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Benign Prostatic Hypertrophy

Short summary

66-year-old male was diagnosed with Benign Prostatic Hypertrophy. The expert recommends to try two different medications before
considering surgery as an alternative.

Patient's questions

1) Would you advise surgery or treatment with medication?
2) If surgery, which do you consider as most appropriate - TURP or open surgery?
3) The patient would also like to be advised regarding the new TURO laser techniques (using KTP laser) or THERMOTHERAPY. Can/should these be considered in his case?

Medical opinion
Patient's History
Sex: M, Age:66 years
DiagnosisBenign Prostatic Hypertrophy
Case History:
Patient has a history of cholecystectomy at 27 years of age and excision of a benign kidney nodule at 64 years of age. He is a carrier of hepatitis C and showed slight hypertension under treatment.
The patient reports that the onset of urological symptoms started when he was 63 years of age.
The patient has been monitored over time and has had two prostate biopsies, which only showed “foci of chronic prostatitis in the tested sample taken from the right lobe”, and one which showed “localized chronic infiltrated aspecific interstitial inflammation. No atypical changes”.
The patient has already been advised to have open surgery due to the size of his prostate, which, based on the ultrasound that was carried out , had the following dimensions: glandular volume of 90 cc (LL 63 mm, PA 44 mm, CC 65 mm). The ultrasound also shows: “continuous capsular echoes; there are no signs in the peripheral portion of the gland to indicate discariocinetic processes. There is a presence of central adenomatosis with a maximum transverse diameter of 55 mm. Some cysts from retention (the largest of which is 10 mm) and intraparenchymal calcifications. Seminal vescicles are within normal limits. Post-mictural residue is not assessable. There is a slight projection of the third lobe into the bladder.”
We are attaching a table provided by the patient showing PSA and PSA Free values.
Certainly BPH is a very common problem in men, which eventually produces lower urinary tract symptoms. The description of the patient’s problems is scant but I will assume that they are typical for BPH. His PSA levels were in the 7-10 range, but they have not shown any increase, while his free PSA is high, which tends to reflect a lower risk of presence of prostate cancer.
Although the patient’s prostate is quite large as measured in the ultrasound (>90cc), it is still prudent to begin therapy with medications. There are many men who do very well even with large prostates on alpha blocker and 5 alpha reductase inhibitor therapy. Because of the large size of the prostate, I would recommend a trial of both types of medication to see if this improves his symptoms.
If he doesn’t tolerate this therapy or doesn’t feel improvement, it is very reasonable to pursue more invasive therapy. Certainly, a wide range of tests are available, such as urodynamics, to prove obstruction before deciding to embark on surgical therapy. I do lean toward at least getting an uroflow and post void residual as a baseline. This very noninvasive pair of tests also provides an excellent method of following patients post therapy along with the international prostate symptoms score.
Typically, microwave thermotherapy is a very well tolerated treatment with a very small side effect profile, however data for this therapy with large prostates is less promising. Although much more challenging, TURP is an excellent alternative for patients with large prostates (60-100g) if the surgeon feels confident with taking on a large prostate. However, risks do arise, especially those of TUR syndrome and fluid absorption. Newer laser procedures such as Laserscope or Holmium Laser Ablation of the prostate are excellent treatments that can provide similar resection to TURP without the attendant risks.
In summary, it is recommended that the patient first embark on a trial of medications. If this does yield satisfactory results, then I would offer him a Holmium Laser Ablation of the Prostate. In our experience, prostates up to 150g can be treated effectively in this manner. If this laser treatment is not available, then a staged TURP would probably be the next best step.