Older men who suffer from benign prostate enlargement, or BPH, now have a new state-of-the-art treatment option that has them back to feeling better within days. . .

		Urology News Archive Featured in the Media JeffNEWS

Tony DeRose has always lived an active life. At 66, he still works as a meat cutter and makes ample time for his family, which includes his wife Carol, his two grown sons and their wives and his four active grandchildren. DeRose also enjoys assisting his wife with the Shaklee nutritional supplement distribution business they run out of their Mayfair home.

Around his mid-50s, DeRose began experiencing annoying symptoms that worsened over the years. He started to have difficulty urinating. He also woke up to go to the bathroom far too many times during his night’s sleep. During the day, he often felt he had to use the bathroom–urgently and too often–and once he had used it, there was often the sensation that his bladder hadn’t been sufficiently emptied.

He soon discovered that two new laser procedures offered at Thomas Jefferson University Hospital were his best hope for relieving these symptoms, with minimal associated discomfort and a brief hospital stay.

When DeRose’s problems escalated and began to seriously interfere with his quality of life, he sought help through his urologist. His physician concluded that the problem was caused by an extremely enlarged prostate gland.  Noncancerous enlargement of the prostate, termed benign prostatic hyperplasia (BPH), affects men as they age, especially those over 50. DeRose tried a prescription medication but that offered little relief. He considered surgery but when he heard he could be off his feet for weeks afterward, he was not eager to sign up.

That was when his daughter-in-law, Kathleen, a nurse at the Kimmel Cancer Center at Jefferson, encouraged DeRose to look into new options for the treatment of BPH offered at Jefferson University Hospital. DeRose soon met with Jefferson urologist Ramsay Kuo, M.D.

“It was clear that Mr. DeRose’s symptoms directly resulted from a significant case of BPH,” says Dr. Kuo. “BPH is a noncancerous enlargement of the prostate gland. The prostate gland sits at the base of a man’s bladder and surrounds the urethra, or tube that carries urine from the bladder through the penis. If the gland enlarges, it can obstruct the flow of urine.”

More than 50 percent of men over the age of 60 have symptoms from BPH, Dr. Kuo says, and DeRose’s presentation is not uncommon. Symptoms of BPH include a slow urinary stream, hesitancy (a delay in initiating urination), frequency of urination, nocturia (frequent urination at night which awakens men from sleep), and incomplete emptying of the bladder. Longer term problems include urinary tract infections and the development of bladder stones.

When men come to see Dr. Kuo with symptoms of BPH, he conducts a thorough physical exam and obtains a prostate specific antigen (PSA) blood test if the patient has not had one recently, to assess for the possibility of prostate cancer.  Patients with elevated PSA levels require further workup prior to proceeding with surgical options for BPH.  Patients are also asked to complete an American Urological Association test called a “symptom index score.” This test objectively documents the severity of their symptoms. 

Questions on the test include: “Over the past month or so, how often have you had a sensation of not emptying your bladder completely after you finished urinating;”“Over the past month or so, how often have you found it difficult to postpone urinating;” and “How many times do you usually get up to urinate during the night?” A sample of the test can be found at http://godot.urol.uic.edu/~web/ASIS.html. DeRose conducted this test for Dr. Kuo and the results confirmed the significance of his urinary symptoms and their negative impact upon his lifestyle.

According to Dr. Kuo, men suffering from BPH are initially treated by medical means with drugs such as alpha blockers, which relax the prostate and improve urine flow, or 5-alpha reductase inhibitors, which gradually reduce gland size to improve flow. Prior to meeting with Dr. Kuo, DeRose had tried an alpha blocker with disappointing results.

When these options are unsuccessful, the next step for men is possible surgery– one that the very active DeRose did not find palatable. DeRose had heard through friends that the traditional surgery for an extremely large prostate, although effective, often left the patient in recovery –and uncomfortable– for many weeks.

Fortunately, through Dr. Kuo, DeRose learned he was a perfect candidate for the “HoLEP” procedure, one of two new Holmium laser procedures offered at Jefferson.

Holmium laser ablation of the prostate (HoLAP) and Holmium laser enucleation of the prostate (HoLEP) are two options that effectively treat obstructive prostates with little blood loss, no risk of dilutional hyponatremia (a fluid and electrolyte imbalance) and a minimal stay in the hospital.

HoLAP involves the use of a side-firing laser fiber to vaporize obstructing prostate tissue, whereas an end-firing laser fiber is utilized for HoLEP to cut directly into the tissue.  The laser fibers are passed through the urethra into the prostate using a special telescope called a resectoscope.  The unique properties of holmium laser energy allow effective control of bleeding during surgery while limiting the penetration depth in tissue to a minimum–only about 0.4 millimeters.  As a result, the surgeon is able to focus the treatment on tissue that he can visualize, without the risk of collateral injury.

With HoLAP, prostate tissue is vaporized, or ablated, to create a wide open channel through the prostate. HoLEP allows the surgeon to completely remove the obstructing lobes of the gland. The surgeon’s decision to use HoLAP or HoLEP is based on the size of the patient’s enlarged prostate.

Patients also undergo a digital rectal exam (DRE) to estimate the size of their prostate. For a more accurate estimation of prostate size, Dr. Kuo uses a transrectal ultrasound of the prostate. In Dr. Kuo’s practice, HoLAP is utilized for patients with prostates less or equal to 60 cc. Glands larger than 60 cc undergo HoLEPs.

Men who undergo HoLAP generally go home the day of surgery and have their indwelling catheters (used to drain the bladder) either removed the day of surgery or the morning after surgery. HoLEP patients can expect an overnight stay in the hospital but the majority go home the next day without their catheters.

DeRose’s prostate was so enlarged that he required the HoLEP procedure. Despite the fact that he had 150 grams of tissue removed, he experienced minimal bleeding and discomfort afterwards. While most HoLEP patients stay in the hospital overnight, DeRose was observed for an additional day upon consultation with his cardiologist, as he had a history of a recent quadruple heart bypass.

The surgery offered nearly instant relief for DeRose’s urinary problems related to his enlarged prostate. “I feel like I am 25 again,” said DeRose, who also credits good nutritional habits and Shaklee supplements he and his wife use and sell in his recovery. He adds that a positive attitude is essential.

According to Dr. Kuo, the HoLAP procedure has proven to be effective in offering relief for an average of 7.4 years after treatment.  For larger prostate glands, HoLEP has been directly compared to traditional treatments such as transurethral resection of the prostate (TURP) and open simple prostatectomy.  In these comparative studies, HoLEP produced equivalent improvements in patient urinary symptoms with significant reductions in hospital stays, catheterization times, and complications.  HoLAP and HoLEP have minimal re-treatment rates.

Men should bear in mind that it is still possible to develop prostate cancer after a HoLAP or HoLEP. According to Dr. Kuo, “This is because the portion of the prostate gland that causes obstruction and symptoms of BPH is not the same area where prostate cancer tends to develop.”

At Jefferson, Dr. Kuo was the first–and is currently the only–urologist in the Philadelphia area offering these HoLAP and HoLEP treatment options to suitable candidates. For more information or to make an appointment with a Jefferson urologist, please call 1-800-JEFF-NOW.