Benign prostatic hyperplasia - also called BPH - is a condition in men where the prostate is enlarged but not cancerous. Other names are benign hypertrophy or benign prostate enlargement. The main symptom of BPH is difficulty urinating, and reduced urine flow can lead to inability to urinate (urinary retention).

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Benign prostatic hyperplasia affects about 50% of men between 51 and 60 years old and up to 90% of men over 80.

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As the prostate slowly enlarges over time, it presses on the urethra. Narrowing of the urethra leads to reduced urine flow, difficulty urinating, and urine retention in the bladder (inability to fully empty the bladder). Typical problems with an enlarged prostate include frequent urination (eight or more times a day), nighttime urination (nocturia), weak or interrupted urine stream, involuntary leakage (urinary incontinence), and the most severe symptom - inability to urinate (urinary retention - an emergency).

Over time, due to difficulty emptying urine, the bladder wall thickens, the bladder weakens, and loses the ability to fully empty. The urine that cannot be emptied is called residual urine (RU). In the worst cases, urine backs up into the kidneys (hydronephrosis), and the kidneys lose function (urea and creatinine accumulate in the blood).

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How is benign prostatic hyperplasia diagnosed?
Diagnosis is easily made with a prostate ultrasound. Usually, a prostate size of 40-45 grams (milliliters) is considered enlarged.

Urethroscopy is planned when a man has a small prostate on ultrasound (up to 40ml) but has difficulty urinating that is not resolved with medication.

A biopsy is performed when PSA tumor marker levels are abnormal (especially monitoring the PSA index).

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When do I need surgery for an enlarged prostate?
Surgery is planned when medications for BPH no longer resolve urination problems. Indications for surgery are based on subjectively and objectively poor urination or complete inability to urinate.

Thus, prostate size alone is not the only indicator of whether you need surgery. Sometimes a very small prostate of about 30 grams can cause major problems, while large prostates over 120 grams may not cause significant issues.

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What type of prostate surgery do I need?
Surgery through the abdomen, so-called PTV, is an outdated procedure, and if someone suggests it, please seek a second opinion.

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Now it is common for all prostate adenomas, regardless of size, to be operated on through the urethra, but prostate surgery can also be performed through the perineal skin without damaging sensitive structures of the urethra and prostate.

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Bipolar transurethral resection and vaporization of the prostate (B-TURP, B-TUVP)
The bipolar device has two electrodes at its tip, between which plasma is created for resection and vaporization of prostate tissue, so this method can be called plasma resection/vaporization of the prostate. The advantages of this method are many: no time constraints (no risk of TUR syndrome), so much larger prostates can be treated, incomparably precise bleeding control (almost no blood loss in these procedures), minimal unwanted damage to surrounding tissues (no parasitic currents), the device itself is smaller (22-24Fr), much more precise, and less invasive. Bipolar TURP is currently the first choice of all urologists worldwide, even if they have access to a prostate laser. Besides precision, urologists prefer this device for its cost-effectiveness. This device is significantly more economical than any laser used in prostate surgery, yet using a bipolar plasma device does not reduce surgical outcomes compared to what can be achieved with a laser.

Removing prostate tissue through the urethra allows normal urination. Although this surgery achieves good urination quality, almost 100% of men experience permanent and irreversible loss of ejaculation after such surgery.

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The TPLA procedure has proven to be truly minimally invasive. It ensures urination quality without damaging ejaculation.

The most modern procedure for treating an enlarged prostate is TPLA. This procedure treats the enlarged prostate while preserving the ability to ejaculate after surgery. This is the biggest difference compared to all other procedures, where 100% of cases result in ejaculation damage.

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Transperineal laser ablation of the prostate (TPLA)
The newest globally recognized and accepted method for surgical treatment of BPH is transperineal laser ablation of the prostate (TPLA). This is the only method that does not enter the urethra to treat prostate tissue. It is also the only method performed with millimeter precision under ultrasound guidance. Laser fibers are precisely guided through the perineal skin to the prostate via ultrasound through thin 19G needles. The laser fiber width is 360nm, which, in addition to extreme precision in treating benign prostatic hyperplasia, ensures almost no complications that can occur with other procedures. This approach treats all prostate segments without damaging urethral tissue, the urethral sphincter, rectum, or bladder, making this method far superior to all previously mentioned surgical techniques. This method resolves urination problems while preserving ejaculation. The downsides of this procedure are a relatively longer catheter use period compared to other procedures and the possibility of prostate regrowth 10-15 years after surgery.

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​Read more about surgical treatment of BPH

 

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Evaluation of all patients for prostate adenoma surgery includes:

• Detailed medical history

• Ultrasound examination

• Urine analysis

• Urethro-cystoscopy

 

All prostate surgeries are typically performed under general anesthesia but can also be done under spinal or even local anesthesia if needed.

 

The procedure itself lasts about 30 minutes for TPLA and around 2 hours for other techniques (surgery duration depends on prostate size).

 

Hospital stay is until the next day. The urinary catheter remains for several days after resection/vaporization procedures, while TPLA requires 7-10 days of catheterization.

 

After catheter removal, urination quality is monitored through regular ultrasound follow-ups.

 

All mentioned procedures significantly improve urination, but only TPLA preserves ejaculation function.

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