Introduction: What is benign prostatic hyperplasia?


The term prostatic hyperplasia indicates a pathophysiological event of the prostate gland increasing in size connected to the onset of particular voiding symptoms that affect humans in the course of the aging process.


Despite intensive studies carried out over the past 5 decades, aimed at discovering the causes of prostate growth, there is still no comprehensive report of cause and effect. Conventionally, it comes to benign prostatic hyperplasia (bph) to indicate this process; whether the concept of benignity always requires histological confirmation (biopsy and/or tissue taken during surgery) otherwise the term would be improper and it would be better to speak only of prostatic hyperplasia.


The prostate gland is the deputy to the production of most of the seminal fluid, thus covering a critically important role in male fertility. It is located below the bladder, which is the organ that functions as a reservoir for urine, and completely surrounding a urethral tract, or the conduit which carries urine from the bladder to the outside of the body through urination.


In the majority of the Western male population, usually starting from 30-40 years of age, the prostate gland begins a dimensional growth process, due to a series of individual hormonal changes. The increase in size of the prostate gland is moderately slow and progresses with advancing age of the subject sometimes reaching considerable volumes: from the size of a chestnut, typical of a man at a young age, the prostate may indeed grow as large as a large mandarin.

Symptoms: How can you realize you are suffering from prostatic hyperplasia?


The enlargement of the prostate gland is a common cause for problems with bladder emptying, and consequently creates a series of annoying problems related to urination.


You can have irritative disorders, characterized by the need of having to get up several times at night to urinate (nocturia), having to urinate more frequently even during the day (urinary frequency) or by the need to rush to urinate as soon as you experience the first stimulus (micturition urgency) with occasional urine leakage (urge incontinence).


There may also be interference due to real mechanical obstruction to urination (obstructive), such as the hesitation when you start to urinate (especially in the morning when you wake up), a weak or intermittent urinary stream (sometimes patients report that they fear wetting their shoes while urinating!), the sensation of incomplete bladder emptying (and consequent abdominal tension) as well as the annoying dripping at the end of urination.

Epidemiology: How common is benign prostatic hyperplasia?


Although the process of enlargement of the prostate gland affects the majority of men over 40 years of age, its symptomatic manifestations (irritative and obstructive) are established gradually over time, initially manifesting as occasional inconveniences until they become bothersome, annoying, and shameful problems that can significantly worsen the quality of life.


An important surveillance study conducted in the US showed that the prevalence of prostatic hyperplasia is moderate by 17% in men 50-59 years of age included in this group, 27% in a group of 60-69 years of age and 37% in the 70-79 years group.


European studies have shown that the overall prevalence of prostatic hyperplasia is 11.8%, varying from a minimum of 0.8% in the thirties to a maximum of 32% in the ultra-seventies.


In summary, the prevalence of urinary symptoms of moderately to severely, taking into account more than 65,000 subjects analysed in 17 different international studies completed in the nineties – two thousand men with an average age of 65 years appear to vary from 14% to 43% with a weighed mean value of 37% (more than 1 out of 3 men!!!!).


Diagnosis: How is it diagnosed benign prostatic hyperplasia?


In most cases, a simple conversation with the patient (anamnesis) focused on some specific questions and the visit (digital rectal examination) are sufficient for the specialist to identify a condition of prostatic hyperplasia.


There are other useful tests for the diagnosis of BPH such as blood PSA (prostate specific antigen), Uroflowmetry with evaluation of post-void residual (in order to objectify the urinary flow and to verify any failure to empty the bladder after urination) and transrectal prostate ultrasonography (to precisely evaluate the prostate volume in anticipation of possible unobstructive intervention).


Treatment: How you treat benign prostatic hyperplasia?


Urinary disorders related to prostatic hyperplasia can often be treated with reasonable success with different types of drugs. Although these are generally well tolerated, however, they are not completely free from side effects, which may include excessive decrease in blood pressure (orthostatic hypotension), temporary loss of ejaculation to the outside and ascent of the sperm into the bladder (retrograde ejaculation), decreased sexual desire and other less frequent side effects.


Although medical therapy has an important role in the treatment of prostatic hyperplasia, when it comes to establishment of a real disorder and urinary obstruction due to prostate enlargement, medications can usually be insufficient and the patient may need an unobstructive surgical intervention.


Historically, the type of surgical approach was to open with a suprapubic incision (adenomectomy). It has later been gradually supplanted by the development of endoscopic techniques, in which access to the prostate is transurethral (TURP – trans-urethral resection of the prostate).


In the recent years, treatment has gradually taken hold in the international field using a new endoscopic technique of prostate laser reduction including the Holmium called HoLEP (Holmium Laser Excision of the Prostate).


HoLEP: How We treat benign prostatic hyperplasia?


In the Hospital San Raffaele Turro, at the Urology Division, in the first years of the new millennium, our experience has led us to abandon traditional surgical techniques mentioned above in favor of this new method. Currently, the overall operating series boasts several thousand patients, since the procedure has become part of daily practice of our team. The real benefits of this type of methodology are identified in the great advantages of the Holmium laser:


§  It is able to cut and coagulate

§  It is effective on prostates of large volumes

§  The patient benefits from the removal of the bladder catheter only 24 hours after surgery

§  Important reduction of postoperative bleeding


This technique consists of administering anesthesia to the patient (usually spinal i.e. without the need to completely numb the patient) and introducing a thin instrument that contains an optical fiber for vision and the Holmium laser fiber.


The urethra is lifted up to the level of the prostate, where the laser enucleates its central portion (called adenomas – the main cause of symptoms), which is then reduced into small fragments (morcellation) and removed through the same tool.


After the procedure, which lasts an average of 45-60 minutes (relative to the prostate volume), a bladder catheter is placed, which is usually removed the next morning. The patient is then able to leave the hospital as early as the same day.


The Scientific Institute San Raffaele in Milan contributed to the completion and publication in prestigious international journals of numerous studies comparing the new endoscopic technique performed using the Holmium laser (HoLEP) and the traditional endoscopic resection technique, defined usually with the Anglo-Saxon abbreviation TURP (Trans Urethral Resection of the Prostate).


The result of these studies, as mentioned above, showed that both methods are effective in curing the patient from his disturbed state. However, for the benefit of the laser technique, the result is the early removal of the bladder catheter in the postoperative time combined with the absence of pain/discomfort and a shorter hospital stay. In addition to the method with Holmium laser, it allows to minimize the intraoperative blood loss completely avoiding the need for subsequent blood transfusions.


The HoLEP method solves prostatic obstruction even in cases of very massive prostates, completely endoscopically and without making any incisions. Therefore, it is considered a minimally invasive, painless technique that is well tolerated by the patient. The Holmium laser also provides the great advantage of being able to be used effectively for the treatment of prostatic adenomas that are very voluminous (over 100 grams of weight) for which, in the absence of the laser method, the only solution would be the traditional open surgery (i.e. with surgical incision of the abdomen). In these cases, the advantages of the Holmium laser are even more evident since with the traditional intervention the catheter must be maintained for 4-5 days, necessarily entail a longer hospitalization and definitely a more bothersome post-operative course for the patient.


In patients treated with HoLEP one can always run a precise examination of the removed prostate tissue. Considering the progressive increase of cases of prostate cancer in the last twenty to thirty years, the great advantage of the opportunity to always perform the histological examination is immediately evident. It is important to point out that similar laser methods available today, in addition to providing functional results decidedly inferior to those of the Holmium laser, they do not allow an analysis of the removed tissue, with the consequent risk of not recognizing cases of occult prostate cancer.


After discharge, the patient can see almost immediate improvement in the quality of their urinary stream and the disappearance of the sense of incomplete emptying of the bladder (obstructive symptoms). The irritative symptoms (small heartburn, moderately increased micturition frequency) and small traces of blood in the urine tend to disappear usually within two to four weeks after the procedure.


The onset of the classic traditional post surgery complications (TURP) such as urinary tract infections, hematuria, and acute retention of urine may still occur even after laser method (HoLEP) but with much lower incidence and are still easily manageable and solvable.


Retrograde ejaculation (i.e. the non-issuance of sperm during orgasm) tends to occur after HoLEP, which is not dissimilar than the traditional TURP procedure. It should be stressed that this issue is often already present in simple medical therapy patients. One possible way to overcome this disadvantage is the use of cryo-preservation of the seed prior to the intervention. It is also important to highlight how the erectile and orgasmic function are not at all influenced according to studies that suggest steps such as improving urinary symptoms in some patients may be related to a better sexual function. More severe complications, such as the onset of a modest urinary incontinence, are described in the literature but are limited to less than 1% of patients.


The patient is then monitored at Our Division with initial check ups of three-six times a month and then yearly, which usually entail blood tests (PSA), Uroflowmetry with evaluation of post-void residual and Ultrasound of the Lower Abdomen. All exams and post-operative visits can be organized at Our Facility.


Finally, the Holmium laser and the HoLEP method are therefore the less invasive and more effective treatment option for patients with benign prostatic hyperplasia with obstructive symptoms, which do not respond or only partially respond to drug treatment.