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Published on April 19, 2022

Men should not ignore symptoms of BPHBenign Prostate Hyperplasia

While medications are usually the first line of treatment for men who are suffering from the bothersome effects of Benign Prostatic Hyperplasia, or BPH, a new procedure is offering hope to some patients who need more help.

Called Aquablation®, it is a minimally invasive treatment that uses the power of water delivered with robotic precision, using ultrasound guidance, to ablate or remove the inside of the prostate. The treatment reduces the prostate size, thereby alleviating the symptoms of BPH, like urinary urgency or kidney damage, said Hyannis Urologist Brian Kowal, MD. The system was recently purchased by Cape Cod Hospital and Dr. Kowal and other hospital urologists are now training with it, with the goal of offering it to patients in the near future.

“It essentially shaves the inside of the prostate using precise, ultrasound-guided measurements to clear as much tissue as possible without violation of the (prostatic) capsule,” said Dr. Kowal, who practices at Urology Associates of Cape Cod in Hyannis and Sandwich.

The system also allows surgeons to leave some extra tissue at the verumontanum, which is where the ejaculatory ducts are. “One thing people are worried about with these procedures for BPH is something called ‘retrograde ejaculation,’ where you don’t see as much semen coming out because it is going backwards into the bladder,” Dr. Kowal said.

A setting on the Aquablation system allows the surgeon to preserve the area of the prostate closest to the verumontanum to help preserve normal ejaculation, he said.

One of the best things about the Aquablation system is there is no risk of thermal injury like there is with a traditional heat ablation technique, although surgeons will spot-cauterize any blood vessels that may bleed during the water jet procedure.

“It’s pretty exciting technology because the principles are the same as the traditional surgeries we’ve done all along,” said Dr. Kowal. “It’s just a bit different source of tissue removal.”

Other Options

Benign Prostatic Hyperplasia is a condition in men in which the prostate gland is enlarged and not cancerous. The prostate, which produces fluid for semen, grows throughout a man’s life, or as long he is producing testosterone, said Dr. Kowal. According to the Urology Care Foundation, the prostate gland is usually about the size of a walnut, but over time can grow to be as large as an orange. As the gland grows, it can press against and pinch the urethra, and the bladder wall gets thicker. This prevents the bladder from emptying fully, leaving men with a low urine stream or the urge to push or strain while urinating. In serious cases, the urinary stream stops altogether, with the danger of kidney damage as a result.

Not all men with lower urinary tract symptoms would be candidates for the Aquablation, and many patients can be successfully treated with medication or other types of treatment, Dr. Kowal said. In some cases, it’s just a matter of changing their fluid intake patterns, he said.

“When I first see a patient, I do a very careful history and I also try to drill down on some of their fluid intake habits,” he said. “A small percentage of people who come in because they have this frequency in urination and getting up at night, and I find out they drink a whole pot of coffee in the morning. So, I suggest they cut down on the coffee and then we can reassess.”

Patients with BPH symptoms are usually referred to a urologist by their primary care provider, Dr. Kowal said. “This is a very common referral for us. It’s a very common issue for men,” he said. Men come to the doctor complaining of having to get up frequently during the night or having to stop every couple hours while driving long distances.

The urologist will generally review their PSA (prostate-specific antigen) score, which is done for most men as part of their annual check-up. The test is used as an indicator of cancer in the prostate, but a high PSA score can also be because the patient has a very large prostate, Dr. Kowal said. The PSA score, together with how well men are emptying their bladder, helps the urologist determine whether someone is suffering from BPH.

Medications are the first line of treatment, according to Dr. Kowal, and there are three classes of drugs that can be tried:

  • Alpha blockers, like Flomax, which facilitate urination.
  • 5-alpha reductase inhibitors, which block the conversion of testosterone to dihydro-testosterone in the prostate, which can help shrink the prostate.
  • Tadalafil, which is used to treat erectile dysfunction, but also helps with urinary issues in men.

Not all men can tolerate the side effects of these drugs, or many may not want to add another medication to their list, or start taking one in the first place, said Dr. Kowal. For those men, he may suggest surgery after he has determined the size of the prostate with either a trans-rectal ultrasound or if they have had a previous MRI or CT scan of the area.

“For people that have a prostate that is less than 30 grams in size, I usually will recommend transurethral incision of the prostate (also known as TUIP), whereby the surgeon goes through the penis to help open the bladder neck and ease urine flow.

“It’s not something where the prostate is big enough that you have to debulk things, it relieves the resistance at the bladder outlet,” Dr. Kowal said.

For larger prostates, in the 30-80 gram range, there are a couple office-based procedures, he said. One is called UroLift®, in which tacking sutures are used to pull the prostate apart in the middle. Another is called Rezum, which uses steam-injected into the prostate to destroy the prostate tissue and debulk the gland.

But the mainstay procedure used at Cape Cod Urology Associates is the GreenLight™ laser therapy, or photo selection vaporization of the prostate, said Dr. Kowal. The technique uses a laser to superheat and vaporize the prostate tissue. It is a same-day procedure with minimal bleeding, he said.

The practice’s standard TURP procedure is a bipolar resection done with a cutting loop to remove tissue bulk from the prostate, he said.

For much larger prostate glands, a simple prostatectomy can be done either in an open procedure or minimally invasively using a robotic surgical technique. This procedure leaves the prostatic capsule intact, which leaves the nerves unaffected for erections, he said.

“There’s only a small percentage of people who have erectile problems (after the procedure) because you don’t violate those nerves as you would if you were having a cancer procedure,” Dr. Kowal said.

The new Aquablation system offers these same benefits, he said.

The bottom line is that men should not ignore the symptoms of BPH, he said. Men should seek a consultation with a urologist if they are having to get up many times during the night to urinate or are having trouble urinating, according to Dr. Kowal. Other signs that something is amiss are:

  • Blood in the urine
  • Incontinence
  • Feeling bloated all the time.

“Depending on how severe their symptom are, how well they’re emptying their bladder, how big their prostate is, what their PSA score is, that’s how we decide how to proceed,” he said. “If I anticipate they may have problems in the future, I will set up some kind of monitoring plan.”

For men who are still sexually active, the fear of the loss of some sexual function often drives their decision to opt for medication over a surgical procedure, Dr. Kowal said. The majority of patients he sees are in the 50-80 year old range, who may or may not be sexually active, he said.

“The drawback of waiting (to treat BPH) is that if you’re in that set of patients that are in danger, it’s better to know now because if you let it go too long, the renal damage could be irreversible,” he said.