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LAST  MAN  STANDING?

 

 

 

 

Are you the last man standing at the urinal?  Do you pee on your own shoes?

Get up multiple times at night?  Couldn’t pee over a fence?  If this is the case you certainly

are not alone.  Most likely this condition may have started in your late forties or early fifties.

Commonly voiding problems in men are secondary to prostate enlargement, or what is

Known as BPH.  There are other conditions that can cause these symptoms such as urethral

Stricture disease, overactive bladder, flaccid neurogenic bladder, however; by far the most common

Reason for these symptoms in men is BPH.

The prostate is a gland in the posterior or back portion of the urethra just below the neck of the

Bladder.  The bladder is a muscle and squeezes the urine out of the bladder, through the prostate and

Out the urethra.  As we get older the prostate most of the time enlarges.  Microscopically this

Begins at age 30, and gradually becomes large enough to block the opening of the bladder

Most commonly noticeable by age 50.  The degree of enlargement is not of major concern.

This is because there are two types of obstruction of urine flow caused by BPH.

OBSTRUCTIVE

The enlarged lobes of the prostate physically block the flow of urine

DYNAMIC

The muscle and prostate tissue squeeze down on the prostate obstructing the flow of urine.

 

Each type of obstruction can cause symptoms of BPH.

 

SYMPTOMS

      When you are the last man standing at the urinal, or you can no longer pee over a fence, or

You are dribbling on your feet or expensive shoes, that usually translates into you have a weak

Urinary stream.  Many times besides just a weak stream, men experience what is termed

“hesitancy and intermitentcy”.   In simple terms, that translates to having to wait to get the

Urinary stream started, and stopping and starting your stream.  Both of these symptoms lead to

A slow and prolonged urination.  This may only turn into missing a touchdown at a football game, or

Maybe the best part of a movie.  However, when the symptoms gradually become worse this may

Lead to incomplete bladder emptying.  This leads to increased frequency of urination, and many times

Causes secondary urgency and having to run to get to the bathroom to make it in time.

Furhtermore, this can lead to getting up multiple times at night and severely interrupting your sleep

Patterns. It can even lead to urinary retention which is the inability to void, bladder stones, and

Even renal failure.

The good news is BPH can be treated before many of these symptoms occur, or serious side

Effects are the end result. 

BPH is best treated by an experienced urologic surgeon.  There are many treatments for BPH.

There is medical therapy, minimally invasive surgical options, and standard surgical intervention.

Generally if you were to see me in the office I would perform a history and physical examination,

Urinalysis, PSA test to rule out prostate cancer and renal function studies.  If the renal function studies

Are abnormal a renal ultrasound to be certain you are not retaining urine that is backing up into your

Kidneys.  I may suggest medical therapy to start, however; I most likely will perform a cystoscopic

examination which is examining the prostate and bladder lining.  I am very big on finding the

Correct diagnosis and being certain of what I am treating as opposed to guessing or playing percentages.

Once we have a diagnosis of BPH and voidng symptoms related to this, there are multiple therapies that

may be of help.

Medical therapy for BPH

There  are two basic types of medications for BPH.  There are many different brands of

Medications but they generally will do one of two things.

Alpha Blockers

Alpha blockers are very commonly used for treatment of BPH.  They, in my opinion, are also the

Most effective for most patients.  Alpha blockers relax the bladder neck and prostate to allow improved

Urinary flow, better bladder emptying which hopefully translates into less trips to the urinal and

Improvement in sleep patterns.  Commonly used Alpha blockers would be “Tamsulosin” “Flomax”

“Terazosin” and “Cardura” for example.

 

5 Alpha Reductase Inhibitors

5 alpha reductase inhibitors generally shrink the prostate in size.  My personal opinion is that

They are not as effective in most patients as alpha blockers.  These types of medications generally

Will take six months of use to know if they will be effective.  I do not think they give as much

Relief, especially in the short term, as alpha blockers.  5 alpha reductase inhibitors seem to offer better

Symptom relief in patients with very large prostates.  Medications commonly used in this class

Are Finasteride, Proscar, Avodart, and Dutasteride.

 

Combinations

5 alpha reductase inhibitors are many times used in combination with alpha blockers.

An example is “Jalyn”.  Combination of Tamsulosin and Avodart.  This can be more efficacious

Than either drug by itself.

.

SURGICAL   TREATMENT  OF  BPH

Clasically the “Gold Standard” treatment for BPH and symptoms of BPH when medical therapy

Fails is Transurethral Resection of the Prostate  (TURP).

TURP is done mainly under general anestetic in 2017.  In the past it had been done with a spinal

Anestetic in the past.  There are no incisions.  The procedure is done through the urethra with

A cystoscope (telescope) and a cutting loop.  The obstructing or BPH tissue is very evident to the

Trained eye, and the obstructing tissue is removed.  This creates a wide open channel to allow

Significantly improved urinary flow.  For most patients, it is not a painful procedure.  Most of the

Time, patients spend one night in the hospital.  Sometimes this is done in an outpatient setting.

This is only my personal opinion, however; my thought on that is the following: “just because

It can be done, does not make it the best choice for patients”.  Why?   Bleeding is fairly common

After this procedure.  Patients will nearly always go home with a catheter in place.  If bleeding occurs

And clots off the catheter, most likely this will require a trip to the emergency room.  After having a

General anestetic, I do not like to take the chance that my patient is going to come home from surgery

Groggy from the anestetic, only to return to the emergency room to have his catheter flushed out

And receive another large bill from the hospital.  That being said, my patients generally will stay

Overnight in the hospital with irrigation running through the catheter to prevent clotting which we

Stop in the morning and then send them home.  Usually very uneventful.  TURP is very efficacious

At symptom relief for most patients.

Unfortunately, there are no

Free rides in medicine and there are potential side effects to TURP.

Prolonged blood in the urine off and on for up to six weeks.

Erectile dysfunction

Retrograde ejaculation (dry ejaculate)

Urinary Frequency and Urgency.

That being said, most patients are very happy with the end result after healing is complete, however;

most are frustrated with the sexual side effects listed above to some degree.  Other patients just

are not happy.  Why?  It depends what was really interfering with their quality of life before surgery.

For example, many patients complain about “nocturia” (getting up at night).  Enlarged prostate is

One of the problems that can cause getting up at night  to urinate, however; a multitude of patients

Get up at night for a multitude of reasons and assume its all because of their prostate and it is not.

It could be a sleep disorder, arthritis, overactive bladder, chronic pain, nocturnal polyuria.

Again, however; TURP is our “Gold Standard” surgical treatment because it has stood the test of time,

Offers excellent symptom relief for most patients, with relatively minor side effects.  I say that with

The understanding that the Urologist is not the one with the “minor sexual side effects.”

 

Minimally Invasive Procedures For BPH

This has led Urologists and research scientists, biomedical device manufactures etc. to search for

A less invasive procedure to treat symptoms of BPH.  This basically would mean the following:

Better or equal symptom relief as TURP

Less side effects than TURP

Quck recovery

Less Costly than TURP

 

Since I have been studying Urology I have seen attempt after attempt to find the “Holy Grail”

Or a minimally invasive treatment for BPH that is less invasive and as good or better than TURP

I will name a few of these off the top of my head:

 

Side Fire Laser TURP

Laser TURP

Interstitial Laser Treatment

Ballon Dilation of the Prostate

TUIP

Holmium Laser of the prostate

Vaportrode of the prostate

Trans urethral needle ablation of the prostate (TUNA)

Microwave Prostate therapy (TUMT)

Rezum

 

I am mentioning all of the above therapies as a group for two reasons.

First, none of these treatments came close to the symptom relief of TURP

Second, at least in this author’s opinion, (minus TUIP) they all taught us a few lessons.

To remove or vaporize prostate tissue the prostate has to be heated to 45 degrees C.

The layers of the prostate closest to the surface may actually be vaporized or removed.

Some of the tissue, however; where the temperatures do not reach 45 degrees C,

Are merely cauterized.  This leaves behind areas of tissue that are not removed

That become charred or cauterized and can turn into coagulation necrosis and

This causes SEVERE  Irritative side effects that can be long lasting.  For the most part,

The symptom relief was minimal, the side effects were intolerable to most patients.

This was a recurring theme in treatment of BPH for many years.

The Greenlight laser was developed later in this era after we had learned from many

 

Of our previous mistakes.  Greenlight laser works at a wavelength most amenable

To vaporization of prostate tissue.  That being said, a much larger volume of

Tissue was vaporized and removed.  However, the same principle is at work with

Other thermal treatments (heat treatments) to the prostate gland.  There is still

An area of deeper tissue that cauterizes and does not vaporize.  This is helpful in

That the perioperative bleeding does not last nearly as long as with traditional TURP.

Unfortunately, the irritative symptoms from coagulation necrosis can be severe,

And very long lasting.  The brochure from the manufacture lists “minor irritative symptoms,

If this lasts more than a few days contact your urologist.”  Generally this will last for a few months

Or longer.  Furthermore, the sexual side effects are not avoided with a PVP greenlight laser TURP.

There is still retrograde (dry ejaculate) most of the time.  There are still patients that have

Erectile dysfunction after surgery.  My personal opinion is that a Laser TURP usually will

Allow a patient to have the procedure as an outpatient, the peri-operative blood in the urine

Does not last quite as long, but the sexual side effects are relatively the same as after TURP,

And the irritative symptoms which can be nearly intolerable last much longer than with TURP.

That being said, Greenlight Laser PVP is somewhat better than the other so called minimally

Invasive procedures, however; certainly not the “Holy Grail” patients are searching for.

 

UROLIFT  

 

I have been a practicing Urologic Surgeon for more years than I wish to admit.  I had seen all

These treatments come and go.  I was introduced to a procedure from “NEOTRACT” known

As the UROLIFT.   I thought I had seen it all at that point and initially was not very impressed.

To me, it did not look at first glance like it could be efficacious.  Although I did take the course,

(my biased opinion from so many previous failed minimally invasive procedures) I was not overly

Impressed. The procedure looked good on paper, however; so do all of the other procedures above.

One day a patient of mine had read about the procedure, was on medical therapy

Which was not very helpful, and was fairly insistent on having a UROLIFT procedure performed.

I performed the procedure for the patient.  It was time to see him post operatively.  I hesitated

Before walking in the door.  I had butterflies because I expected he would have a less than favorable

Outcome and have had more side effects than what the studies had shown.  To my surprise,

I asked how he was doing??

“GREAT”

Did you have problems with the recovery?

“WHAT   RECOVERY?”

So you are happy?

“VERY  HAPPY”

Now trust me, I read medical studies, I use medical studies to help me make decisions etc. etc.

However, my criteria for a procedure to be successful is not the P value the statistition assigns to

Whatever is being studied.  My personal criteria is “are you happy?”  “would you do it again or

Recommend this to a family member or good friend?”.

That is exactly why I recommend UROLIFT to many of my patients.  Most of my patient’s responses

After surgery are very similar to the above.  Occasionally I have patients that are not happy with the

Outcome, however; the majority of the time it has nothing to do with the procedure itself.  It may be

They got up at night before the procedure and still do.  However, why they are getting up at night

Has nothing to do with their prostate nor the UROLIFT procedure most of the time.

Urolift offers excellent relief of obstructive urinary symptoms.  It can be performed in the office

Setting very safely.  It can be done with no anastetic, however; I always go back to my personal

Caveat: “just because you can do something, does not mean it’s the best choice for your patient.’

We use the same type of anestetic used for a colonoscopy under an anestesiologists monitoring.

My patients are comfortable and usually do not even remember coming in the room.

The procedure (I am not sure why but I am supposed to only say “less than an hour”) takes

Lets say…….much less than an hour.  Patients go home right afterwards.  Many with no catheter.

Patients with larger prostates  that can get swelling I send with a catheter overnight.

The procedure is far less costly than a TURP.  The symptom improvement is very similar

To a TURP.   The procedure has been used in the USA for five years and the data still holds up at

Five years.  This is not allowed to be used by the FDA, however; the procedure has been around

For 12-15 years in Germany and Australia with similar findings.  The side effects from the

Procedure are blood in the urine for usually two to three days.  Urgency of urination

For a few days to one week (majority of patients).  Patients will generally see improvement

In their voiding symptoms within the first week or two.  Patients are back to their normal activities

Usually in less than a week.  Minimal discomfort.  Most important and different from even medical

Therapy there is essentially no sexual side effects.  No retrograde ejaculation.  No erectile dysfunction

That has been shown to be related to Urolift.  UROLIFT  truly fits the criteria for a minimally

Invasive procedure for treatment of BPH.

Efficacy comparable to TURP

Less side effects than even medical therapy

No sexual side effects

Much less costly than TURP if done in the office especially.

 

After being around the Urologic community for as many years as I have, it is difficult to

Get me excited about a new treatment for an old problem.  Why?   Most of the treatments

For BPH other than TURP were somewhat less invasive, however; never approached the

Efficacy of the TURP and either had many of the same side effects, or even more irritating

Side effects than TURP.   UROLIFT, however; excites me greatly.  Not all patients with bph

Are candidates, but most fit the criteria.  I offer UROLIFT to nearly all my patients that are candidates

For the procedure because it offers a very safe, effective solution to symptoms of BPH with less

Side effects than even medical therapy.  Far less side effects and markedly improved recovery

Time over TURP.  If you are suffering from symptoms of BPH or the last man at the urinal

And your medicines are not helping or you would like to get off of your BPH medications

Give us a call and set up a consultation.  Ask for Dr. Simoncini specifically.

 

Frank L. Simoncini, DO, FACOS

Southeast Valley Urology/division of Ironwood Cancer and Research

1501 N Gilbert Rd #204

Gilbert AZ  85234

Ph 480-924-7333

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