BPH Drug treatment
alpha blockers relax smooth muscle at the exit of the bladder reducing the resistance to urinary flow. Approximately 2/3 patients notice an improvement in symptoms. This family of drugs was originally introduced to control high blood pressure and so is designed to be used daily for several years. Because it lowers the blood pressure it can cause dizziness, headache and tiredness.
5-alpha reductase inhibitors prevent the conversion of testosterone to its more powerful form dihydrotestosterone and so gradually reduce the size of the prostate over a period of years. They are only really effective in men with large (>40 ml) prostates. Possible side effects include reduced libido, impotence, breast tenderness and enlargement and a reduced sperm count. Women who are pregnant must avoid exposure to the drug because of possible side-effects to the foetus.
Surgery for BPH
TURP
Transurethral resection of the prostate (TURP) involves coring out the central part of the prostate (rather like one might core out the centre of an apple) to physically enlarge the channel one passes urine through. It was the first ‘keyhole’ operation and remains the standard to which other operations for BPH are compared. It is performed under general or spinal anaesthetic, usually lasts 30 minutes and involves no incisions on the outside. It is performed using a hot wire loop, which is used to remove the prostate in slivers, inserted into the urethra via a telescope. These are washed out at the end of the operation and a catheter is inserted for 1-2 days, through which irrigation fluid flows into the bladder to rinse any blood in it.
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Fig. 3.3 Occlusive prostate. |
Fig. 3.4 Post-TURP. |
Patients are discharged from hospital after 3 days and should avoid heavy physical exercise for 2 weeks. Urinary flow is usually markedly improved immediately but frequency may take 6-12 weeks to completely settle. All patients experience retrograde ejaculation after TURP i.e. sperm going back into the bladder at the time of climax, rather than coming out of the penis, and being washed out of the bladder the next time it is emptied. There is also a 5% risk of impotence after TURP, usually in men aged over 70 years.
GreenLight™ photoselective vaporisation of the prostate (PVP)
PVP uses a high-energy laser to vaporize prostate tissue and seal. Its advantages over TURP are less bleeding and a much shorter catheterisation time and hospital stay. The procedure is performed via a telescope inserted into the urethra under spinal or general anaesthetic and usually lasts 10-30 minutes.
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Fig. 3.5 Post-GreenLight laser prostate vaporisation. |
Laparoscopic prostatectomy
Very large (>200 ml) prostates might be more safely and efficiently removed from the outside-in, as opposed to the inside-out method of telescopic removal. Traditionally, this has been done via an incision on the lower abdomen but can equally be done telescopically using a similar technique to that used to performed laparoscopic prostatectomy for localised prostate cancer (of which I have done more than 1,000 cases), but without the risks to continence or potency.
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Fig. 3.6 Laparoscopic
prostatectomy 1. |
Fig. 3.7 Laparoscopic
prostatectomy 2. |
Fig. 3.8 Laparoscopic
prostatectomy 3. |
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