Arguably, it's more trouble than it's worth: a walnut-sized gland just downstream of the bladder that facilitates the transfer of sperm during intercourse. However, the ride that's provided is hardly a free one.
By age 50, half of all men come down with what's called benign prostatic hyperplasia, or BPH. And by age 80, 90% percent of men are said to have it.
To be sure, BPH is not the same as prostate cancer, a disease that annually kills 42,000. Nor is there any evidence to suggest that the former triggers the latter. Still, even without the threat of malignancy, BPH can wreak havoc on a man's plumbing. The condition first manifests itself as a need to urinate more frequently and can lead to painful infections, bladder stones, or even a complete urinary shutdown.
The actual mechanics of the condition are pretty easy to understand. As a prostate ages, it tends to grow larger. It also tends to tighten its grip around the urethra, obstructing the flow of urine. Meanwhile, upstream, the ability of the bladder to thoroughly empty itself is compromised, increasing the need to urinate more often. Not everything about this disease, however, is so simple. For example, the actual size of a prostate seems only roughly correlated to the onset of symptoms. Moreover, while the occurrence of urinary difficulties tends to be gradual, the disease does not always progress in such an orderly fashion.
Urinary Shutdown Followed Infection
Several years ago, a man in his early 50s we'll call Richard Wade was told by his San Francisco Bay Area doctor that he had an enlarged prostate, but not to worry since he experienced no symptoms. Then, in 1996, Wade, who didn't want his real name used, underwent a hernia operation, after which he came down with an infection of the esophagus. The next thing he knew he couldn't urinate at all. Subjectively, Wade feels there was a causal connection between his infection and the shutdown. Doctors aren't so sure. But the bottom line was that he now had a severe case of BPH that required surgery.
The standard surgical procedure for BPH is transurethral resection of the prostate (TURP). The procedure calls for inserting a hot wire loop through the urethra. This loop emits an electrical current that cuts through the prostate gland like an electric knife. Among urologists, TURP is still considered to be the gold standard for BPH patients. But Wade, who had earned a PhD in political science, was inclined to do his homework on the topic. And in light of what he found out, he wanted no part of it.
He learned, for example, that there was a distinct, though relatively small chance of becoming either incontinent or impotent from the operation. He also knew that almost all TURP patients end up ejaculating backward into their bladders during intercourse--a permanent condition that, as a practical matter, renders one infertile. Having been married once to a woman with whom he had no kids, Wade still entertained the idea of raising a family someday.
"As crazy as it sounds," he says, "I didn't want to lose that option."
So Wade made a break with convention. Instead of surgery, he elected to walk around with a catheter connected directly to his bladder and a bag strapped to his leg. He lived with that indignity for about four months. Then he learned of a minimally invasive procedure just approved by the FDA that avoids cutting by directing heat to the prostate. It's the latest thing in BPH treatment and it seemed to offer Wade everything he was looking for.
"I call these designer procedures, and, personally, I still consider them investigational," says Dr. Gerhard Fuchs, a professor of urology at UCLA who has observed and pioneered the use of a number of minimally invasive options over the last decade, beginning with lasers then moving on to microwave and radio wave-based technologies--all of which deliver heat to the prostate in a highly targeted way. "These are technologies that are being driven by the patient," he adds.
Technique Described as 'Cooking the Prostate'
Dr. Harcharan Gill, associate professor of urology at Stanford University, agrees. Gill evaluates new surgical technologies and has helped develop one of the first lasers used for BPH surgery. "Basically, what we're doing here is cooking the prostate," he says of these heat-related therapies.
Compared to cutting, cooking is a lot less bloody. Also, the procedure can be done under local anesthetic. And while TURP patients generally need from one to three days of hospital recovery time, the newer procedures can be done on an outpatient basis--something that insurance companies as well as patients are likely to warm up to.
But perhaps the most impressive thing about minimally invasive prostate surgery is that those who go through it seem to experience fewer post-operative complications, specialists say. This is particularly striking when it comes to retrograde ejaculation. While up to 85% of TURP patients are left with dry orgasms, only 10% to 15% of those who are treated with the newer procedures show any sign of this phenomenon.
Still, experts agree that thermotherapy has a way to go before it can supplant TURP on a large-scale basis. One concern is because these procedures are so new, there is no way to know whether the positive results that are attained will sustain themselves over time. Nor is thermotherapy for everyone. (Indications are that men with the largest prostates are poor candidates.)
And while minimally invasive procedures are somewhat cheaper than conventional surgeries, the swelling that cooking causes means that, compared to TURP patients, thermotherapy patients actually tend to need a catheter longer, according to Stanford's Gill. "I tell my patients that I'm going to make them worse before I make them better," he says.
Not that surgery is the only method of treatment. In fact, it was back in 1992 that the FDA approved a drug called finasteride (brand named Proscar). Manufactured by Merck, it was shown to actually shrink the size of the prostate. This, it was believed, would make a lot of prostate surgery completely unnecessary.
And then there are the alpha-blockers: a class of drugs that work by relaxing the smooth muscles of the prostate and the opening of the bladder. Yet, half the patients who take these pills end up going through prostate surgery anyway, either because the medication proves ineffective or because of unpleasant side effects, including dizziness, fatigue and headaches.
Of course, for people like Richard Wade, who suffer a sudden and complete urethral shutdown, pills may not even offer temporary relief.
Radio Waves One Treatment Method
On Dec. 19, 1996, he underwent what in the business is called a transurethral needle ablation, or TUNA for short. As with TURP, the surgeon doing the procedure goes in through the urethra. But instead of a wire loop, what's trained on the prostate is a pair of tiny needles that emit heat-producing, radio-frequency energy. So far, there is little evidence to suggest that radio waves are any more effective than microwaves or advanced lasers, but it's the technology that Wade's Marin County physician, Dr. Harry Newirth, is most comfortable with.
To date, Newirth has done about 30 of these procedures. Two-thirds of them, he says, have been quite successful. A couple failed completely. Wade's, however, wasn't one of them.
"The first week after the surgery I was really scared that it hadn't worked because I remained completely dependent on the catheter and there was some blood in my urine," says Wade. "But by the second week I could urinate really well. Everything worked out fine."
Now, almost three years later, Wade is aware that the durability of the procedure isn't known, so he might have to go through it again. However, he also notes that the TUNA he went through was less traumatic than his hernia operation, and that by availing himself of this minimally invasive procedure he's been able to hold on to his fertility.
"I probably won't ever have children," says Wade, who is now 56. "But it's still nice to know that the option is still available."
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The ABCs of Prostate Surgery
TURP (Transurethral Resection of the Prostate): The gold standard of conventional prostate surgery. Complications include infertility and infection, and there's a slight chance of impotence and incontinence. The good news is that once you undergo the procedure, it's unlikely you'll have to repeat it.
TUNA (Transurethral Needle Ablation): A minimally invasive procedure that targets the prostate with bursts of radio frequency radiation. The procedure is done on an out-patient basis with a local anesthetic. Complications are minimal. The procedure is so new that it's unclear how long the procedure will be effective.
TUMT (Transurethral Microwave Thermotherapy): A minimally invasive procedure that targets the prostate with microwave energy. Results said to be similar to what's seen with TUNAs.
TULIP (Transurethral Ultrasound-Guided Laser Induced Prostatectomy): No, this isn't a secret weapon invented by the Defense Department. It is, however, the most technically complex and expensive way of delivering heat to the prostate. Its expense means it's unlikely to be widely used.
TUVP (Transurethral Laser Vaporization of the Prostate): Here, a high-instantaneous burst of radio frequency radiation is created that vaporizes prostate tissue.
VLAP (Visual Laser Ablation of the Prostate): This employs a lower level of energy that causes prostate tissue to dry and slough away with time. Requires multiple treatments for larger prostates. Also, post-operative irritation tends to be longer. Generally, not in favor with doctors at this time.