What is the best treatment for an enlarged prostate?

We speak to two consultants about the treatment options available for benign prostate enlargement. Mr Barnaby Chappell and Mr Simon Woodhams from BMI Goring Hall Hospital share their advice.

Prostate enlargement is a common complaint. It affects many men in the UK and can lead to painful and disruptive symptoms.

However, with new treatments becoming available and a huge amount of information out there, it can be baffling trying to understand what's on offer and work out which option is best for you.

This guide explains the main treatments available and gives you a clinician's view of each. We hope it will help you cut through the noise and feel informed to make a decision.

What is benign prostate enlargement?

Benign prostate hyperplasia (BPH) - often referred to as benign prostate enlargement (BPE) - is an enlargement of the prostate gland. It is very common in men over 50 and is not normally a serious threat to health.

What are the symptoms of BPH?

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The main symptoms of an enlarged prostate are urinary problems. If the gland becomes swollen, it can put pressure on your urethra and bladder, disrupting the flow of urine.

This can cause urinary symptoms including difficulty starting to pee, difficulty completely emptying your bladder, and feeling the urge to urinate more than usual.1

If you are failing to properly empty urine from the bladder, there is also a chance of developing bladder stones and in serious cases blockage to the kidneys.2

What treatments are available for prostate enlargement?

Some men with an enlarged prostate find that it does not affect their quality of life. However, if you're experiencing pain or urinary problems, you should speak to your doctor.

You may first be recommended lifestyle changes to try to manage the problem, such as improving your diet or bladder training to relax the muscles.There are also medications that can help, such as diuretics or alpha blockers.1

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If these approaches don't work, you will likely be recommended surgery. Below are some of the most common treatments for BPH along with a clinical perspective on their benefits and who they are most suitable for.

TURis - Plasma resection of the prostate

The key advantage of TURis is that we know it is extremely effective because it is essentially an improved version of the standard TURP (trans-urethral resection of the prostate) treatment.

TURP has been around for many years and is widely considered a safe and effective treatment option.3

The improvements found in the TURis/Plasma technique have made the operation safer, offering reduced bleeding and less serious side effects.

As with TURP, t is very likely that if you have the TURis procedure you will never need anything else done to help your waterworks symptoms in your lifetime.4

The operation is so safe that it can even be performed as a day case procedure in a hospital with no facility to admit patients overnight.5

TURis is suitable for most men, but not those who aren’t fit for a general anaesthetic. That being said, some men have very large prostates that are better treated with the holmium laser (HoLEP).

HoLEP - Holmium laser enucleation of the prostate

Holmium laser enucleation of the prostate, or HoLEP for short, is a highly effective endoscopic procedure. It uses laser energy to remove parts of the prostate.

The operation was first developed in the 1990s and many studies have demonstrated excellent short and long-term outcomes for HoLEP.6  The operation has two parts two it. Both are performed in one sitting, under spinal or general anaesthetic.

The first half of the operation uses a holmium laser to enucleate or 'shell out' the inside of the prostate; this results in two or three large pieces of prostatic tissue floating around the bladder.

The second half of the operation uses a surgical tool called a morcellator that 'chomps up' that tissue, which is then completely removed from the bladder and sent for analysis.

This operation is suitable for all sizes of prostate.7 It is our operation of choice for larger prostates.

HoLEP has been found to have a lower risk of bleeding than resection procedures (such as TURis or TURP), and tends to remove a larger quantity of the prostate.8

UroLift

This technique involves gently moving the enlarged prostate aside so that it is no longer squeezing the urethra and restricting the flow of urine. Your doctor will anchor the prostate in place with permanent implants.

The UroLift operation takes about 20 minutes. Patients do not need a catheter afterwards and can normally go home a few hours later once we are satisfied they have passed urine.

This treatment is probably not suitable for all men, but it's an exciting new option for those who have severe problems with their waterworks.

The risks include blood in the urine due to irritation caused by the procedure, and moderate discomfort for a week. It may also irritate your waterworks for three or four days afterwards.

The improvement in symptoms and urine flow rate is not quite as good as with conventional surgery but there is a complete preservation of sexual function as well as a return to normal activities in just a few days.5

Rezum- Steam ablation of the prostate

With Rezum, a handheld device is used to apply steam to the enlarged prostatic tissue. The steam encourages the prostate cells to die, shrinking the gland so that the obstruction is relieved.5

This method to reduce the prostate is a small procedure that is most useful for men with moderate enlargement of the prostate who would prefer to avoid a more major operation.

We would not recommend it for men with catheters or prostate cancer. Also, very large prostates won't benefit as well from this treatment.

Rezum has had lots of media attention in recent months9  and offers the opportunity to improve symptoms in eligible men who would prefer to minimise the side effects of more widespread treatments. Some recent studies have shown encouraging data with up to three years of follow up.10

PAE – Prostate artery embolisation

For PAE, a radiologist will insert a catheter (a small plastic tube) through an artery in your thigh. Using X-ray to ensure precision in what they are doing, they will inject tiny plastic particles into the blood vessels that feed the swollen prostate.

These particles 'plug' the blood vessels, forcing the prostate to shrink.

Although this procedure takes a long time and involves significant exposure to radiation (from the X-ray), it has a low complication rate and can be done under local anaesthetic. This makes it suitable for some older men who are not suited to more invasive operations or general anaesthetic.11

If we consider this treatment to be the most appropriate for you, we will refer you to an interventional radiology team who specialise in this new procedure.

BMI Goring Hall is able to refer patients to the team at University Hospital Southampton, the first UK centre to perform prostate artery embolisation.

West Sussex urology offers the full range of these treatments.

Our consultants are available to talk through these options and help you choose the right treatment option for your individual needs.

To find out more call us on 0808 101 0337

or make an online enquiry.

Sources
1https://www.nhs.uk/conditions/prostate-enlargement/
2https://www.nhs.uk/conditions/bladder-stones/
3https://www.nhs.uk/conditions/transurethral-resection-of-the-prostate-turp/
4https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2950762/
5http://europe.nxtbook.com/nxteu/sageuk/jcu_201806/index.php?startid=71#/74
6https://www.ncbi.nlm.nih.gov/pubmed/21883820
7https://www.cambridgeurologypartnership.co.uk/urology-info-for-patients/prostate/holep-urolift/
8https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4446381/
9https://www.urologytimes.com/article/demistifying-less-invasive-solutions-bph
10https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6180381/
11https://www.uhs.nhs.uk/OurServices/Radiology-scansandimaging/PatientInformation/Prostatearteryembolisation.aspx

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