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So You're Having Prostate Surgery
By Eric A. Klein Leah Jamnicky Robert Nam
John Wiley & SonsISBN: 0-470-83344-0
Chapter Oneis prostate surgery right for you?
What Happens in this Chapter
Reasons for recommending surgery
The inside story on TURP for BPH
Pros and cons of other BPH options
The inside story on prostate cancer surgery
Pros and cons of other cancer options
Whether you have benign prostate enlargement or prostate cancer, your medical history, physical examinations, lab tests, and imaging technologies are guides that help your physician recommend which treatments he or she thinks are best for you. However, the decision to proceed with treatment is yours. In some cases, test results are indisputable, the diagnosis certain, and the benefits of treatment obvious. But sometimes things aren't so clear-cut. Understanding the benefits and drawbacks of your options may help you make this important decision.
Benign Prostatic Hyperplasia
If you have BPH, there are three treatment options to consider: watchful waiting, medication, and surgery. The pros and cons of these options are summarized in the chart on page 35. Most commonly, physicians tend to start with the least invasive options. Surgery is usually reserved for men whose symptoms do not improve with medication, or when BPH starts to cause serious medical problems.
BPH: The Case for Watchful Waiting
Watchful waiting is the medical term for a"wait-and-see" approach. You and your physician will keep a close eye on your symptoms, but do nothing unless something changes.
Large clinical studies indicate that BPH symptoms improve or disappear on their own in 20 to 50 percent of cases approximately. Therefore, many men do not need any treatment. However, about a third of those who choose to wait and see will experience progressive worsening of their symptoms and some may eventually lose the ability to empty their bladder. The 10-year risk for developing acute urinary retention (see page 9) is about 13 percent-or odds of slightly better than 1 in 10. The risk for requiring surgery for BPH is about 5 percent (or odds of 1 in 20). These low probabilities make watchful waiting quite attractive, especially when BPH symptoms are mild and not too bothersome.
Living with Mild Prostate Enlargement
Most men adjust to mild urinary symptoms-a visit to the washroom before leaving home, scouting out the public lavatory at the mall, taking the aisle seat at the movies, and reducing fluid intake after dinner or before bedtime.
Certain medications can aggravate BPH symptoms. If you have allergies or catch a cold, you'll have to think twice about taking non-prescription medications known as adrenergics because they mimic the effects of adrenaline (also called epinephrine). This is the "fight-or-flight" hormone that evolved in mammals to speed up the body for coping with such emergencies as outrunning a lion or avoiding an oncoming car. Many decongestants contain a synthetic version of adrenaline, called pseudoephedrine, which relaxes the lung's bronchial passages, stimulates the heart rate, and constricts blood vessels. Another problem with adrenergics is that they constrict muscles in the prostate and bladder making it harder to urinate. Antihistamines, such as diphenhydramine (Benadryl), can also slow urine flow in some men.
Anyone who has BPH and hypertension (high blood pressure) or congestive heart disease, and is taking diuretics, such as chlorthalidone or hydrochlorothiazide, should discuss the risks and benefits of this drug regimen with his doctor. Diuretics (also called "water pills") decrease the amount of fluid in your body by encouraging the kidneys to produce large quantities of urine. This might be a good thing for hypertension, but clearly there's a conflict for someone who has lower urinary tract symptoms or is prone to urinary retention. However, no one should stop taking diuretics without medical supervision since these drugs are an important treatment for cardiovascular disease.
BPH: The Case for Drug Therapy
Medication has become a popular treatment choice for BPH. In the United States, the number of prescriptions written monthly for BPH drugs increased from less than 400,000 to more than one million between 1993 and 1996. The obvious advantage of drug therapy is that it provides effective relief of BPH symptoms without surgery.
Two classes of prescription medications are used: alpha blockers and 5-alpha-reductase inhibitors. For a more detailed discussion of the medications used to treat BPH, see Chapter 11. Saw palmetto, an over-the-counter herbal medication, may also help alleviate some of the mild symptoms of BPH (seee page 113).
So if these medications are effective, why does anyone opt for surgery? For one thing, although alpha blockers and 5-alphareductase inhibitors can slow up the progression of the disease, either alone or in combination, studies show that this does not work for all men. Symptoms can worsen during drug treatment and the risk of developing acute urinary retention still exists. Symptoms return soon after you stop taking the drugs, so you may need to take medication for the rest of your life. Also, some of the drugs aren't currently covered by public or private drug plans, so this approach may prove to be expensive. Some men also find side effects, such as dizziness, ejaculatory problems, or nasal congestion, troublesome. Although drug therapy alone can be an effective method of treating BPH, regular check-ups with your doctor are a must if this is the route you choose.
BPH: The Case for Surgery
Surgery for BPH is considered "elective"-that is, it's your choice if and when you have the procedure. For many men, their choice depends on how well they can put up with reduced urinary flow and frequent urination (especially during the night). Some can tolerate urinary tract symptoms with little difficulty; others cannot. However, you may not really have a choice under certain circumstances, such as if you experience a decline in kidney function, repeated episodes of blood in your urine, multiple urinary tract infections, and bladder stones. Surgery is also a good option if you develop diverticulae, abnormal pockets of tissue in the bladder that can trap urine and cause infection.
The Advantages of TURP
The surgical gold standard for treating BPH is transurethral resection of the prostate (TURP). This procedure involves removing the prostate tissue that surrounds the urethra to relieve the pressure. TURP is described in detail in Chapter 6.
Studies have repeatedly shown that, after TURP, patients don't have to urinate as often and their urinary flow is much stronger.
The benefits of TURP are long-lasting, and the procedure reduces the chance that you'll need additional drug therapy. There's only a 1 in 20 chance that you'll need repeat surgery after 5 years. Repeat surgery becomes necessary if prostate tissue re-grows and obstructs the urinary passage, but this second procedure poses no greater risk than the original operation.
Recovery from TURP is fast because the procedure is done via the urethra, with no surgical incision. Once the catheter that was inserted in the urethra is removed after surgery, you should be able to urinate right away and will notice an immediate improvement in symptoms. You should be able to return to normal daily activities (light duties only) in as little as 1 week after the procedure, although complete healing usually takes about 6 weeks. TURP also generally causes few complications. Severe complications are extremely rare.
The Downsides of TURP
Although most patients do well after TURP, a few suffer a complication called urinary retention, in which they are unable to empty their bladder. A variety of factors contribute to this complication, such as an individual's overall health, whether he experienced acute urinary retention before the operation, and inflammation and bleeding caused by the surgery. If this happens to you, a catheter will be inserted into your bladder and removed several days later when you have healed properly. If there is excessive bleeding, the catheter will need to be irrigated with fluid in order to flush out any blood clots that may have formed.
If urinary retention occurs on a regular basis, a technique called intermittent self-catheterization (ISC) may help. The patient is taught to insert a catheter himself whenever urinary retention occurs, to relieve himself. For most men, this solution is only necessary for a short period and the bladder settles down in time. For a rare few, ISC may be needed indefinitely.
Another downside of TURP is that it can cause at least temporary sexual dysfunction (erection difficulties) in about 1 in 25 patients. It can also cause urinary leakage, or incontinence, in up to 1 in 100 patients. About 75 percent of patients will experience retrograde ejaculation, a harmless condition in which some (or all) of the ejaculate goes into the bladder, rather than out of the penis, during orgasm.
Minimally Invasive Treatments
Over the years the search has been on to find alternatives to TURP. Several minimally invasive procedures have been developed, some of which are still experimental and others are available only at some hospitals or at private clinics. They include techniques to shrink or destroy the prostate tissue (high-intensity ultrasound, laser treatment, transurethral electrovaporization, transurethral needle ablation, hyperthermia or thermotherapy) and procedures to stretch and "prop open" the urethra (transurethral balloon dilation and intraurethral stents).
Two techniques that have gained popularity more rapidly than the others are transurethral microwave thermotherapy (TUMT) and needle ablation (TUNA).
TUMT and TUNA can be performed as day procedures in a hospital or private clinic. TUMT uses microwaves to destroy the prostate tissue that is causing obstruction, while TUNA uses radiowaves to coagulate or "melt" the tissue. Although these techniques have not been studied very extensively as yet, and their long-term benefits are still unknown, they do appear to genuinely improve symptoms. The downside of these procedures is that they may not be covered by health care plans, in which case you may be in for a bill of several thousand dollars.
BPH Treatment-Pros and Cons
There are many factors to consider when you're deciding what treatment is best for you. This quick reference chart may help.
For prostate cancer, there are currently four main options: a wait-and-see approach (watchful waiting), radiation therapy, medication, and surgical removal of the prostate (radical prostatectomy). These options are summarized on page 46. Your age, lifestyle, PSA level, and biopsy results will largely shape your options. If your physician recommends active treatment, it is worth realizing that radiation and surgery appear to be equally effective. As long as the cancer is confined to the prostate, the chances of a complete cure with either treatment are extremely good.
Prostate Cancer: The Case for Watchful Waiting
Watchful waiting involves having no treatment for your prostate cancer until you start experiencing symptoms, at which time your physician will treat the symptoms only, usually with medication.
Watchful waiting can be very appealing to men who don't want any type of treatment for prostate cancer. Unlike some other kinds of cancer, prostate cancer can be very slow growing, taking 5 to 15 years to spread and become potentially lethal. That's why many men who develop prostate cancer late in life die with the disease rather than from it.
Despite the appeal of "doing nothing," watchful waiting is really only an option for a select group of men. Men in their late 60s or older whose cancer appears less aggressive and men who are too ill from other causes to undergo treatment are the best candidates for watchful waiting. If your cancer has already started progressing, you will be advised to start curative treatment without delay, i.e., radiotherapy or surgery.
If you opt for waiting, you'll need to have regular check-ups. Your oncologist will do regular PSA measurements and DRE checks to determine the status of your prostate cancer.
Deciding When to Treat
For most men, particularly younger men with localized cancer, the treatment decision hinges on factors such as TMN stage, Gleason grade, and PSA level (see Chapter 2). With these factors in mind, you and your oncologist will first discuss whether treatment for your prostate cancer is necessary, and then which treatment is best for you.
Prostate Cancer: The Case for Radiation
Radiation therapy for prostate cancer has been around for many years and studies so far show that it is as effective as surgery in controlling cancer in certain kinds of patients (see More Detail box on page 38).
The two kinds of radiation treatment commonly used to treat prostate cancer are external beam radiotherapy and brachytherapy. There are a number of factors to consider when you're trying to decide if radiation treatment is right for you. Its main advantage is that you are spared a major, invasive procedure. External beam radiotherapy does not require any anesthetic and, although brachytherapy requires a general anesthetic, the process of implanting the radioactive seeds is fairly minor.
Rates of incontinence can be lower for patients who undergo radiation compared to surgery, but radiation can still have unpleasant side effects such as other urinary symptoms and irritation of the rectum. In addition, external beam radiotherapy requires a significant time commitment, which may be difficult to schedule. However, the most important downside is that the prostate gland is not removed so it cannot be examined to see how serious your cancer is.
External Beam Radiotherapy
This treatment approach involves directing radiation beams to the prostate using a device called a linear accelerator. Standard therapy consists of 10 to 15 minutes each day, 5 days a week, over a period of 7 to 8 weeks. Radiation is given in daily, low-dose bursts to give the healthy tissue surrounding the prostate a chance to recuperate. Cancerous tissue doesn't repair itself as quickly as normal tissue, so over time, the cancer cells cannot cope with the repeated bombardments and sustain so much damage that they are destroyed. The surrounding areas of normal tissue, however, do recover from the radiation damage.
Conformal Radiotherapy and IMRT
Conformal radiotherapy has added a new dimension to external beam radiotherapy.
Excerpted from So You're Having Prostate Surgery by Eric A. Klein Leah Jamnicky Robert Nam Excerpted by permission.
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