What to Do When BPH Medications Fail
February 6, 2020
Benign Prostatic Hyperplasia (BPH) is a common urological condition that affects about 40 million men in the U.S. The prostate is a small gland located below the neck of the bladder and the urethra. It runs through the center of the prostate from the bladder and through the penis where urine flows out.
As the prostate grows and enlarges (BPH), it begins to press on and obstruct the urethra causing BPH symptoms such as frequent daytime urination, getting up at night frequently to urinate, a weak or slow stream, the feeling of not emptying the bladder completely, an urgent need to urinate or difficulty starting a urinary stream.
Although BPH is a benign condition, many men find it disruptive to their lives and often have symptoms of BPH that begin in their 50s. Due to the proliferation of BPH and the incredible inconvenience it causes for men, there have been several treatment methods and surgeries for BPH developed over the years.
BPH Treatment Options
A majority of BPH treatment options include medications that help reduce or eliminate symptoms. However, BPH medications can cause side effects and can become a hassle to remember taking.
When BPH becomes bothersome enough and medications are no longer effective or side effects prevent use, surgical options become the treatment of choice.
As technology has advanced, multiple surgical treatment options for BPH have become available and widely practiced. The traditional TURP procedure has been well-studied and stands alone in its effectiveness. The only turn off is that it comes with anesthesia and oftentimes, a longer recovery time than the newer procedures now widely offered.
Some of these surgical treatments for BPH include:
The old standby. Tried and true, the TURP, or, transurethral resection of the prostate tissue, has been performed for decades and is a great surgical treatment option for BPH. The TURP works by removing the obstructing prostate tissue. It’s performed in a surgical center and under general anesthesia. The surgery is simple and the outcomes are well-studied and come with a low risk of changes in sexual function. However, recovery time is a bit slow as the prostate tissue must heal and scar over post-surgery with moderate restrictions on activity level for a few weeks, often taking up to 3 months to fully gauge urinary changes. Additionally, a catheter is placed for the first day or two after the procedure. This being said, it may be the best surgical treatment option for BPH as its reliability for results is proven.
UroLift used to be the new kid on the block, but now it has some competition. UroLift is a very simple procedure to help with BPH. This surgical treatment option for BPH is typically a one-time, in-office solution that provides rapid relief and recovery of BPH symptoms. The goal of the UroLift procedure is to relieve symptoms so daily life isn’t disrupted by urinary issues. It provides a less invasive treatment option for BPH than a TURP along with less risk. UroLift also diminishes the concern about anesthesia and possible lasting erectile or ejaculatory dysfunction that a TURP could potentially cause. As UroLift has been studied more thoroughly, it has become the surgical treatment option of choice for most urologists. It works by implanting small “stents” that lift and hold the enlarged prostate tissue so it no longer blocks the urethra. It does not require heating, cutting, or removal of the prostate tissue. The procedure takes under 30 minutes and is performed using local anesthesia in a physician’s office. Research has demonstrated that after one month, approximately 80% of men that had the UroLift procedure described their BPH symptoms as “much” or “very much better”, with 89% recommending the procedure. Recovery time tends to be shorter than a TURP with improved urination in about 2 weeks. Additionally, a catheter isn’t usually necessary post-procedure. The UroLift procedure is not appropriate for all patients, but for most, it’s an alternative option to a TURP.
● Prostatic artery embolization (PAE):
PAE is a very new addition for the treatment of BPH. Post-surgical outcomes have been widely variable in research and although PAE appears to be a future surgical treatment option for BPH, more studies need to be done before stacking it against a TURP, Urolift or Rezum. PAE is a minimally invasive treatment performed by an interventional radiologist (IR – a doctor who uses X-rays and other advanced imaging to see inside the body and treat conditions). Initially, a Foley catheter may be inserted into the bladder to provide a reference point for the surrounding anatomy. PAE is then performed through a small catheter inserted by the IR into the artery in the wrist or groin. The interventional radiologist then guides the catheter into the vessels that supply blood to the prostate. Following this, an X-ray with dye (arteriogram) is performed to map the blood vessels that “feed” the prostate. Finally, tiny round microspheres (particles) are injected through the catheter and into the blood vessels that feed the prostate to reduce its blood supply. Ideally, following this procedure, the prostate begins to shrink, relieving and improving BPH symptoms usually within days of the procedure. It received FDA approval relatively recently and is not widely used yet as patient outcomes and complications vary greatly in research.
Rezum is another new option for the treatment of BPH. Rezum works to improve urinary symptoms by inserting sterile water vapor (steam) into the prostate gland during nine-second intervals. The procedure consists of two to seven injections, each of which are nine seconds long. First, the prostate and the penis are numbed. Then, the Rezum device is inserted, a needle is deployed, and vapor is injected into the prostate for nine seconds. This vapor disperses between cells, then cools, releases heat, and gently disrupts the prostate’s cells. The procedure takes one to two hours in the office depending on the size of the prostate. Due to swelling, a catheter is placed for a few days and removed in the office. Urinary benefits are usually seen within a few weeks and improve within months.
Since its introduction in the late 1990s, Holmium Laser Enucleation of the Prostate (HoLEP) has gained traction and popularity for the management of benign prostatic hyperplasia (BPH), or enlarged prostate. The principles behind the HoLEP procedure are to provide patients with the fastest relief coupled with the most optimal outcomes when it comes to prostate symptoms.
What is the HoLEP and how is it performed?
Holmium laser enucleation of the prostate (HoLEP) is a minimally invasive treatment for BPH. It is all done through a natural urinary orifice (through the penis) without the need for any incisions. Utilizing general or spinal anesthesia, the holmium laser is used to dissect, enucleate, and peel the prostate gland tissue, leaving only the capsule (outer layer) of the prostate in place.
The Enucleated prostate gland tissue is then pushed into the bladder under complete endoscopic vision and extracted through a morcellator device. The extracted tissue is then sent to a pathology lab for further analysis, to ensure other conditions such as prostate cancer are not present. An analogy that is often used: If the prostate is an orange, the HoLEP removes the “fruit” and leaves the “peel.”
Why aren’t all urologists performing the HoLEP?
HoLEP is an extremely specialized procedure that requires intensive mentored training during a urology residency or fellowship. Due to the difficult and steep learning curve, there are very few urologic surgeons and institutions in the United States who are currently teaching and performing this procedure. Dr. Tsai has been very fortunate to train under one of these highly skilled mentors who has passed his technique for this unique and game-changing procedure onto him.
HoLEP offers some unique advantages:
– Ability to treat any size prostate gland with minimal bleeding.
– Complete cleaning of the enlarged prostate tissue down to the prostatic capsule, resulting in a re-treatment rate of less than 2 percent and a high durability rate.
– Early, immediate relief of symptoms and fast return to normal activity.
– Back to work within 2-3 days and can resume physical exercise within 2 weeks.
– Next-day catheter removal in most of the cases with less than 24 hours of hospital stay.
– Minimal pain.
– Tissue available for examination to check for malignancy or cancer.
– There is zero to minimal effect on sexual function, erections, climax.
Which BPH Surgery is Right for Me?
Other than the TURP, all of the newer surgical procedures for BPH are good options. However, research has shown that UroLift and HoLEP tend to have the most favorable outcomes when it comes to fast urinary improvement, little recovery time, preservation of sexual function and a quick return to normal lifestyle.
For more information about BPH and BPH treatment options, contact Austin Urology Institute at (512) 694-8888 to make an appointment with a provider.