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.
The enlarged lobes of the prostate physically block the flow of urine
The muscle and prostate tissue squeeze down on the prostate obstructing the flow of urine.
Each type of obstruction can cause symptoms of BPH.
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 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.
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.
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
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
Interstitial Laser Treatment
Ballon Dilation of the Prostate
Holmium Laser of the prostate
Vaportrode of the prostate
Trans urethral needle ablation of the prostate (TUNA)
Microwave Prostate therapy (TUMT)
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.
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??
Did you have problems with the recovery?
So you are 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
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