Every man has some enlargement of prostate after the age of 50 years. Approximately 17 percent of the men above 50 years and 35 percent of the men above 70 years suffer from Lower Urinary Tract Symptoms (LUTS). The common causes of enlargement of Prostate include benign (Non cancerous) enlargement or Cancerous enlargement of the Prostate.
Benign enlargement of prostate
Benign enlargement of prostate may result in lower urinary tract symptoms like frequency of urination, sudden strong desire to pass urine (urgency), urge incontinence or poor urinary stream etc. If diagnosed early, these problems can be treated by medication or surgery. If neglected, these problems may result in complications like retention of urine, urinary tract infection, blood in urine, kidney failure, stones etc.
The rationale for medical management is based on the fact that Benign Prostatic Hyperplasia (BPH) has both dynamic and static components. The dynamic component is due to increase in smooth muscle tone of prostate stroma, capsule and bladder neck due to alpha-receptors. The static component is due to stromal and epithelial growth that results in increase in size and volume of the prostate gland. 5 alpha reductase inhibitors play an important role of static component due to conversion of testosterone to DHT. The management of dynamic component is by alpha-blockers and static component by hormonal treatment.
Alpha-blockers are grouped according to their affinity for the receptors and duration of action. The adrenoreceptors can be alpha 1 and 2 types. The type 2 receptors are mainly present in blood vessels and give rise to lowering of blood pressure. There are 3 distinct alpha 1 receptors i.e. alpha 1a, alpha 1b and alpha 1d in the prostate. 70 percent of alpha-receptors are alpha 1a and drugs blocking these receptors are known as uroselective aplha blockers.
The first generation aplha-blockers like phenoxybenzamine and phentolamine were non-specific and are not recommended for use due to their side effects. The second-generation selective alpha-blockers are Prazosin, Terazosin and Dexazosin. Selective alpha-1 blockers cause a fall in blood pressure and therefore have to be used with caution and their dose has to be titrated. However, in-patients of BPH along with hypertension, selective alpha-1a blockers are preferred as they help both in relief of prostatic symptoms and hypertension. The third generation super selective alpha-1a blockers are Alfuzosin, Tamsuosin and Silodosin. They have minimum effect of blood pressure and are the drugs of choice. The short acting drugs like Prazosin has to be given 2-3 times a day but now slow release formulations are available which can be given once a day like other alpha-blockers.
For static component of BPH, the drugs of choice are 5 alpha reductase inhibitors. Finasteride, a synthetic 4-azasteroid compound, is a specific, inhibitor of type-2 alpha reductase, whereas Dutasteride has effect both on type 1 and 1 alpha reductase enzymes. After these drugs have been administered for some time, improvement in symptoms is noticed. In about 25% of cases, size of the prostate reduces by 28 percent. They have minimal side effects and therefore there is no need for titration of the dose. These drugs also have the potential to alter the natural history and progression of disease and minimize risk of acute urinary retention. The results of this therapy are better if the volume of the prostate is more than 40ml and PSA is more than 1.4 ng/ml. These drugs cause atrophy of the glandular epithelial tissue and serum levels of PSA decrease by 50 percent. In further evaluation of these patients, PSA should be multiplied by 2 for decision-making in terms of prostate cancer detection.
Combined medical management with selective alpha-1 blocker and alpha-5 reductase inhibitors is recommended for those who have large prostate along with symptoms as the mechanism of action of these two drugs is different and they work synergestically. Long-term studies have found good effect of the combination therapy. The episodes of urinary retention and need for prostatic surgery may decrease. It is important for patients who are on medical treatment to have regular check for PSA, ultrasound and uroflowmetry as in the long run, some patients may need surgical treatment.
Transurethral resection of prostate (TURP)
Transurethral Resection of Prostate (TURP) is the Gold standard in surgical management of BPH. TURP has stood the test of time during the last 70 years and became the most common surgical procedure in the hands of the Urologist. It is termed as gold standard because of effective long term out come and can be performed safely. During the last two decades, several advances have taken place to reduce complications and morbidity of TURP. Eglesias continuous irrigation resectoscope is routinely used, which resects under low pressure and reduces absorption of the irrigating fluid. Advances in imaging like endovision camera and digital endoscopes, provides magnification and anatomy can be clearly delineated during the TURP. Initially distil and boiled water was used for irrigation, which causes dilutional Hyponatremia and TUR syndrome and haemolysis. Glycin 1.5% isotonic solution decrease absorption of the fluid during procedure and no haemolysis but hyponatremia can occur. Saline is used for bipolar TURP, which have advantages of minimum fluid absorption and hyponatremia. Thick loop resection provides better coagulation along with resection of the tissue. As a result, bleeding is less. The thick loop can be used with monopolar as well as bipolar cautery. Bipolar diathermy reduces the passing of current through body and saline can be used for resection. There is efficient cutting with less bleeding and there is no temperature at the time of resection, as a result, there is less damage to the surrounding tissue and scarring. The anatomy is clearly delineated throughout the procedure and one can be more accurate in resection. Due to use of saline, there is no limitation of time of resection and large prostate can be resected. The patient has better post operative recovery, less irrigation and shorter hospital stay.
In comparison to any minimally invasive treatment, TURP is the most cost effective with better outcome and is useful in developing countries where affordability of the treatment by a patient is equally important.
In a little more than 15 years, Laser Prostatectomy (LP) for the management of obstructive benign prostatic hyperplasia has evolved into three principally different techniques – coagulation, cutting or enucleation and vaporization.
Holmium Laser is an ideal surgical tool in the management of benign prostatic hyperplasia. Holmium laser can cut, vapourize, and resect prostate tissue with minimal bleeding. It creates a channel identical to the TURP with immediate removal by obstructive adenomatus prostatic tissue. The removed tissue is available for histopathological diagnosis. The advantage of holmium laser is that the bleeding is minimum because while cutting the prostate, the holmium laser also coagulates. In Holmium laser enucleation of prostate (HOLEP),large size gland can also be removed.
Holmium laser is a pulsed wave laser, therefore, there are vibrations which results in poor vision and difficult to learn. The Thulmium laser has similar wavelength and same properties as Holmium laser but is a continuous wave laser and easy to learn and operate.
Photoselective vaporization of the prostate (PVP)has gained global acceptance because of its safety, efficacy outcomes on a par with TURP, long-term durability and applicability to high risk and coagulation-deficient patients. Currently, 120 watt 532-nm Lithium Triborate laser vaporization prostatectomy is more effective and fast and produces a nicely healed prostatic cavity. There is a less steep learning curve for this procedure. The cost of the machine and disposable fiber is prohibitive. If a prostate is very large, more than one fibre will be required.
Prostate cancer is the most common cancer in males in USA. In India, the exact incidence is not known due to lack of awareness and unavailability of such information on a wide scale. At an early stage of prostate cancer, there are no specific symptoms and thus the patients are often diagnosed late when the disease is already advanced. Prostate cancer, if diagnosed early, can be completely cured, but when diagnosed at an advanced stage, it can only be controlled for some time. If untreated, prostate cancer can be a cause for significant morbidity & mortality. In USA, 90- 95 percent of prostate cancer cases are diagnosed early, where as in India, 90-95 percent are diagnosed in advanced stage. This reverse scenario is primarily due to lack of awareness about this potentially curable disease. Changing the outlook of this disease is a big challenge for India.
Surgery – robotic radical prostatectomy
This is indicated in men who have life expectancy more than 10 years, no significant associated diseases, are less than 75 years and the disease localized to the prostate gland. In this operation, the complete prostate gland is removed. The advantage of the operation is that as the disease is completely removed, patient can have a normal life span. However, the patient has to come for regular follow up.
Radical Prostatectomy can be done by open surgery by transpubic or perineal approach, laparoscopic (key hole surgery) or Robot assisted laparoscopic surgery.
Robotic Associated Laparoscopic Radical prostatectomy (RALP) started around 2000 and today more than 80% of radical prostatectomy in USA is done robotically. The advantages of Robotic Surgery are less blood loss, early recovery, less hospitalization. The functional and oncological outcome is as good as open surgery. The complications of surgery have significantly reduced and patient does not require any blood transfusion. The recovery is fast & patient can go home in 48 hrs. The incontinence rate has significantly reduced and 90 percent patient become fully continent in 6-9 months. With nerve sparing technique, the incidence of erectile dysfunction has reduced and can be treated by drugs.
Contributed by Narmada P.Gupta
Chairman, Academic & Research, Urology, Medanta- The Medicity