UT-BPHBenign Prostatic Hyperplasia Unit

Benign prostatic hyperplasia (BPH) consists of the normally progressive, growth of the central area of the prostate or transition area.

It is therefore a physiological phenomenon which affects almost half the men over 65, and almost all of those over 80.

This growth, however, can cause symptoms that worsen the patient’s quality of life, which is why it has become the most frequent reason for urological consultation in men over 50. Every male should attend periodic consultation starting at the age of 45-50.

  • BPH specialised consultation.
  • Validated questionnaires.
  • Urological ultrasound (performed by a specialised radiologist).
  • Flowmetry.
  • Laboratory for blood and urine tests.

This growth can constitute an obstacle for urine output, causing obstructive symptoms: a split weak stream, need for abdominal pressure when urinating, delayed onset of urine output or terminal dribble, as well as nocturia (getting up at night 2 or more times to urinate). Filling symptoms (triggered while the bladder is filling with urine) may also take place: continued desire to urinate, urge and micturition urgency, with or without incontinence, and increased micturition frequency. Finally, there may appear the so-called post-voiding symptoms, such as a feeling of incomplete bladder emptying and dribble after micturition is complete.

The symptoms referred to are those that define the pathologic micturition situation or lower urinary tract symptoms (IUTS), and although BPH is the most frequent cause, there are other aetiologies that reproduce such a situation, such as urethral stenosis that, in certain cases, should be conveniently ruled out.
To achieve diagnosis, it is essential to fill in a detailed medical record. When assessing the symptoms and their intensity, it is very useful to fill in a validated clinical questionnaire, such as the IPSS (which consists of 8 questions in total), which will help to establish the clinical situation as accurately as possible. During the physical exam it is essential to perform a digital rectal examination, which will inform about the approximate size and consistency of the prostate, contributing to rule out other pathologies. In addition, this is accompanied by a blood test, urine analysis, flowmetry and ultrasound of the urinary system.

In our unit, we put at your disposal the latest alternatives of minimally invasive surgical treatments for BPH. We have the widest experience in the country and worldwide in several of them (see specific section):

As for the general treatment of BPH, it will vary depending on the clinical situation of the individual.

In those patients with minimal symptoms and little effect on the quality of life, expectant monitoring shall be suggested, sometimes including recommendations on changes in habits and lifestyle, although its effectiveness is debatable.

There are a number of factors that indicate a high probability of disease progression and worsening of symptoms:

  • Elevated PSA.
  • High score in IPSS.
  • Low maximum flow.
  • Prostate size.
  • Renal failure.

BPH therapy, when necessary, begins with pharmacological therapy. The choice of one drug or another is based on the type and intensity of the symptoms, prostate size, possible incompatibilities with other medications and, in some cases, according to the patient’s preferences.

» When obstructive symptoms predominate:

 · Alpha-blockers:
Indicated in prostates under 40 cc with predominantly obstructive symptoms. Achieves an improvement in IPSS scores and maximum flow. They do not decrease prostate size.

Side effects include a drop in blood pressure and may cause ejaculation alterations. There is a possibility that they may lead to floppy iris syndrome. So, if you are taking alpha-blockers and are going to undergo cataract surgery, you should notify your ophthalmologist.

· 5-alpha-reductase inhibitors:
It takes between 6 and 12 months before their effects are noticeable. They are used in patients with moderate to severe symptoms and with large prostates. They have been proven to stop the progression of the disease.

As side effects, ejaculation alterations stand out. They can contribute to the appearance of erectile dysfunction and, in 1% of cases, gynaecomastia (increase in breast volume) with slight mastodynia (breast pain) has been described.

· Combination of alpha-blockers and 5-alpha-reductase inhibitors:
More effective in combination than separately. It is administered to patients with mild to severe symptoms and prostate volumes above 40 cc. They increase maximum flow, reduce prostate volume and reduce the risk of disease progression.

» When filling symptoms predominate:

· Anticholinergics:
They produce bladder relaxation during the filling phase, reducing the symptoms.

The most common side effects include dry mouth, constipation and blurred vision.

· Beta 3 adrenergic receptors:
The mechanism of action is different, and they do not produce the same adverse effects as anticholinergics.

They cannot be administered to a patient with poorly controlled elevated blood pressure.

· Combinations:
Anticholinergics + alpha blockers. Indicated for patients with mixed symptoms.

» Other treatments:

· Phytotherapy:
It has a limited role, but a good general muscle tone improves the strength of the bladder muscles and, therefore, micturition.

· Phosphodiesterase type 5 inhibitors:
First line of treatment for erectile dysfunction. There are studies that support the effectiveness of tadalafil while treating lower urinary tract symptoms administered on a daily basis. Treatment option mainly for patients with BPH and Erectile Dysfunction.

All these drugs, like all pharmacopoeia in general, have contraindications, incompatibilities and possible side effects, which must be overcome, as well as implement monitoring after prescription to adjust the dose for each patient according to their clinical situation.

  • Transurethral resection of the prostate (TURP)
  • Open adenomectomy
  • Laparoscopic Adenomectomy
  • Robotic adenomectomy

Surgical treatment is proposed when symptoms have progressed despite treatment with drugs, when the quality of life is affected, when there is a high risk of complications, or when we encounter one of the following:

  • Bladder stone formation..
  • Incomplete bladder voiding and bladder deterioration..
  • Impaired kidney function.
  • Need for catheterisation due to urine retention.
  • Haematuria or persistent bleeding in the urine.
  • Recurrent urinary tract infections.

The choice of surgical technique depends on the prostate size, the characteristics or biological status of the patient and their preferences.

· Transurethral resection of the prostate (TURP):
It consists of the removal of the prostatic transition area or adenoma by resection and fulguration through the urethra, without any skin incision. It is an endoscopic surgery procedure. It is used in prostate glands between 30-60 cc. It is a very effective treatment. In 65% of the cases, ejaculatory alterations appear.

· Laser adenomectomy:
: Another endoscopic procedure which uses laser energy. Different types of lasers are used in the treatment of BPH: green light laser, Holmiun Laser and Thulium laser.

Each one is used with a different technique (vaporisation or enucleation) and for different prostate sizes.

All of them yield good results, although we believe that the Holmium laser is the most appropriate one because it is the most versatile, and due to its proven effectiveness, safety and high performance.

· Open adenomectomy:
Prostate adenoma removal through open surgery. It is reserved for very large prostates.

Today, the  Holmium laser achieves the same results without the need for external wounds and with more dynamic recoveries, shorter admission time and a very reduced incidence of bleeding. Open adenomectomy is therefore less and less prescribed.

· Laparoscopic/robotic adenomectomy:
It is similar to the open adenomectomy, but employs a laparoscopic abdominal approach. Implies abdominal lesions.

· Aquabeam:
New robotic system that removes tissue with a high-pressure water jet.

· Rezum:
New system that, using water vapour, removes prostate tissue and relieves the obstruction produced by the prostate hyperplasia.

There are a number of other non-invasive techniques: Urolift, stents, TUNA, TUMP. They are rarely used and we do not consider them among the standard procedures, except in very exceptional cases or very precise indications.

In general, patients who undergo surgery present good results, with symptom suppression and improvement of their quality of life. The most prevalent or least improved symptom is nocturia or night-time urination, as there are other mechanisms involved.

BPH prostate surgery very rarely affects erectile function or continence. These are instead common complications of prostate surgery due to cancer.

Retrograde ejaculation commonly appears. It does not produce any adverse effect on the body, but it may occasionally cause mental discomfort in the patient at the beginning

Two new instrumental methods for the prostate called Aquabeam and Rezum have been incorporated with certain favourable results in the prevention of retrograde ejaculation, and seem to decrease the incidence of such sequelae. The initial results appear to be optimal, although more experience is needed over time to consolidate them. It should not be forgotten that the main objective of prostate surgery in BPH, and in any of its modalities, is to permanently solve the Obstructive Uropathy.

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