Benign Prostate Hyperplasia

Benign prostate hyperplasia is generally seen in older men without any obvious cause. Prostate hyperplasia causes urethral obstruction, which presents itself as bladder outlet obstruction.

So, the patients need more force to overcome this resistance and to empty their bladders.

Subsequently, the patients cannot totally empty their bladders and residual urine is seen inside the bladder.

Prostate hyperplasia is actually a benign tumoral growth. Usually, it is seen in men over the age of 50.

Risk Factors

Non-modifiable and modifiable risk factors also contribute to the development of BPH. These have been shown to include Metabolic syndrome,obesity, hypertension, genetic factors

What are the signs of prostate diseases?

• Frequency,
• Nocturia,
• Urgency,
• Urge incontinence,
• Hesitancy,
• Strain to void,
• Intermittent voiding,
• Post voiding residue,
• Inability to void

In time, prostate blocks urethra passing through it and the patient cannot void easily. So, the detrusor muscle of bladder gets thicker and more sensitive as it tries to overcome the outlet obstruction. By the time muscular layer of bladder (detrusor) gets weaker and the patient cannot completely void and residual urine stays inside.

What is the cause of BPH?

The exact cause of BPH is not well-documented yet. Age and testicular function are main factors influencing the development of BPH. During a man’s lifetime, testicles produce testosterone as the main male hormone while estrogen is also present in rare amounts in his body. With aging, active testosterone levels decrease and estrogen levels increase. The estrogen induces some cell evolutions inside the prostate in the elderly population.

During aging, testosterone levels decrease while dihydrotestosterone (DHT) levels inside the prostate increase and accumulate. So, this state of testosterone is thought to induce prostate cell growth.

What are the signs of BPH?

Social life disturbances such as daytime frequency and nocturia are among the main signs of BPH.

Somnolence, fatigue and looking for toilets everywhere are the main problems.

Therefore, the calibration of voiding is weaker and problems such as hesitancy and post-voidal dripping may be expected.

Prostate examination, serum tests and prostate needle biopsy can all help in the diagnosis of BPH.

Based on the complaints of patients, medical treatment or surgical approaches are recommended.

All men with no symptoms over the age of 50 are recommended to get their prostate examined and get their serum PSA levels checked on a yearly basis.

Diagnostic tools for BPH are as follows:

• Digital rectal examination
• Serum PSA (total and free PSA),Creatinine
• Ultrasonography
• Prostate biopsy (if needed)
• Urine flow test -uroflowmetry-
• Cystoscopy (if needed).

Treatment options?

The first option should be medical treatment.

In case of unsatisfactory results from medical treatment or recurrence after a certain period of time, alternative treatments should be considered.

In case of insufficient medical treatment modalities, interventional treatment options should be considered.

Open or laparoscopic surgery is considered when the size of prostate is over 100-120 cc.

Laser Prostate Surgery

HoLEP Technique

New surgical developments in prostate surgery appeared with the frequent use of laser technology. Successful results with popularity created a new method called Holmium Laser Prostatectomy (HoLEP).

HoLEP is a totally endoscopic surgical procedure allowing for the removal of the entire prostate tissue.

This procedure enables the removal of grown prostate tissue from its capsule through normal urinary tract. With the help of a special device, the removed prostate tissue is fragmented in the bladder and taken out.

HoLEP in Turkey

HoLEP has become the gold-standard surgery in prostate hyperplasia treatment due to its advantages. Both in the USA and Europe, HoLEP has been commonly used during the last decade. Because of the use of 120W holmium laser in this method, a high technological infrastructure is needed. Therefore, a few centers can perform this method in Turkey.Prof. Dr. Tunc and his team have performed hundreds of successful HoLEP surgeries. The team has observed appreciation, satisfaction and comfort regarding those patients.

Advantages of HoLEP

HoLEP can be performed independently from prostate volume and is valid for every prostate size.

Patients who are candidates for prostate surgery are also candidates for HoLEP. Spinal anesthesia (numbness below waist) is sufficient for the HoLEP procedure. As electric energy for the fragmentation of prostate, laser is used to separate prostatic tissue from its surrounding capsule. Thus, dysuria is not expected during voiding after the urethral catheter is taken out.

There is no tissue corruption as specimen of surgical tissue is obtained without the use of electric energy. Thus, pathologist can easily examine this specimen and it is not possible for him/her to misdiagnose any malignancy.

Nerves passing through both sides of the prostate are associated with sexual functions such as erection. Depth of holmium laser within tissue is at least 0.4mm so healthy tissues are not expected to be subjected to any harm. As a result, those patients are not expected to complain about a potential erectile dysfunction.

Recurrence of the disease is not expected because the prostate tissue is completely removed. With the use of laser, HoLEP is also safe for patients who cannot stop anti-aggregant treatment before the surgery.

Lower bleeding risks, shorter hospital stay and faster recoveryare the main advantages of HoLEP as patients get rid of urethral catheter in a period shorter than 24 hours and return back to their normal lives.

Last but not the least, patients state that they feel like they are back in their 30s.

References:

Roehrborn CG. Benign prostatic hyperplasia: an overview. Rev Urol. 2005;7Suppl 9:S3-S14.

Roehrborn CG. Pathology of benign prostatic hyperplasia. Int J Impot Res. 2008 Dec;20Suppl 3:S11-8.

Michael Ng , Krishna M. Baradhi . Benign Prostatic Hyperplasia.In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. 2021 Aug 11.

Foo KT. Pathophysiology of clinical benign prostatic hyperplasia. Asian J Urol. 2017 Jul;4(3):152-157

SercanYılmaz , Engin Kaya, EymenGazel, SerdarYalcın, HalilCagrıAybal, Mehmet Yılmaz, OnurAçıkgöz, HakanÖzdemir, LutfiTunc. HoLEP after prostate biopsy: does it have any impact? World J Urol.2021 Jul;39(7):2605-2611.