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Benign Prostate Enlargement

This is a common condition affecting most men as they get older. Enlargement of the prostate gland results in narrowing of the urine passage and subsequently results in difficulty passing urine.

The most common symptoms include:

  • Weak, slow stream of the urine
  • Difficulty starting urination or straining to pass urine
  • Increased frequency or urgent need to urinate
  • Increased urination at night (nocturia)
  • Inability to completely empty the bladder
  • In more severe cases, some patients may develop urine infections, bladder stones, and at times urinary retention (inability to pass urine). In the long-term, due to high pressures in the bladder, patients may develop kidney injury which if left untreated could result in loss of kidney function.

Digital rectal examination: a simple procedure, where the doctor palpates and examines the prostate gland as well as lower part of rectum.

Ultrasound of urinary tract and prostate: provides information about the size of prostate gland, degree of bladder emptying, bladder stone or cancers as well as detecting any signs of kidney blockages.

PSA value
Measuring the PSA level helps in early detection of prostate cancer and has implications of further management of the patients.
Urine flow testing: during this investigation, the speed of the urine flow is measured using a Uroflow device.

During this procedure, the urologist inspects the urinary system using a small scope. This procedure could be performed under local or general anaesthesia and provides anatomical information regarding the urine tube, size of prostate as well as any bladder pathology.

Other tests
It is often necessary to perform other tests to further evaluate the cause of urinary symptoms. Rarely the symptoms could be due to unusual reasons such as cancers and voiding dysfunction. The urologist will determine when to perform these tests based on the clinical evaluation during the visit.

What are the treatment options?

Observation and lifestyle modification
For men with mild symptoms, the symptoms could be observed and treatment could be differed until the symptoms are more bothersome. It is important to seek a review by your GP or urologist to have an initial check to see if this option is the right one for you.

Herbal medication
Even though some men might find herbal and over-the-counter medications helpful, there is limited evidence in medical literature regarding their efficacy. Herbal medications are often ineffective and at best, may provide very mild symptom improvement.

Men with mild to moderate symptoms may benefit from medical therapy. The options include:

Alpha blockers
Flomaxtra (tamsulosin), Minipress (prazosin), Urorec (Silodosin)

These medications result in relaxation of the smooth muscles, fibres, bladder neck and prostate, and result in mild improvements in urinary flow and bladder emptying.
The disadvantages can include cost, as well as dizziness, and retrograde ejaculations where semen goes back into bladder rather than out from the urine passage. Patients who are undergoing eye surgery should not use this medication.

5-Alpha Reductase inhibitors
Avodart (dutasteride), Proscar (finasteride)

This medications blocks the conversion of testosterone inside the prostate gland and results in some shrinkage of the prostate gland. It is important to note that it takes a few months (up to 6 months) to work and the side effects include reduction in libido and energy level as well as erectile dysfunction. Combination of this class of medication and alpha blockers (Duodart) is also available for treatment of benign prostate enlargement.

It is important to note that PSA value would be affected (usually halved), which could complicate interpretation of PSA blood test for diagnosis and monitoring of the prostate cancer. There is also some controversy regarding this group of medications, resulting in higher rates of high-grade prostate cancer.

Surgical therapy
A variety of options are available for men who require treatments for benign prostate enlargement. It is important to discuss this with your urologist to find out which option is the best option for you. These include:

TURP (Transurethral Resection of the Prostate)
This procedure remains the gold-standard of therapy for benign prostate enlargement. It is considered to be safe, durable and provides good symptom relief. The procedure is performed under general or spinal anesthesia, and the whole procedure is performed through the urine passage and does not involve any incisions. During this procedure, using a scope, the surgeon removes the inner and central part of the prostate to widen the urinary channel. Patients usually stay in hospital for 1-2 days while the bladder is irrigated using a catheter.

Laser surgery
There are several types of laser used to perform this procedure, including the following; Green-light laser, Holmium laser, Thulium laser. The approach is similar to TURP, where the surgeon performs the procedure under general or spinal anesthesia through the urine passage. The prostate is either resected (enucleation laser prostatectomy) or ablated (ablative laser prostatectomy). Patients still require 1-2 days of hospitalisation while the bladder is irrigated with a catheter.

Is another minimally invasive approach for treatment of benign prostate enlargement. During this procedure the surgeon deploys the Urolift device to compress the prostate tissue away from the urinary passage, thus creating a wider channel. The main advantages of this procedure is that it is a day procedure and patients can often go home on the same day, usually without a catheter. Furthermore, this procedure often does not affect ejaculation or erections, and the results from the studies so far have shown the treatment to be durable and provide effective symptom relief.

Robotic Rezum is a new minimally invasive modality which has recently become available in Australia. It is also performed through the urine passage under general or spinal anaesthesia. The Rezum device uses radiofrequency-generated water vapor directly to the prostate tissue that is causing the obstruction symptoms. Patients are able to go home on the same day after surgery, and usually notice improvement of symptoms within 2 weeks after surgery. Sexual function (erection and ejaculation) is often not affected by this treatment and patients usually don’t require hospitalization. The complications of this procedure can include urinary retention as well as urinary tract infection.

Robotic enucleation prostatectomy
This treatment is not to be confused with da Vinci Robotic radical prostatectomy, which is performed for prostate cancer. This procedure is reserved for men with very large prostate sizes (larger than 80ml), who have bothersome urinary symptoms. Due to size of the procedure, these minimally invasive approaches mentioned above are often less effective and carry higher complications rates.

In this procedure the central part of the prostate is removed and the outer layer of the prostate is preserved. Patients often require 1-3 days of hospital stay. The erectile function is usually not affected by this procedure, and the degree and durability of the symptom relief following this procedure is usually superior to other minimally invasive treatment options. This procedure should be performed only by experienced surgeons.

Dr Ahmadi has had dedicated training and experience during his fellowship in this field and offers da Vinci robotic enucleation prostatectomy for suitable patients, who have very large size prostate.