Recurrence of enlarged prostate after surgery

A team of urologists at Columbia Asia Hospital, Kolkata give an outlook about the problems faced by patients with enlarged prostate

70-year-old Abhirup Biswas (name changed) of Bangur came to Columbia Asia Hospital, Kolkata with signs of obstruction to urine flow, poor stream and incomplete emptying of bladder, despite having undergone a surgery for an enlarged prostate five years ago. “I thought I would be free of most symptoms but the problems recurred.” He rued, as he made his way to the doctor’s consulting room.

Why did Biswas’s prostate problem recur?

Prostate recurrence does not happen in all men who have undergone surgery. It depends on the age when the surgery took place, the size of the prostate, type of the procedure and completeness of the surgery. In Biswas’s case, he had a conventional open surgery five years ago. Since the enlarged prostate was not removed completely then, it began growing back once again and is now 123 grams over an average 20-30 grams.

Effective surgical option which would have cured him completely was to remove the enlarged prostate.

Five years ago, before the advent of newer procedures like laser, HoLEP and others, the conventional method was done and a sizeable portion of the prostate was left behind. Re-growth is possible in three to five years.

What is prostate and what are the common problems afflicting it?

Prostate is the male reproductive gland that produces the fluid that carries sperms. It surrounds the urethra, the tube through which urine passes out of the body. An enlarged prostate means the gland had grown bigger. As the gland grows, it can press on the urethra and cause urination and bladder problems. Infections, prostate enlargement and cancer are some of the conditions affecting the organ.

Do all men suffer from enlarged prostate?

Enlarged prostate, also called Benign Prostatic Hyperplasia or BPH, is a natural condition and is associated with ageing, probably due to hormonal changes. By age 50, about half of all the men would have begun to develop an enlarged prostate and this condition is likely to continue through the rest of their lives. An enlarged prostate rarely occurs in men before the age of 40. Normal size of the prostate is around 20 grams. It starts growing in size after 45 to 55 years. 50 per cent of the men will face symptoms either directly or indirectly.

What are the treatment options?

This is the one organ in the body which has no one standard treatment because of the complexity of its nature in individual patients. Treatment depends on the age, size of the prostate (normal size is 20 grams), cardiac conditions, patients with cardiac stents, those who are on blood thinning agents or anti-platelets, with irritable symptoms and who are sexually active.

Why is the treatment individualised?

If someone has a prostate enlargement at 50 years weighing more than 50 grams, he might have the potential for the prostate to regrow even after surgery and this propensity increases with larger prostates of more than 80-90 grams, as they tend to recur with age mostly five to ten years later.

Holmium Laser Technique – the Global Gold Standard

According to the urologists, there are five types of lasers to treat an enlarged prostate. This is one organ with multi-modality treatment options including the Holmium laser enucleation of the prostate, also known as HoLEP. HoLEP has been the standard of care worldwide in select high volume centres for those with prostate weighing more than 80 grams.

What makes HoLEP most effective?

The Holmium laser procedure uses laser energy to alleviate symptoms with fewer complications than invasive surgery, by removing enlarged prostate tissue with high powered laser energy. This procedure is generally performed under spinal, epidural or general anesthesia. A miniscule camera is passed through a tube placed in the urethra, enabling the urologists to view the bladder and prostate. The Holmium Laser fiber, small flexible tube, is also passed through the same tube. This operation involves the telescopic removal of obstructing prostate tissue using a laser and temporary insertion of a catheter which is removed the day after surgery in majority of the patients. The laser is used to separate the obstructing prostate tissue from its surrounding capsule and to push it in large chunks into the bladder. An instrument is then used through the telescope to remove the prostate tissue from the bladder. A catheter is normally left to drain the bladder at the end of the procedure. The treatment is usually done in an outpatient setting and may require a catheter up to 23 hours following the procedure.

Post-surgery, patients experience immediate symptom relief, little if any bleeding and can go home the same day.

Advantages of HoLEP surgery for enlarged prostrate

• < Bloodless
• < Painless
• < Brief hospital stay
• < No infection
• < Complete removal possible

Symptoms of enlarged prostate

While the actual cause of prostate enlargement is unknown, factors linked to aging play a role in the growth of the gland. It is so common that doctors say a small amount of prostate enlargement is present in many men over 40 and more than 90 per cent of men over 80 years.

Less than half of all men with BPH have symptoms which include:

• < Dribbling at the end of urinating
• < Inability to urinate (urinary retention)
• < Incomplete emptying of bladder
• < Inconsistency
• < Need to urinate two or more times per night
• < Pain with urination or bloody urine – these may indicate infection
• < Slowed or delayed start of the urinary stream
• < Straining to urinate
• < Strong and sudden urge to urinate
• < Weak urine stream