NON-SURGICAL or MEDICAL TREATMENTS FOR BPH

Medical treatment for prostate disease has gone in multiple directions over the period of the last few years. The two major thrusts are in reducing prostate size and secondly, to relax the muscles that surround the prostate to allow flow through urinary channel.

SIZE REDUCTION BY ANDROGEN SUPPRESSION (FINASTERIDE)

The prostate gland composes of cells that depend on male hormone to maintain its growth and size. Finasteride or Proscar, blocks the action of the male hormone testosterone in these prostate cells without affecting the level of testosterone in the blood stream. This allows a majority of men to have normal libido while causing the prostate gland to shrink. Studies have shown an approximate 25% decrease in size of the prostate gland with the use of finasteride. Many studies show that patients on finasteride demonstrate a reduction in prostate volume with a regression of their symptoms as well as an improvement in flow rates over a four to twelve month period compared to placebo. The drug is taken once a day, has very little in the way of side effects and the cost is approximately $45 a month.

BLADDER MUSCLE RELAXATION BY ALPHA ADRENERGIC RECEPTOR BLOCKING MEDICATON:

TERAZOSIN, DOXAZOCIN AND PRAZOSIN

The prostate gland is composed of smooth muscle that surround the prostate channel. These smooth muscle are similar to those in blood vessels that help maintain blood pressure. These muscles maintains a certain level of muscular tone and can be relaxed by taking specific medications. These medication are known as alpha adrenergic receptor blocking drugs. Although they are also blood pressure medications, they have been found to relax the prostate gland smooth muscles. These drugs include Hytrin (terazosin), Cardura (doxazocin) and Minipress (prazosin). By relaxing the smooth muscles in the prostate and bladder neck, the urinary channel passage opens enough to allow many men to have both subjective and objective improvement of their urinary flow. The medicine does not stop the growth of the prostate, and theoretically, as the prostate grows over the years, these medicines will become ineffective. However, many studies shown that patients can maintain their improvements in both symptoms and flow rates for up to three years and more. A small percentage of men will have difficulties with lowering of their blood pressure to a point where dizziness and even fainting can occur. In addition, certain men with heart disease may not tolerate these medications without some risk. However, in men with high blood pressure, it can be an advantageous drug treating two problems. Finally, these alpha blocking agents action are immediate with symptoms improvement maintained up to three years or more

THE CONTROVERSY:

ALPHA ADRENERGIC BLOCKERS OR ANDROGEN SUPPRESSION MEDICAL THERAPY OR BOTH?

There has been much debate in the urologic community about which drug works better and whether they work at all. In addition, it would seem logical that if one drug could shrink the prostate while the other could relax the prostate, combining the two would produce better results. To address these issues, many studies have been performed comparing the drug to placebo and to each other. While there have been many large studies demonstrating that both drugs work better than placebo, controversies exist because of criticisms directed at the way the data are collected, analyzed and interpreted. For example, a much publicized recent study on a populations of aging male veterans in a Veteran Administration Cooperative Study compared terazosin, finasteride, placebo and various combinations of the three in a double blind, randomized study. It was reported that finasteride did not work better than either placebo while terazosin did demonstrate improvements compared to placebo. This was in contradiction to many published large series on finasteride. However, the study was criticized because the population of men in the study had small prostates and the age distribution of men with symptoms and flows resembled that of an aged matched community of normal men (Olmstead County). In addition, it appeared that a subpopulation of men in the study with large prostate did benefit from finasteride compared to similar men on placebo. However, this data was not conclusive. These complex questions and controversies concerning which is better and what works are currently being studied in a large double blind, randomized multicenter NIH study that is currently in progress. Columbia Presbyterian Medical Center is one of the main participating centers.

STANDARD TRANSURETHRAL RESECTION OF THE PROSTATE (TURP)

Transurethral resection of the prostate (TURP) has been the standard choice for the past 50 years of treatment for urinary symptoms attributed to a large prostate condition commonly known as BPH that causes obstruction of the bladder outlet and voiding symptoms such as urinary frequency, voiding at night and a slow urinary stream .

About 400,000 TURPs are performed each year in the United States. TURP is a safe procedure with 80% of patients experiencing resolution of their voiding symptoms and improvement of urinary flow measurements. A TURP involves the removal of the obstructing portions of the prostate with a telescopic hot wire loop that cuts like an electric knife. The TURP requires an anesthetic and takes about 30-60 minutes to perform. A tube or catheter is inserted into the bladder and is left in place for 2 to 3 days. The hospitalization lasts from 2-5 days and requires two weeks of severe activity restrictions and another two weeks of modest restrictions. The long term effectiveness of TURP in alleviating obstruction and symptoms caused by BPH has made the TURP the gold standard to which new procedures are compared.

However, the TURP is a surgical procedure with potential risks and complications such as bleeding, impotence and incontinence. To decrease hospitalization costs and recuperation time from work, alternative therapies are being developed and introduced by the urologic community. These include medical treatments and alternative surgical treatments that have the potential to decrease complications and be as effective as the gold standard TURP.

OPEN ( SUPRAPUBIC OR RETROPUBIC) PROSTATECTOMY

Prior to the TURP, prostate obstruction was treated with an formal operation requiring an surgical incision on the lower aspect of the abdomen to remove a large part of the blocking portion of the prostate gland. In current practice, it is still applied to patients with large prostates, prostates with a middle lobe or to patients who have other condition that requires an open operations such as the removal of stones in the bladder. Since it is a formal operation, patients are subjected to the usual risk and complications of an open pelvic operation requiring anesthesia. In addition, their hospitalization is longer and recuperation with a catheter and from normal activity is longer. Patients have a scar from their surgical incision. The long term success rate for the treatment of BPH with this procedure is similar to the TURP.

TRANSURETHRAL INCISION OF THE PROSTATE (TUIP)

A transurethral incision of the prostate (TUIP), is a simplified alternative to TURP that simulates its results in both symptom relief and flow rates improvements. The procedure is performed by making a simple deep cut or incision along the entire length of the prostate to split it open. This allows the circular muscle fibers running around the prostate to spring open and increase urinary flow by opening the prostatic urinary channel. TUIP is ideally suited for smaller prostates and has a lower incidence of ejaculation abnormalities. In appropriately selected patients with relatively small and anatomically appropriate prostates, the success rates for TUIP are similar to TURP with the advantage that hospital stays and recovery are much shorter.

TRANSURETHRAL ELECTROVAPORIZATION OF THE PROSTATE (TVP)

A new modification on the TURP technology, termed transurethral electrovaporization of the prostate, (TVP), applies electrical energy to electrosurgically vaporize or remove the obstructive enlarged prostatic tissue. The technique involves the application of a simple, specially designed grooved rollerball electrode that allows the surgeon to channel open the urethra that is blocked by the prostate tissue. Compared to the standard TURP, the procedure is safer and has minimal side effects. There is less bleeding, shorter hospitalization and catheter times and faster recovery period.

The procedure allows the grooved rollerbar electrode to rapidly heats the tissue cells so that they turn into steam, leaving a space where the prostate tissue was previously present. The majority of heat that is turned into steam is then washed away by a constant flow of water. As the electrode moves to fresh tissue, new cells are removed creating an incision or vaporized space. The resulting pathway does not bleed because it is coagulated and sealed by the electrically heated rolling action of the rollerball electrode. Technically, this is a new way to do a TURP and TVP can also be utilized to perform a TUIP.

Our experience has demonstrated significant improvement in symptoms and urine flow that parallel that reported for either conventional TURP and laser assisted prostatectomy. Anesthesia utilized included general, regional, and intravenous sedation with local intraurethral xylocaine. Patients had their urethral catheters removed within 24 hours after surgery and were able to void spontaneously, unlike patients who were treated with TURP. There was minimal blood loss during the surgery. Patients who reported adequate sexual erectile function before surgery, reported no change in their sexual abilities after surgery. There was no incidence of incontinence from sphincter damage.

Our current experience numbers over 170 patients with similar results to our earlier published series. Long term data on its efficacy as well as multicenter trials are currently underway to compare it to other procedures to treat BPH such as the standard TURP and laser TURP. The major potential advantage of TVP compared to the conventional TURP and laser assisted prostatectomy is cost, few side effects, rapid convalescence time and short hospital stay overnight as well as the simplicity of the procedure. This makes TVP or transurethral electrovaporization a useful, safe and versatile tool in the treatment of the enlarged prostate disease that cause urinary outflow obstruction or BPH.

TRANSURETHRAL LASER VAPORIZATION / ABLATION OF THE PROSTATE (VLAP)

The laser is a high energy source that has gained much attention as a unique surgical tool in the surgical treatment of many diseases. In urology, the light energy is converted to heat on contact to tissue to produce its surgical effect. It is an energy modality utilized in breaking stones, treating bladder tumors and removing prostate tissue.

With laser prostatectomy, a laser fiber is passed into the prostatic channel under telescopic guidance. The laser is then used to destroy the obstructing portions of the prostate by heating it up. The two techniques to remove tissue are laser vaporization and laser ablation. With vaporization, high instantaneous heat is created to vaporize or steam away prostate tissue. With ablation, a lower laser energy is applied which heats up the tissue enough to dry it out, and let it shrink and slough away with time. Compared to standard transurethral resection or TURP, the advantages of these laser procedures are: no significant bleeding, shorter hospitalization and reduced operating time. The laser albation or VLAP has not been optimum in large prostate because of the necessity for multiple treatments. Laser vaporization, on the other hand, has been able to remove more tissue at one treatment. With these laser procedures, there has been a greater amount of swelling around the prostate channel after the procedure (3-10 days) which requires temporary catheter drainage (tube into the bladder to drain urine). In addition, patients can experience a few weeks of urinary frequency and irritation while the prostatic channel is healing. Its significant advantages are no bleeding and a short hospital stay.

One concern of this procedure among the urological commiunity is that no prostate tissue is removed. Therefore, one cannot be certain that cancer does not exist. However, with the excellent diagnostic techniques available today with PSA and Ultrasound, appropriate assessments can be performed and biopsies taken if indicated.

MICROWAVE HYPERTHERMIA OF THE PROSTATE

Similar to the laser ablation procedure, transurethral microwave hypertermia of the prostate utilizes heat to remove prostatic tissue. A microwave probe is placed into the prostatic channel, microwave energy is utilize to heat the prostate tissue to temperatures above 50 degree Celcius. This causes destruction to the prostate tissue and shrinkage of the gland. No prostate tissue is removed for pathologic diagnosis. The new generation microwave machines use a catheter that cools the lining of the prostatic urethra while the prostate tissue deep inside is heated. This allows patients to recover with less irritation after the procedure. These new generation machines also control the delivery of microwave energy and the heat level they produce more accurately with the advance computer technology that is employed. The newest machines are available at Columbia Presbyterian Medical Center as part of several clinical trials across the USA and their results are promising as an intermediate modality between medical therapy and more invasive surgical approaches.

TRANSURETHRAL NEEDLE ABLATION OF THE PROSTATE (TUNA)

Applying the heat ablation principle to coagulate and necrose prostatic tissue, this technique utilizes electrical radiofrequency current through small needles place bilaterally into the prostate gland via a transurethral approach to induce tissue destruction by local heating. This technique can be performed with minimal anesthisia and as an outpatient procedure. Preliminary data on small series of patients suggest it has potential a viable minimally invasive surgical alternative for the treatment of BPH. This device is currently not FDA approved.

INTERSTITIAL LASER COAGULATION OF THE PROSTATE (ILC)

Similar to transurethral needle ablation of the prostate, a thin laser fiber is inserted into the prostatic adenoma via a tranurethral or transrectal route under ultrasound guidance. Laser energy is then utilize to induce tissue destruction by local tissue heating with the laser light energy. Preliminary data on small series of patients suggest it has potential as a viable minimally invasive surgical alternative for the treatment of BPH. This device is currently not FDA approved.

PROSTATIC STENTS

Stents are wire devices shaped like small springs or coils. Stents are placed within the prostate channel and are used to keep the channel open. Stents are generally placed under local anesthesia and require about twenty minutes to place in the prostate. Its use has been reserved for patients who medically cannot tolerate a surgical procedure requiring a greater level of anesthesia. Major problems with stents concern the irritation and debris that form on the stent as well as a higher incidence of urinary tract infections . This device is currently not FDA approved.

BALLOON DILATION

Balloon dilation has been used clinically as an alternative to prostatectomy. It is very similar to the angioplasties done for coronary artery disease. Basically, a balloon is placed into the prostatic channel, either by finger guidance or telescopic guidance, and the balloon is then inflated to stretch the prostate channel. This has the apparent end result of tearing the prostate gland and creating a wider opening in the urinary channel. No prostate tissue is removed and the procedure does not work well for very large prostates. Recent numerous studies have demonstrated that most of the patients after balloon dilation have recurrence of their symptoms relatively soon and require repeat treatments within two years. With today's wider and more efficaceous variety of BPH treatments, balloons are less accepted as a viable alternative treatment.

COMMENTS ON THERAPY

While severe prostatic obstruction requires treatment, not every man needs treatment for mild prostatic obstruction. It is normal for a man's urinary flow to reduce as he ages. Mandatory reasons to proceed with some form of treatment include recurring infections, repeated bleeding episodes, bladder or kidney damage and the presence of cancer. When any of the above problems occur, or when one's lifestyle is changed by the presence of prostate obstruction, consideration to treat the prostate enlargement should be given.

As time goes on, additional medications and surgical procedures will be developed to treat prostatic enlargement. The armamentarium that we have now is quite ample to handle most of the problems that present, and each patient must be assessed individually as to what will give them the best chance for success with minimal side effects.