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Urology/Surgery again or medications for a recurrence of elderly age BPH?

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QUESTION: My 85 years father ever had BPH surgery 20 years ago to correct his BPH prostate enlargement problem. But the prostate is enlarged again. He has been hospitalized and placed a catheter in his urethra for month to prevent from urinary retention and infection. He has other common elderly diseases such as high blood pressure, type 2 diabetes. In my fatherís age, what is the best treatment option for him, medications or surgery again? If the medications, what medication may work best for him? If the BPH surgery is better, is the laser surgery the best choice or TURP?  Thank you for your answer.

ANSWER: Ryan,
I am huge advocate of laser surgery as you may have read, there are cases when the laser is not the best choice also. Being your grandfather is 85 and his health is less than optimum I would say that the Green Light laser preferably an HPS or XPS unit is his best option. Let me explain a bit about thermal physics and surgery.

A TURP is done with a electrocordery loop , this is a wire that is in a loop shape that becomes red hot and is able to cut tissue at high energy and then low energy for cauterizing tissue. A surgeon will put the loop through a large 22-24 french resectascope as its within the penis and prostate to visualize the surgery as glysine or sugar water is circulated in the bladder and out of the outflow of the scope. This allows the bloody water to clear and keep good visualization while the urologist works at cutting out tissue. They must make two swipes for every piece of prostate removed once for a cut and the other to coagulate or cauterize. This procedure causes a decent amount of blood loss as between each swipe water seeps in the vessels and blood seeps out. After the surgery the patient is cathiterized with a 22-24 and even 26 french catheter and in many cases with CBI or constant bladder irrigation, meaning the circulation of glysine continues while the gland still bleeds and clots. This has been the gold standard to resect a prostate for many many years.

Now all lasers do not do the same thing and there is a reason I researched and use a Green Light laser. There is two kinds of laser TURP 1st generation is called a laser ablation of the prostate that is done with a holmium laser the procedure is called HOLAP or holmium laser ablation of the prostate. This laser targets water as its chromophore and boils it in an instant with subsequent explosion of the tissue and pieces break off. The problem is it fogs your visual field trying to ablate tissue in a so called snow storm. We all know how much fun driving in a snow storm is. The other issue is it does not optimally coagulate tissue from bleeding  but does a fair job. The thermal penetration is excellent with a holmium laser but its a very slow process leaving the patient under anesthesia longer.

The Green Light laser from American Medical Systems is the Ferrari of lasers now let me explain. 1st the GL works off a 532 nm wavelength which is known to target red, blue and brown colors.Red is the key word as blood is red and this laser attracts to it and absorbs it as its chromophore. In this process since tissue is saturated with blood the laser goes after all bloody tissue. Now this laser does not ablate tissue or explode it , this actually vaporizes the tissue into nano particles smaller than the eye can see. The scope used is a 17-20 french cystoscope like used in the urologists office, much smaller than the resectascope. This circulates saline through the scope into the bladder and out of the outflow port usually crystal clear like clean water. How does it do this you ask? Well the laser can vaporize tissue and coagulate tissue virtually causing tiny to no blood loss at all. No blood loss is a good thing huh! Well its even better than that , its thermal penetration is similar to holmium where as the vaporization takes place the remaining tissue is left uncooked in pristine condition. As a result no significant swelling of tissue takes place and therefore cathiterization is used for 1 day after or not all and never is CBI necessary. After PVP (photoselective vaporization of the prostate)there is little or no pain at all to need narcotic pain meds. The patient goes home right after surgery or can have a 24 hour observation in the hospital unlike TURP that requires a 3 day hospital stay. (bigger hosp bill)

The choice for most men is crystal clear just like the irrigation during the surgery that comes out of the scope. I think your grandfather will do great if he can have the PVP procedure done by a skilled laser surgeon. I would look at the AMS website www.greenlightforbph.com  and find a PVP certified surgeon for the case. Good luck and my prayers are with yall !

---------- FOLLOW-UP ----------

QUESTION: Thank you for your answer. It seems my father has to go for the surgery again but by the PVP. I have a follow up question about the catheter. How long can the catheter usually stay in? My father has been placed a catheter for one month. Are there any potential problems/risks if a catheter stayed in long time?

Answer
Ryan
He needs that cath changed now a month is long enough , indwelling catheters develop infections, encrusted debris and are very uncomfortable for the patient. Demand the cath be changed and make sure prophylaxis antibiotics like Cipro or Levaquin are given even for 2-3 days if he is not infected now, bc after the cath comes out he most likely will develop a UTI.  

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Thomas A Suppe RDMS CLT

Expertise

Invervential urologic radiology , urologic laser surgery, cryotherapy of the prostate and kidney, extracorporal shockwave lithotripsy, holmium laser lithotripsy, urodynamics (video-non video),male infertility, erectile dysfunction, Peyronies disease, hypogonadism ,kidney stones, prostate cancer detection, BPH, voiding dysfunction, bladder cancer and continent diversions.

Experience

For the past 20 years performing intervential and diagnostic uro-radiology for a multitude of urologic surgeons from New York, New Jersey, Lousianna and Texas. Founder of DMS medical LLC introducing the Texas Medical Center to the first high power Green Light laser for the treatment of BPH just after its release by the FDA from Laserscope and its sucessful trials at the Mayo Clinc.

Organizations
American Registery of Diagnostic Medical Sonographers (ARDMS), American Urologic Assocoation (AUA), American Medical Systems (AMS) Laserscope,Oncura, Allergan and Auxilliam pharmaceuticals.

Publications
Comprehention of Urologic Ultrasonography for the Resident Physician (Journal of Urology 2012), Author of the syllabus for the uro-radiology residency course at The Scott Dept of Urology at Baylor College of Medicine Houston Texas (2010 to present). Past Clinical Studies: Principal radiology investigator Allergan Inc for "The treatment of BPH with intra-prostatic injections of Botox" with Larry I Lipshultz MD 2011-2012, principal radiology investigator for Allergan Inc for "The treatment of Peyronies disease by intra-lesional penile injections of Botox" with Mohit Khera MD MBA MPH (2011-2012). Current studies: Principal investigator of "Blood pressure risk factors of intra cavernosal injections of Trimix and PGE1 during Penile Duplex's.

Education/Credentials
BS from Ramapo College of NJ, Registered diagnostic medical sonographer with the ARDMS, 2 year fellowship of Uro-Radiology and intervential sonography at Baylor College of Medicine Houston TX, laser safty officer in state of Texas and certified in KTP, Holmium and Lithium Tri-boride laser systems from Laserscope San Jose, California and American Medical Systems Minnatonka Minnasota, trained and certified by Oncura Inc Isreal in ultrasound guided argon cryotherapy of the prostate and kidney.

Awards and Honors
Honorary instructor of GU ultrasound course 2012 international meeting of the American Urologic Association. Author of the the AUA course for "Ultrasonography of the Testes and Scrotum" 2012.

Past/Present Clients
Baylor College of Medicine (BCM) Lousianna State University (LSU), LSU Medical Center Shreeveport LA, The Methodist Hospital Houston Texas, St Lukes Episcopal Hospital Houston Texas, Memorial Herman Health Systems Houston Texas, Palestine RMC Texas, Doctors Regional Hospital Corpus Christi Texas, Valverde Regional Medical Center DelRio Texas, Current instructor/technologist for two internationally recognized urologists : Larry I Lipshultz MD and Mohit Khera MD, MBA, MPH at Baylor College of Medicine. I served as intervential sonography consultant for Oncura Inc cryotherapy systems. Former lead trainer for Urosource mobile medical services , training new surgeons in PVP or photo-selective vaporization of the prostate for BPH, BNCs and urethral stricture vaporization.

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