Benign Prostatic Hyperplasia

WHAT IS IT?

Benign prostatic hyperplasia (BPH) is the benign enlargement of the prostate gland. It is a very common pathology that affects 40% of men over 40 years of age.

This enlargement of the prostate is at the expense of the so-called MacNeal’s transitional zone, which is the part of the gland that embraces the urethra. It is because of this anatomical location around the urethra and at the exit of the bladder that urinary symptoms and alterations in the genito-urinary system occur.

The patient usually presents with:

• Loose urine stream
• Difficulty in initiating urination
• Incomplete emptying of the bladder
• Postvoid dribbling
• Need to urinate at night
• High daytime urination frequency
• Urgency to urinate
• Urinary leakage
• Urinary incontinence
• Other

This symptomatology affects the patient more and more and worsens his quality of life substantially. The patient’s life becomes conditioned by his or her quality of urination: he or she has to make sure that there is a bathroom nearby, does not rest well at night and suffers from urine leakage. So the impact on the sufferer is very high if we do not remedy it in time. In addition, it can end up causing serious complications such as:

• Bleeding in the urine or hematuria.
• Urinary tract infection and sepsis.
• Formation of stones in the bladder.
• Deterioration of renal function.
• Inability to urinate, with chronic urinary retention.
• Require a bladder catheter to empty the bladder.
• Deterioration of the bladder and development of bladder diverticula.

TREATMENTS

There are a multitude of treatments and strategies to treat this pathology. Our obligation is to consider all the possibilities and conditioning factors and to offer you the one that best suits you in a personalized way.

The usual clinical practice is based on correcting, first of all, lifestyle habits: lose weight, reduce intake of diuretic beverages, reduce intake of bladder irritants such as caffeine and alcohol, do not drink too much after 7 pm, put your feet up for 2 hours before going to bed, among many others.

When conservative measures are not enough, then we resort to medical treatment. In many cases, prostate symptoms can be controlled with medication. However, we warn our patients that most of them are only to produce a temporary improvement but do not change the course of the disease, do not prevent complications, nor do they prevent surgery. Moreover, they can have an impact on sexual function and other spheres of the human economy. Therefore, it is important to assess and discuss well with the patient why we recommend one treatment or another, for what purpose and for how long.

In cases where medical treatment is not sufficient, it is usually necessary to perform surgery, evaluating each patient beforehand to weigh the type of prostate surgery modality that is ideal for his case.

See the following tabs “Classic Surgical Techniques”, “Laser” and “Other Techniques” to learn more about the different treatments.

Classic surgical techniques

1. Transurethral resection of the prostate (TURP): Classically, hyperplasia of less than 60cc has been treated by transurethral resection of the prostate (TURP). It consists of removing the prostatic adenoma little by little through the urethra without incisions. The energy source is a classic scalpel. This fact conditions a limitation of size that we are able to resect and that a series of complications may occur such as: bleeding, absorption of liquid, need for reintervention in the medium to long term.

2. Open adenomectomy: When the adenoma is larger than 60cc open surgery is required, as it is not possible to remove all the tissue through the urethra. Open surgery is the most aggressive, but it is the one that manages to unblock the patient the most. The entire prostatic adenoma is removed. By removing the entire adenoma it is impossible for this disease to recur, there are no recurrences. Although this surgery is for life and the one that unobstructs the most, it has a lot of associated morbi-mortality: bleeding, high percentage of blood transfusion, surgical wound, requires hospital admission and prolonged bladder catheterization, recovery and reintegration to our daily life is slower.

For these reasons lasers have arrived in urology, to try to resect as much tissue as possible through the urethra without incisions. (See lasers tab)

Lasers in urology for prostate surgery due to prostatic enlargement or BPH

The classic surgical approaches have been widely surpassed by Holmium or Tulium Laser enucleation. This surgical technique is becoming the most widespread, as it is valid for all patients (regardless of prostate size, the other techniques are not), since it achieves the best functional results with minimal complications. Our team is an international leader in this technique.

The arrival of lasers in urology sought to be able to resect more tissue through the urethra than the classic transurethral resection of the prostate (60 grams maximum) and thus avoid having to make the incision of open surgery with the associated complications associated with this surgical technique. Laser technology theoretically offered optimal qualities to achieve this goal.

The different types of laser are basically defined by their wavelength and the frequency at which they are fired. This confers different characteristics to each laser that cause it to penetrate more or less into the tissues and to have a greater or lesser affinity for hemoglobin or water.

1. Prostatic vaporization or green laser: it has an affinity for hemoglobin (protein that transports oxygen in the blood) and penetrates 0.8mm. These characteristics allow it to be very good at vaporizing tissue. It literally vaporizes it and makes it disappear.

Indicated for prostates smaller than 60-80gr, it consists of vaporizing the prostatic adenoma through the urethra. A channel is opened through the prostate to facilitate the passage of urine and thus avoid the obstruction caused by the adenoma or hyperplasia.

It is not possible to treat concomitantly diseases or pathologies that the surgeon sometimes finds when operating on a prostate unexpectedly: bladder tumor, urethral stenosis, lithiasis or bladder stones and others.

• Pathological anatomy is not available, since the tissue is vaporized, disappears and there is nothing left to refer to the pathologist.
• Due to its high penetration into the tissue, it can leave an irritative syndrome or perineal discomfort not infrequently.
• Functional results are similar to those obtained with classic transurethral resection of the prostate, but inferior to open surgery or prostatic enucleation.
• High reoperation rates in the medium term in patients with medium and large prostates. That is to say, by not eliminating the entire adenoma, the remains of hyperplastic or adenomatous tissues can grow back and obstruct the patient again, requiring a new operation in a few years.

2. Holmium laser or Thulium Laser: they have an affinity for water and penetrate 0.4mm, which gives them optimal characteristics for precise tissue dissection. The difference between the two lasers is the frequency of the wave: the Holmium Laser (Holep) uses pulsed light and the Tulium Laser uses continuous light. This makes the Tulium Laser cut a lot but makes it difficult to identify the surgical planes, while the Holmium Laser cuts a little worse but favors the identification of the surgical planes.

Both lasers are optimal for enucleation of prostatic adenomas. This technique consists of eliminating the entire adenoma or prostatic growth. A dissection of the hyperplastic tissue is performed, the pathological adenoma is separated from the prostate capsule and at the same time that the adenoma is dissected, all the blood vessels are sealed preventing bleeding. The adenoma remains in the bladder, where it is morcellated, i.e. crushed, and removed.

In addition to these two lasers, there are others that are used for enucleation, but it seems quite scientifically evident that these two modalities are the optimal ones and are the ones that are being consolidated and imposed.

Enucleation has proven to be as effective as open surgery but without incision and allows treating all volumes or sizes of prostatic adenoma (from 40 to 300 grams or cc).

This translates into:

• No incision: there is no wound, whereas there is in open surgery.
• No bleeding: in open surgery there is bleeding and blood transfusion is required in a high percentage.
• Bladder catheter 24-36 hours.
• Shorter admission time 24-36 hours.
• Shorter time to reinsertion to normal life.
• Indicated in any prostate size.
• Can be treated concomitantly with bladder tumor, urethral stricture, bladder lithiasis.
• Pathological anatomy is available.
• Functional results: superior to classic prostate resection and similar to open surgery.

There is more robust scientific evidence (there are more and better studies) in Holep or Prostatic Enucleation with Holmium Laser. Even so, each surgeon will prefer to use one or the other laser depending on the experience each surgeon has with these lasers. In this sense, Dr. Romero-Otero has extensive experience with both.

For all these reasons, the European Urology Guidelines recognize Holmium or Holep laser enucleation as the best treatment for benign prostatic hyperplasia, being the gold standard.

Dr. Romero-Otero’s recommendation regarding the learning of surgical techniques, if he had to choose only one, it would be prostatic enucleation, since it is the most versatile technique and the one that can help the most patients. The prostate size does not matter and it is very safe in people taking antiplatelet and anticoagulant drugs. In addition, if other concomitant pathologies are found, such as bladder lithiasis, bladder tumors or urethral stenosis, they can be resolved at the same time. It is not only the technique that unobstructs the most, but also provides the best functional results with the least complications.

HoLROC, the oldest prostate enucleation program, directed by Dr. Romero-Otero, is a leader in this type of intervention with more than 14 years of experience and 3,000 cases treated.

Aquabeam & Rezum

Aquabeam and Rezum are among our therapeutic arsenal. These are two minimally invasive procedures that are characterized by preserving ejaculation in patients. Although they are very attractive techniques, it is important to select very carefully to whom this type of treatment is offered.

Aquabeam

It is a surgical technique or robotic procedure guided by ultrasound that, with a jet of physiological saline (water + sodium chloride) at a very high speed and high pressure (10,000 PSI) and without using any type of thermal energy, produces an ablation of the pathological or hyperplastic prostate tissue to eliminate the obstruction that occurs at the exit of the bladder.

The surgeon, through continuous ultrasound and cystoscopic monitoring, makes a personalized treatment plan and evaluates, with the utmost precision, the volume of tissue to be removed by the robot. Like other technologies for benign prostatic hyperplasia (BPH), Aquabeam takes advantage of real-time cystoscope imaging, the only technology to combine this simultaneously with real-time ultrasound imaging. Both imaging modalities provide the surgeon with a complete, multidimensional view of the entire prostate, allowing him to create a surgical map of which areas of the prostate to remove and which to avoid. Since each prostate is unique in size and shape, the map can be customized and adapted to each patient’s unique anatomy.

The Aquabeam robotic system is indicated for all patients with Benign Prostatic Hyperplasia, regardless of prostate size. The best candidates are those patients with moderate to severe lower urinary tract symptoms (LUTS) secondary to BPH that have not responded to medical treatment.

Advantages:

• It is an effective treatment for BPH, obtaining excellent functional results in terms of urination, with rapid improvement of urinary symptoms and rapid recovery and reincorporation to daily life.
• The patient usually requires a very short hospital stay (average 24-48 hours) and is discharged without a urinary catheter in more than 90% of cases.
• The shape and size of the prostate do not affect the possibility of performing the treatment, nor its results.
• It uses water (physiological saline) at room temperature, therefore, it does not produce any thermal damage and recovery is faster than with other techniques that use thermal energy sources.
• The procedure can be performed under intradural anesthesia (without the need to subject the patient to general anesthesia).
• It is performed in a short surgical time, with an average resection time of 3-6 minutes, independent of the prostate volume.
• It is a minimally invasive technique with a low complication rate.
• It is a robotic technique, systematizing the procedure and making it a highly precise and safe technique.
• It is the surgical technique for BPH with the best preservation rates of sexual and ejaculatory function, since it preserves the responsible anatomical structures. It preserves anterograde ejaculation in 9 out of 10 cases.

Disadvantages:

• Pathologic anatomy is not available due to tissue liquefaction.
• If the surgeon unexpectedly finds the presence of a bladder tumor, urethral stricture or narrowing, presence of stones or bladder lithiasis or other conditions, they cannot be treated.
• There is less scientific evidence available than with other less novel surgical techniques, although there is enough to demonstrate its safety and efficacy.
• It is possible that, by not resecting all the adenoma or pathological tissue, it may grow again over the years and reintervention may be required in the future.

Rezum

It is a treatment for Benign Prostatic Hyperplasia (BPH) that, through the use of steam, causes an unblocking of the lower urinary tract, pursuing two objectives: to alleviate the symptoms and to slow down the progression of the disease and the appearance of associated complications.

This therapy comes to urology as an alternative treatment for patients with mild symptomatology or initial stages, who are candidates for medical treatment. In this sense, it becomes a potential alternative to medication, either by the patient’s own decision, who does not want a treatment prescribed for years, or because of the side effects or drug-drug interactions with their usual treatment that these may cause. In addition, the Rezum System preserves ejaculatory function in most patients, which makes it a therapeutic alternative to be considered in men with lower urinary tract symptoms (LUTS) and genital desires, or those for whom the loss of ejaculation has a significant impact on quality of life.

It is not a surgical technique like the others, it is a procedure only valid for patients strictly selected on the basis of a series of personal, clinical and anatomical parameters, with a mild condition and for prostates with a size not exceeding 80cc. In case of large prostate size, catheterization or other complications, other surgical techniques must be used.

The Rezum system uses the thermal energy stored in water vapor to treat obstructive prostate tissue. The device is introduced through the urethra and the steam is injected into the prostate tissue in pre-planned individualized areas. There it is immediately converted back into water, releasing the stored energy into the cell membranes. These are selectively destroyed until cell death occurs. Over time, the body absorbs the treated tissue, decreasing prostate size and allowing for a significant improvement in voiding quality.

Advantages:

• Preserves ejaculation in most cases.
• It is a minimally invasive treatment administered on an outpatient basis, that is, without requiring hospital admission.
• It is a safe treatment (with few transitory and mild side effects).
• Procedure performed under local or regional anesthesia or sedation.
• Therapy free of bleeding or minimal bleeding.
• Quick return to normal activities.
• Allows treatment of different prostatic anatomies including the presence of medial prostatic lobule (obstructive intravesical growth of prostatic adenoma).

Disadvantages:

The main disadvantage of this therapy is the limited experience available because it is a young therapy. At the present time there are no studies that evaluate the results of this treatment in the medium to long term. Therefore, Rezum therapy should not be understood as a definitive treatment, but as a bridge therapy that allows us to improve our quality of life and delay the progression of the disease, which may require retreatment in the future.

Another drawback is that it does not allow treating large prostates and/or some complications such as bladder lithiasis and there is no material available for analysis in pathological anatomy.

The scientific evidence:
The scientific evidence available up to the present time presents results
at 4 years of follow-up. These are encouraging in terms of improvement of symptomatology (IPSS).
symptomatology (IPSS), peak voiding flow, preserving ejaculatory function and continence.
function and urinary continence.

It is a safe treatment with few transient and mild side effects during follow-up.
and mild side effects during follow-up.