Recent Innovations in Prostate Surgery
Benign prostatic hyperplasia does not increase the risk of prostate cancer. Surgical treatment is considered in two major situations. The first involves cases where complications have already occurred and thus must be treated by surgery. For example, a critical complication like urinary retention, where one cannot urinate and requires a catheter, necessitates surgery. Another strong indication is severe prostate obstruction. Some patients may not even realise the extent of the obstruction, which can cause urine reflux into the kidneys and then kidney dysfunction. Surgery is strongly recommended in such cases. .
If other complications such as inflammation, bladder stones, or hernias (commonly known as inguinal hernias) due to straining during urination occur, doctors will also recommend patients with benign prostatic hyperplasia to consider surgery as soon as possible. The second group of patients belongs to patient not having severe and various complications, but symptoms cannot be controlled well after taking medication, or if one prefers not to take medication due to excessive side effects and persistent discomfort, it means pharmacological treatment fails, and in this case surgery should also be considered.
Q2. How is conventional surgery performed? What are its side effects and limitations?
Conventional surgery, known as Transurethral Resection of the Prostate (TURP), is a minimally invasive procedure. While it may sound complex, we can start from understanding the structure of the prostate, and the male lower urinary tract first. After we drink water, urine is stored in the bladder. When one feels the urge to urinate, the two sets of sphincter muscles relax and the bladder contracts, allowing urine to pass through the prostate to the urethra and be discharged from the body. The procedure involves insertion of a pen-like instrument called endoscope via the urethra to the prostate under anaesthesia. A wire loop which can cut tissue with electric current, is then used to resect the enlarged prostate tissue. The tissue pieces are flushed away from the bladder with saline to clear the urethra and prostate. As a standard TURP procedure, this conventional surgery is highly minimally invasive. It has been proven effective with decades of clinical experience. But it is not without risks, side effects, and limitations. According to statistics, severe complications, such as mortality, occur in only two out of every thousand cases. It means the procedure is low-risk and is relatively safe.
What should patients be concerned about? It is mostly incontinence. The risk of incontinence is relatively low, with an average of about 2 to 5%. It might affect sexual function, the risk of which is not particularly high, or about 10%, and will more likely affect ejaculation. Doctors will explain to patients that, while one may lose the ability to ejaculate, this does not mean a complete absence of semen or no ejaculation at all. It is called “retrograde ejaculation”, where one can still have an erection, engage in sexual intercourse, and reach orgasm, but the volume of semen is much reduced at the time of ejaculation, as most of it flows backward into the bladder.
In theory, recurrence is possible, though the rate is not high. On average, about one in five patients may require further treatment after ten years, making TURP a relatively effective option. Regarding limitations, this surgery is suitable for most cases of prostate enlargement. However, if the prostate is significantly enlarged, i.e. over 80cm³ or even 100cm³ or more according to international guidelines, newer surgical methods may be considered.
Q3. I am very worried about the risks of conventional surgery. Are there any other alternatives?
Yes. For instance, if one cannot urinate and wants surgery due to a significantly enlarged prostate, a new procedure known as Aquablation can be considered. As an endoscopic surgery, it is carried out with a pen-like instrument being inserted through the urethra. An ultrasound probe is also placed via the anus to map the prostate contour using computer technology, and also plan for the removal of the enlarged prostate tissue. Aquablation can remove the prostate tissue within a short period of time by flushing it away within the urethra, thereby overcoming the difficulty in conventional surgery when the prostate has become too large for resection. This procedure has been proven to be effective and safe, and can even reduce the risk of retrograde ejaculation.
If the condition is less severe, with prostate enlargement under 100cm³ and less tissue, and one isd worried about impact on sexual function or incontinence, there are two more established treatment options for benign prostatic hyperplasia. One of them is the Urolift procedure, which is somewhat like using a stapler. The surgery involves inserting an endoscope through the urethra to reach the prostate. Instead of using an electric knife to remove tissue, a staple-like device is employed to place small implants in the prostate and pull the prostate tissue apart, like drawing back curtains to allow light in. These small implants can quickly open up the prostate passageway without removing any tissue. Side effects, such as sexual dysfunction, incontinence, or ejaculation problems, can be largely avoided, making Urolift a very good choice.
Another method is Rezum. Similar to Urolift, Rezum also involves the insertion of an endoscope through the urethra via a minimally invasive approach. Instead of a stapler or electric knife, this technique involves inserting a fine needle into the prostate tissue to deliver steam, i.e. water at 100°C, and destroy the prostate tissue through thermal energy. The enlarged prostate will then gradually shrinks and widen the passageway, thereby restoring smooth urinary flow. This procedure is very safe, and rarely causes incontinence, affects sexual function or interferes with ejaculation.
Q4. Do these new surgeries have any side effects? What should patients pay attention to?
Each of these new methods has its own drawbacks. In aquablation, while a high-pressure water jet can quickly remove a significant amount of enlarged prostate tissue. However, conventional electrode methods are still required to control bleeding after flushing, and catheter insertion is needed for a period of time. This involves much equipment and can be quite costly.
Urolift involves less risk, shorter hospital stays and less catheter time, typically around one day. However, many patients do not like the concept of this surgery and worry about the health impact, as it involves the insertion of a few staple-like metallic objects to hold the prostate open. However, this is not the case; and the impact may be more psychological than physical. For instance, the metallic objects are not detectable by airport security devices. Even if one suffers spinal injury, the inserted objects do not compromise the safety of magnetic resonance imaging scans. Reports show that displacement of staples to the bladder occurs in rare cases. These occurrences are extremely uncommon.
While Rezum carries low risk and involves no metal substances, the results are not immediate. Due to needle insertion and steam delivery, initial reactions include redness, swelling and pain. The benefits of tissue contraction are not immediately visible. A catheter may be required for a longer period of time after surgery, probably up to a week. If you opt for this surgery, you should be patient to await for symptoms improvement.
Long-term follow-up of large-scale studies show that, compared to Transurethral Resection of the Prostate (TURP), Urolift and Rezum may not be as durable in terms of clinical outcomes. The recurrence rate is about 20% ten years after TURP, while Urolift and Rezum have a similar rate. Statistics indicate that 80% of patients are satisfied five years after treatment, which means 20% are not. According to current data, these two procedures are less durable than conventional surgery in terms of clinical outcomes. If recurrence occurs 5 or 6 years after treatment, would these procedures lead to other issues? It is unlikely, and one can still resort to options such as medication, Urolift, Rezum, or even TURP, just like when first diagnosed. These procedures do not limit future treatment options, and arrangements can be made as long as necessary.
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