Improvements in the treatment of benign prostate enlargement mean that side effects and recovery time can now be greatly reduced.
The doctor’s perspective
Kate Warren
Consultant Urological Surgeon, Bristol Urological Institute, Southmead Hospital
Benign prostate enlargement (BPE) is something that will affect a significant number of men during their lifetime. It is increasingly more common as men get older. The prostate gland’s position is below the bladder and it surrounds the urethra. Its function is to produce secretions, which make up the ejaculate but as it enlarges it can obstruct the flow of urine. The resulting symptoms may be a slowing of the urinary stream, stopping and starting of the stream, difficulty emptying the bladder and as a result more frequent visits to the toilet, both during the day and night.
Men present to their GP with symptoms if these are affecting their quality of life or they are worried about the possibility of prostate cancer. GPs will refer to secondary care on a fast track pathway if there are symptoms suggestive of prostate cancer. GPs will also consider if the symptoms are typical of bladder outflow obstruction because of BPE by taking a history and performing a clinical examination.
Initially, patients presenting with symptoms of BPE, would be advised on lifestyle alterations by their GP and potentially offered medication to improve the urinary flow. The choice to go on medication should involve information about potential side effects of medication versus how bothered the patient is by their symptoms. If medication and lifestyle modification is not enough to sufficiently improve the symptoms, GPs will refer to secondary care for further investigations and consideration of surgical treatment.
Surgery involves removing part of the prostate gland
After a secondary care assessment, if the lower urinary tract symptoms are due to BPE and the patient wishes to consider surgery, a transurethral resection of the prostate (TURP) is one option.
This involves removing part of the prostate gland, using a device called a resectoscope, which is passed through the urethra (waterpipe). A heated loop is used to remove the central part of the prostate gland creating a channel through the prostate to reduce the obstruction.
As with any operation, there are potential side effects and anybody considering surgery should be fully informed of the alternatives to this surgery and of the potential complications. Patient information leaflets can be found on the British Association of Urological Surgeons website about the risks of urological surgical procedures.
Approximately 50% of men in the sixth decade of their life and 80% in their eighth decade are affected by symptoms due to BPE.
The traditional monopolar TURP has been replaced in many NHS trusts by a bipolar or PLASMA device to remove prostate tissue. The electrical current passes between two electrodes rather than through the patient and uses a combination of cutting and vaporization of the prostatic tissue. The benefits of this is a reduction in bleeding during and after the procedure and the ability to use an irrigation fluid during the surgery that has a similar concentration to the body’s own fluids. This reduces the chance of a complication called TUR syndrome, which is when the dilute irrigation fluid (used with older TURP techniques) can be absorbed into the body causing complications. Miss Kate Warren, a Consultant Urological Surgeon from Bristol, where the treatment is performed as standard, explains why such techniques are needed.
“As men get older and live longer, lower urinary tract symptoms due to BPE become very common. Approximately 50% of men in the sixth decade of their life and 80% in their eighth decade are affected by symptoms due to BPE. There are a number of surgical treatment options available for BPE and each patient should have their surgical options discussed with them. Some patients may opt to pursue non-surgical options but if their symptoms are increasingly bothersome, they may consider surgery in the future.”
Improved urinary flow reduces the risk of UTIs
The intended benefit of surgery is a better urinary flow and ability to empty the bladder more completely. Poor bladder emptying can result in recurrent urinary tract infections, bladder stone formation and sometimes altered kidney function. In these situations, a patient would be recommended a surgical option or, if not fit enough, a long-term urinary catheter.
The potential long-term side effects of surgical treatment of the prostate include incontinence, alteration in ejaculation and reduced ability to get erections. The different surgical techniques have different risks of each of these and need to be discussed fully with the surgeon.
The newer technologies for prostate surgery aim to be more minimally invasive and patients are able to recover more quickly. “We have been able to treat 80% of our TURP patients as day cases, which is a considerable advantage compared to previously, when patients stayed in hospital for a couple of days,” says Miss Warren.
And her patient’s journey…
Anthony Pagano
BPE Patient
I started to suffer with increased symptoms of BPE when I was in my mid-70s. First, my urine slowed to a trickle, then I found myself getting up two or three times in the night. I went to visit my GP who suggested medication with Finasteride tablets, but despite an improvement for the first few months, it soon lost effect. These tablets also blocked the production of testosterone, which caused a very significant loss of sexual functions. My GP then offered muscle relaxants, but this gave me nausea that I found quite scary.
I was referred to the Bristol Urological Institute and offered the TURP procedure. I met my consultant, Miss Warren, on the morning of the operation and, despite the risks, explained I was eager to go ahead as my BPE was getting worse – to the point that it was affecting my sleep and my way of life. Although I knew it was a relatively new procedure, it was well-tested, so I wasn’t worried.
My anaesthetist decided on a spinal anaesthetic, which meant I was awake for the two-hour operation. I was anxious, but my nerves were calmed every step of the way.
I could not move my lower limbs for several hours after the surgery. I was kept under observation until medical staff were satisfied I was OK, and then my wife came to collect me to take me home. Although slightly unsteady on my feet I was able to walk to the car.
That was 18-months ago and, despite the odd urge to get up in the night, my symptoms are better. I’m so pleased that I went through with it. I understand that there are risks involved, like with any operation, but I felt informed about my decisions and was treated with dignity and respect. It really was excellent care.
