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Urology/self-catheter and “GreenLight" Prostate laser surgery

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Question
Dear Dr. Goldstein,

My urologist after cystoscopy advised me that I have a large middle lobe of prostate causing obstruction at the bladder outlet that is preventing me from voiding on my own.  I self-catheter 3 times at night from 11pm to 8am and one time about 4pm for more than 2 months now. I use a size 14 self-catheter and most of the time when I insert it 2/3 of the way some urine rushes out from around the catheter and I wait till they get out then continue inserting the cath to the end and drain the rest. My CMG test showed that my bladder muscle is OK.

1- I would like to ask if the urinating pattern I described fits the cystoscopy finding I have been told for having “large middle lobe of prostate causing obstruction at the bladder outlet?
2- I am a 61 year old male with good health (except for this problem). For my case, do you recommend “GreenLight" Prostate laser surgery over TURP/TUIP?
3- What are the possible disadvantages of GreenLight that dictates to go with TURP/TUIP?

Best Regards,
Ivan.

Answer
Ivan, you do not have a "urinating pattern" as from what you described, you do not void on your own having to rely on catheterization.  I generally recommend that patients on self catheterization use the technique around the same number of times they would normally void.  This would be about every 4-5 hours during the day and once at night.  

Certainly a large middle lobe can cause significant obstruction to the flow of urine.  On cystoscopy, one generally notes marked thickening of the bladder wall which is called trabeculation.  Absence of this suggests that the bladder muscle is rather flaccid but you normal CMG suggests that this is no so in your case.

The following article from Harvard compares the relative value of TUR of the prostate compared to green light laser therapy:  The comparison below is from this article.

http://www.harvardprostateknowledge.org/harvard-experts-discuss-surgical-options

Transurethral resection of the prostate (TURP):

Performed in operating room
Requires general or spinal anesthesia
May spend one to two days in hospital, with catheter inserted to enable urination
Heavy physical activity may be restricted for two weeks or more to prevent bleeding
Full recovery may take four to six weeks
Provides symptom relief in 70%–85% of men treated   
6% or fewer men will experience erectile dysfunction
May cause ejaculatory problems
Blood loss, urinary incontinence, infections, and complications from anesthesia are less common but do occur

Photoselective vaporization of the prostate (PVP or GreenLight):
  
Most patients treated in outpatient setting
Catheter remains in place at least overnight for most patients
Can resume light activity and return to work within two to three days
Can resume vigorous activity in four to six weeks
Improvement in symptom relief similar to TURP   
Ejaculatory problems similar to TURP
Less bleeding than TURP
Urinary frequency or urgency in first month may be more troublesome (temporarily) than after TURP

The choice is best left to the preferences and experience of the surgeon.  To follow is some information I have written on the treatment of BPH that may be of interest to you.

Benign enlargement of the prostate gland (benign prostatic hyperplasia or BPH) occurs to varying degrees in all men as they age.  The prostate surrounds the urinary canal (urethra) just after its connection to the urinary bladder.  Inward growth of the prostate either into the bladder neck (opening) or into the urethra itself can cause difficulty with urinating.  The prostate is checked by digital examination through the rectum.  This gives the doctor an idea as to the size and benignity of the gland.  However, it does not always correlate to symptoms as a small gland may have significant inward growth and a large glands enlargement may be entirely peripheral.   

The ability to urinate involves the urinary bladder muscle actually becoming stronger as it works against increasing resistance from the prostate.  This delicate balance can be upset by any factor that decreases the bladder muscles ability to contract with sufficient force to open the prostate (such as medications, anesthesia, too much alcohol, ignoring the desire to urinate, etc.) or those factors that might cause the prostate to suddenly swell (ie acute prostatitis, sitting  for extended periods of time, biking,
horseback riding, etc.). The typical symptoms that occur include diurnal frequency (daytime), nocturia (night-time frequency), urgency, hesitancy, slow stream and dribbling after voiding.  This complex of symptoms is termed “prostatism”.  If the obstruction to flow progressively worsens, the bladder eventually may not be able to empty completely.  This leads to the accumulation of “residual urine” which may predispose to urinary infections and  kidney damage from back pressure.

However, relatively asymptomatic men with BPH do NOT necessarily require therapy.  Treatment is indicated to relieve symptoms and prevent complications.  In many cases medications can be used.  Alpha - blockers (ie Hytrin, Cardura, Flomax, Uroxatral etc.) work by relaxing the bladder neck and urethra so the pressure generated by a bladder contraction has less resistance to work against.  Natural herbal products such a saw palmetto and pygeum often provide symptomatic relief but the exact mechanism of action has not yet been defined.  The prescription drugs Proscar and Avodart actually shrink the prostate.  They work best in the larger glands and improvement may not be noted for up to 6 months.   In cases refractory to medication, interventional measures are indicated.  The “gold standard” for treatment is the time honored transurethral resection (TUR) of the prostate.  For huge glands, open surgery may be necessary.  In the past 20 years a number of other less invasive interventional therapies have been developed to reduce the obstructing prostate tissue utilizing various forms of energy.   These include laser prostatectomy (green light), microwave (TUMP or transurethral microwave of the prostate), and radiofrequency (TUNA or transurethral needle ablation of the prostate).  TUMP & TUNA actually are minimally invasive, out-patient treatment that can be tried initially if the patient's gland size is appropriate.  

Here is an explanation of a TUR of the prostate gland.  The prostate gland can be thought of as being composed basically of three parts which from inside to out are: the prostatic portion of the urethra (urinary canal), the prostatic glandular tissue causing the obstruction (adenoma) and the compressed capsule of the prostate.  In a TUR, the prostatic urethra and adenoma are removed leaving only the capsule.  This surgery can be likened to coring out an apple from the inside leaving only the skin.  The prostate is resected into many tissue slivers which wash into the bladder and then are removed at the end of the operation by suction.  This leaves a raw bed, which, over a period of 6-8 weeks, regenerates a new urethra!  At the termination of the procedure, one can look from the far end of the prostate into the bladder without residual obstruction.  A catheter is left in for a few days to drain the bladder and to initiate the healing process.   Good luck!

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Arthur Goldstein, M.D.

Expertise

Problems or questions related to the field of urology; ie urinary stone disease, urinary cancers (kidney, bladder, prostate, testis, etc.), urinary infections, etc. I no longer answer questions related to erection problems or male sexual dysfunction.

Experience

I am retired from the active practice of urology. My 34 years was totally in the clinical field and involved the entire gamut of genitourinary problems, with special interest in endourology.

Organizations
American Medical Association, American Urological Association, American College of Surgeons

Education/Credentials
College degree - BS Medical degree - MD Master of Science - MS

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