Which is the best surgical treatment for benign prostatic hyperplasia?

Thanks Dan. Which options are considered the best? Are there any reliable evidence-based comparisons readably accessible on the internet? Moreover what is the consensus here - which procedure gets the most positive comments from the guys here and which gets the least?

There is no best treatment for dealing with an enlarged prostate. There are many effective treatments and deciding which is the best for you is a decision you and your doctor have to make. There are no medical professionals on this forum other than "Jersey Urology" and that person hasn't posted in quite a while.

Here's my advice, which along with every other piece of advice here, is worth exactly what you paid for it.

1. Look at clinical trial data. It is widely available on the internet. Just search on clinical trials and the name of the procedure. What it is likely to show is that TURP, PVP (Greenlight laser), and HoLEP all have similar outcomes in clinical trials.
2. Take with a grain a salt any comments on a particular procedure unless that person has actually undergone said procedure. Lots of people here who haven't had one, bad mouth TURP. I had a TURP 6 months ago and I am very satisfied. I am voiding better than I have in years and I would do it again in a heartbeat.
3. Try alpha-blockers before surgery. That may be all you ever need although many find (as I did) that they lose their effectiveness as the prostate grows.
4. The newer revisions to TURP, i.e., bi-polar and plasma button, seem to be "better" in terms of patient recovery and side-effects than the mono-polar version. I spent one night in the hospital and went home the next day without a catheter. Other than the typical burning during urination for a couple days, I was never in any pain and resumed all normal activities in 3 weeks. I was 70 when I had it and had been on doxazosin for several years.
5. Find a doctor you are comfortable with. Not sure how that works in England but I think this is important. Have him (or her) explain the surgical procedures available and what he (or she) is most comfortable with. A younger urologist is more likely to be knowledgeable about the latest procedure.
6. People who visit forums like this tend to be the ones that have a problem and want to vent. Those of us who have had a satisfactory outcome see little need to return. This is probably my first post in 2 months and I visit this forum less than once a week since my successful TURP.

Good luck with your decision.

What a wonderful post lee! Please stay in touch. This is very much appreciated!

I left you a message about UroLift, which is a procedure that opens up the pathway from the bladder to the urethra, and leaves the prostate intact. For some reason, this message was deleted.

Dan

Lee, i think that most guys are understandably concerned about Retrograde ejaculation after the TURP procedure. Can you tell us how that has been working out for you? Were there any other complications or a need to continue with the medication post surgery?

thanks,

Dan

I have been reading and commenting on this forum for many years but I have yet to see any information regarding research into the cause and prevention of BPH.

Lee, i think that most guys are understandably concerned about Retrograde ejaculation after the TURP procedure. Can you tell us how that has been working out for you?

I had RE before the TURP from the alpha-blocker I was on. It didn't bother me. I still have it after the TURP, as the doctor said I would, and it still doesn't bother me. Being able to pee normally is more important to me. I had no post-surgery complications. I discontinued the alpha-blocker immediately and a couple months later discontinued the bladder spasm medication I had been on for 20 years. The uro had said that was a possibility also and he was right. My only regret is that I didn't do it several years earlier.

Lester,

There was a discussion a few weeks back about Gat/Goren in Israel. They have a theory that BPH is caused by varicoceles in or near the testicles. Varicoceles are enlarged viens similar to varicose veins. Both are caused by failure of the one way valves in the veins that prevent blood from flowing backwards, and keep it flowing towards the heart. When the blood fails to flow back to the heart it pools and, in the case of the legs, can cause dark or black/blue areas. When this happens in the area of the testicles/prostate it can be a path for blood to flow directly from the testicles to the prostate, and cause a higher than normal concentration of testosterone in the prostate.

I don't know if I have all this quite correct, but you can research Gat/Goren on the internet yourself to find out about their theory and their procedure to close off the varicoceles to prevent the problem. I am surprised there are not more people researching the Gat/Goren theory, it sounds plausible to me, but not much research has been done on it.

The theory sounds plausible because varicose veins get worse as we age, and it may be likely BPH is caused by testosterone, because of the fact that men that have been castrated do not produce testosterone, and do not get BPH.

Thomas

There was a recent UK article that I cannot find high testosterone is the cause of BPH.

Lee, again thanks for this - being able to pee normally is the important thing for me too. Obviously I'd prefer not to have retrograde but as I don't intend to have any kids being able to pee is the priority. The key thing at the moment is to get rid of this damn catheter.

Looks like the precise cause(s) of BPH is/are still a bit of a mystery. But high testosterone could well be a factor - and of course the other explanation mentioned above here too could also be a factor - and no doubt many other things as well. Dihydrotestosterone appears to be a factor - as the effectiveness of Finasteride appears to indicate by decreasing this.

look into the Urolift procedure, which doesnt remove any of the prostate

Thanks Dan

Lee Which kind of TURP did you have?

Lee,

Can you provide references to CTs that show Greenlight (PVP) and TURP equal to HoLEP in terms of (1) improvement in Qmax, (2) improvement in Q of L scores; (3) reduction in prostate volume; (4) reduction in PVR; and (5) reduction in PSA?

In terms of improvement in Qmax and prostate reduction only simple prostatectomy rivals HoLEP.

I'm not here to sell HoLEP to anyone, but in my research, it just out-performs other BPH treatment options, especially among the MISTs.

Thanks

Michael

Lee,

In re: your response to dan25410 3 days ago,

I've also experienced RE from both Flomax and Finasteride (Proscar). When on Finasteride, RE was pretty much constant. On Flomax alone, RE exists but not always.

For men facing bladder or kidney damage, and who already are experiencing RE from meds that no longer work, facing RE is not nearly as daunting as kidney damage or permanent bladder damage. No man wants to volunteer for RE, but when the meds cause it and even so after losing their effectiveness, RE as an unfortunate complication of needed treatment is no longer a deal breaker.

I'm still not sure what I will do but the thought of peeing normally and sleeping through the night are vastly more important than normal ejaculation. Sure, I'd like to have both but with a very big prostate like I have, some options are simply off the table at this point (Urolift, Rezum).

Michael

I didn't know that a very big prostate made Urolift no longer an option. I will have to see if i am a candidate based on prostate size, or any other factors/requirement that they may have.

When you mention kidney or bladder damage, would this be from having the symptoms of BPH that are not being treated, or not responding to the medication? What exactly causes the kidney or bladder damage?

Which kind of TURP did you have?

My doctor does a bi-polar TURP. He starts with a loop electrode because it's faster at removing tissue. Then he switches to a plasma button to smooth the resected surface and cautherize any bleeders. I know from my research that other doctors are doing the same thing so it's not a unique approach. All I can say with certainty is that it worked well for me.

' the thought of peeing normally and sleeping through the night are vastly more important than normal ejaculation. Sure, I'd like to have both but with a very big prostate like I have, some options are simply off the table at this point (Urolift, Rezum) ' Michael - my thoughts precisely!

Lee Thanks for this.

In the past, the moderators have not allowed links to be posted. Below are the from one paper (from the American Journal of Clinical and Experimental Urology) showing the change in Qmax. There are 4 studies and the Holep change is first, followed by the TURP. With the exception of the 2nd study (13.8 vs 9.5), the TURP results were similar.

Change in Qmax |+20.2+21.8| |+13.8+9.5| |+16.9+15.9| |+19.9+19.2|

The conclusion reads: "Based on all available evidence, HoLEP offers patients a safer, more efficient, and at least equally efficacious, if not more efficacious, treatment for BPH related LUTS when compared to other surgical therapies. When compared with TURP, currently the reference gold standard, patients undergoing HoLEP benefit from a shorter catheterization time, shorter hospital LOS, and fewer complications."

I'm not suggesting that TURP is "better" than Holep. I think the issue with Holep is that not many urologists are doing it because it has a long learning curve. And based on my experience, the latest improvements in the TURP made it a very easy procedure that produced a very satisfactory outcome.

Again many thanks lee. Yes I've seen similar results.

Thanks Lee,

I had not seen Qmax of +21 for TURP previously. That is quite impressive.

You do mention other advantages of HoLEP, and another is that tissue can be sent to pathology to screen for cancer and if present, assign a Gleason score.

HoLEP is a difficult procedure to master.

Thanks for your helpful contributions to this thread.

Dan,

If a man has severe urinary retention, urine can back up into the ureters and over time, damage the kidneys.

Guys who are not able to void completely should have their kidney function periodically checked for glomerular filtration rate (GFR) and creatinine level. Also, a simple ultrasound of the kidneys can tell your doctor a lot.

I know someone who waited too long before having Greenlight (which was a total success). The result was one kidney at 20% function and the other at 80%.

Other guys on the forum know more about potential bladder impacts. I think as the bladder stretches from chronic retention it loses its ability to contract and void properly. Some guys here self cath to keep their bladders functioning.

Michael

Michael,

Thanks for this information. I already knew that a complete blockage is serious enough to send you to the ER to get you going again. But i didn't know that chronic incomplete voiding could also lead to bladder or kidney problems. I am often not able to void completely, but i simply wait a few minutes, or go back to the restroom again after a few minutes for a more complete voiding of the retained urine. I go often, since i don't like the sensation of the retained urine. Is this good enough? If not, i will ask for an ultrasound of my kidneys to see how they are doing, just in case.

I have been seeing a urologist for the past 4 years, but he hasn't mentioned this, nor the GFR nor the creatinine tests. So far I've only been getting prescriptions for tamsulosin and PSA tests.

You do mention other advantages of HoLEP, and another is that tissue can be sent to pathology to screen for cancer and if present, assign a Gleason score.

This is possible with traditional TURP also but not with Greenlight laser (PVP). In fact, a 12-core biopsy I had 5 months before my TURP (due to a significant increase in my PSA) came up clean but analysis of my prostate tissue from the TURP showed prostate cancer. Gleason score was 3+3 so we're in the "active surveillance" stage. My 3-month post-TURP PSA was 2.2 and my uro says we'll do another measurement in 6 months. Since the PC was found in only a small portion of the tissue, the doctor says it's possible the TURP removed it all. We'll see what the next PSA number is at the end of the year.

Wishing you all the luck on that lee. My last PSA was 3.3 in April this year. It has risen from 1.1 fairly steadily from 11 years ago. My next door neighbour who is the same age as me had no uro symptoms whatsoever but last year in a free 'Well Man Clinic' check found he had prostate cancer - shortly prior to this check his prostate according to his doctor felt smooth and normal and his PSA level was within the normal range for his age . He was shocked as you can imagine at the clinic's discovery and had a prostatectomy some months ago. He's apparently clear of cancer now - or so his recent test results show - but he went into retention due to scarring. He's had further treatment for this and now appears ok.

Dan

Ask for metabolic panel, which includes GFR and creatinine

US will tell if kidneys are inflammed along with other information

Sounds like you're double voiding, so you are emptying. But it would be prudent to check kidney function.

Michael

Thanks, will do. I haven't had any UTI so far, so i thinks that the double voiding (often) helps in that regard.

Great Dan.

I hope the metabolic panel gives you peace of mind.

It's a simple test (blood draw) and good indicator of kidney function. You just want to watch your numbers to make sure GFR is not dropping and creatinine is not rising.

I've not had any UTI but am retaining more urine, so time for a procedure is fast approaching.

I sincerely wish you all the best, Dan.

Michael