"Current Options in the treatment of BPH: Role of TUR-P in Present Scenario."

Prostatic enlargement medically is termed as BEP - Benign Enlargement of Prostate - This is an age related process.

Age Group:
This problem usually occurs in the geriatric age group. 70 % of the people above 70 yrs are affected by it.

Symptoms:
The lower urinary tract symptoms (LUTS) in BPH are:

A] Obstructive symptoms: hesitancy, straining, weak stream, sense of incomplete evacuation. These occur during the voiding of urine and are due to increased resistance because of enlarged prostate.

B] Irritative symptoms: frequency of urination, urgency and urge incontinence (ie leakage of urine). These occur during the storage phase of urine and are due to uncontrolled bladder contractions.

Causes:
These symptoms have two components, dynamic and static. The relative contribution of each varies in individuals.

A] Dynamic Component: is caused by the increased tone of smooth muscle fibers in the bladder neck, prostatic urethra, surgical capsule and fibromuscular stroma of the prostate. This tone is maintained by alpha-adrenergic sympathetic receptors. Drugs blocking these receptors relax these muscles and relieve dynamic obstruction.

Alpha-Blockers: The clinical response to alpha-blockers is quick and the plateau is reached in two weeks. The worrisome side effect is "postural hypotension" seen in 3% of patients. To minimize this, the drug is give at bedtime, starting with small dose, which is gradually increased depending on the response & the tolerance. The other side effects include dizziness 8%, asthenia 7%, and headache 1.5%. The latest in this group are Tamsulosin & Alfuzosin.

B] Static component: is provided by the adenoma whose growth is initiated and maintained by dihydro-testosterone (DHT) derived from testosterone. Anti-androgen drugs can interfere with this growth. The latest in his group is Dutasteride

General Treatment & Management:
Assessment of Patient:
     A patient with symptoms of enlarged prostate is assessed both subjectively and objectively. American Urological Association Symptom Index gives subjective assessment. The objective assessment is usually done by digital rectal examination (DRE), ultrasound study and uroflowmetry. In selected cases, urodynamic study may be required. P.S.A. estimation is done as a routine in all patients above the age of 50 yrs.

Mandatory indications for surgery in BPH as per International guidelines are :

1. Retention of urine and failure of at least one catheter-free trial
2. Recurrent urinary tract infection thought to be due to BPH.
3. Recurrent gross Bleeding in urine due to BPH.
4. Renal insufficiency secondary to BPH.
5. Bladder stone.
6. Large bladder diverticulum (out-pouching)

In the absence of above, a patient has the following options depending on his assessment:

1. Watchful waiting
2. Medical treatment with one or more drugs.
3. Surgical intervention which could be a] minimally invasive or b] Invasive.

Surgery:
Trans-urethral Resection of Prostate [TUR-P]:
In this endoscopic procedure, the entire prostate is cut under vision all the way to the capsule of the prostate. Electric energy source is used for cutting of the tissue. Catheter drainage is maintained in the post-operative period usually for 48hrs. The removed tissue is sent for histology. The largest series from 13 institutions world-wide gives following results: mortality:0.2%, 6.4% required blood transfusion, 2% TUR-syndrome,1.2% mild incontinence, 0.5% severe stress incontinence, 90% retrograde ejaculation, <5% urethral stricture & or bladder neck stenosis, 10-20% chance of re-operation within 5-8 yrs.

The newer developments such as continuous-irrigation resectoscope, macro-lens telescope, use of video camera during surgery and better electro-surgical units have made the TUR-P surgery easy to perform and easy to teach. This has reduced the rate of complications even further. In vast majority of patients, a good resectionist can perform excellent TUR-P with minimal blood loss not requires blood transfusion & minimal absorption of irrigating fluid not causing TUR-syndrome.

In addition, the advantages of TUR-P over laser surgery are:

• Less expensive, the cost of additional day in the hospital is far less than the additional cost for use of laser equipment.
• Tissue is obtained for histology hence an unsuspected focus of carcinoma in not missed,
• The depth of resection is controlled thus giving excellent immediate and long-term results.

Symptoms of frequency and urgency persist after TUR-P and the blame wrongly placed on surgery. These symptoms are due to the Bladder instability, which may be primary or secondary to obstruction. The treatment is drugs after relief of obstruction.

Open Prostatectomy:
     The only method that significantly minimizes the chance of re-growth in larger adenomas is open prostatectomy. Though the mortality of open surgery has reduced over the year, elderly patients with cardiac and respiratory problems are high-risk patients. It is more prudent to take the chance of re-operation 5-7 yrs after TUR-P than to risk to life.

     It has been seen that with change in surroundings, like after traveling, patients who are suffering from BEP & are borderline cases do land up in acute urinary retention & that to in a new place where they have traveled to. There they do not have their medical record in case it is required to consult a doctor. So it is good if they understand there disease process & take appropriate measures.

     In earlier days the only definitive treatment for BPH was open surgery to remove the adenoma. High-risk patients were left on catheter drainage for retention or large residual urine. In 1930s came a revolutionary development of Trans-Urethral Resection of the Prostate (TUR-P) as an alternative to open surgery. Initially, TUR-P could be performed for only small prostates. Refinements in instrumentation and technical know-how soon made it possible to apply this technique to even larger prostates.

     TUR-P substantially reduces the mortality and morbidity of surgery. Patient acceptance was good and for almost fifty years thereafter, urologists did not look for alternative methods of treatment instead the emphasis was on improvising the equipment so as to make TUR-P easy to learn and easy to perform.

     In 1980s there came an unexpected upsurge of interest to find alternative approaches to the management of BPH. There were two reasons for this-- one was the realization of economic impact of TRU-P surgery in ever increasing aging population on the government financed health care system and the other was the new knowledge about the pathogenesis of bladder outlet obstruction.

In summary, a good urologist is an astute clinician and a good craftsman. He not only should perform surgery well but also must select the proper option for his patient. Medical treatment has reduced the requirement of surgery to a great extent. However, when surgery is indicated, TUR-P is the "Gold Standard" in majority of patients. Open surgery is reserved for very large adenomas in a younger (<60 yr.) and otherwise healthy patients.

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