prostate tissue dissolves and sloughs in the urinary stream over a period of several weeks. The procedure is performed through a cystoscope.
Ho:YAG laser resection of the prostate (HoLRP)--The laser light of the Holmium laser is used to resect prostate tissue via a cystoscope.
Interstitial laser coagulation (ILC)--This procedure also uses a Nd:YAG laser to cause coagulation of prostate tissue. The treated prostate tissue does not slough in the urinary stream, but is resorbed by the body. This procedure is performed via a cystoscope.
Balloon dilation of the prostate--This procedure involves inserting a balloon in the prostate via a cystoscope, inflating the balloon, thereby dilating the prostate.
Transurethral needle ablation of the prostate (TUNA)--This procedure uses radiofrequency energy to destroy prostate tissue. The cystoscope is used to insert paired needle electrodes into the enlarged prostate and heating is used to produce coagulation necrosis.
Transurethral microwave thermotherapy (TUMT)--This procedure uses microwave energy via a coaxial cable inserted through a urethral catheter. The high temperatures produced have the ability to cause coagulation necrosis of the prostate.
*UroLume® Endoprosthesis Stent
Courtesy of American Medical Systems, Inc.