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Sexual preservation for BPH prostate surgery – Important for men of all ages

Case study ( 1606 views as of December 18, 2024 )

James is a 78-year-old retired psychologist with three children. Although he remains active and physically fit, he has been experiencing urinary troubles progressively for the past 3 years. He presented to his family medicine MD to be evaluated and had otherwise normal blood work. After being told he may have an enlarged prostate, he was initiated on Flomax medication to relax the prostate. The relief was minimal and James continued to have a markedly slow stream and continued to wake up 2-3 times per night. He was offered other medications to potentially shrink the prostate (Proscar) however being still sexually active, he did not want some of the potential side effects of these prostate medications, notably a reduced libido and ejaculatory dysfunction. As such, James was referred to see a urologist.

Upon urology consultation, non-invasive studies were conducted to objectively assess the urinary flow rate (Uroflowmetry) and ultrasounds to assess the residual urine volume in the bladder along with the prostate size/volume/dimensions. Since medications were no longer an option for the enlarged prostate, surgical treatments were discussed. While there were several to consider, from the gold standard technique of TURP to office based, minimally invasive procedures (including iTind and REZUM), James was most impressed with the most advanced technique of Aquablation.

Aquablation has the unique merger of ultrasound imaging to help personalize and customize the treatment contour. After creating a real-time map of the treatment prostate area, the robot system utilizes high pressure water to ablate obstructive prostate tissue. Furthermore, such a precise treatment of BPH helps preserve critical apical anatomy to conserve full urinary continence and ejaculation. These were most important for him to remain physically active and continue with his sexual life.

Now 4 weeks following his Aquablation, James is relieved of all of his obstructive lower urinary tract symptoms and no longer continues on any medications. He has full erections and unchanged ejaculation functions. James is now an advocate that sexual parameters are essential to be discussed for BPH (benign prostate hyperplasia) enlarged prostate discussions. All so often overlooked, most men globally are receiving TURP for the BPH surgery with >80% likelihood loss of ejaculation from such surgery.

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Conversation based on: Sexual preservation for BPH prostate surgery – Important for men of all ages

Sexual preservation for BPH prostate surgery – Important for men of all ages

  • Dr. Kevin Zorn
    Dr. Kevin Zorn Urologist, Montreal, QC 19 March 2024 Steinberg Urology Montreal
    benign prostatic hyperplasia (BPH). Here's a breakdown of the procedure based on the description: Preparation: The procedure is performed under local anesthesia, typically a block, which means the patient is awake but the area being operated on is numbed. Device Insertion: A small flexible camera (cystoscope) is inserted into the urethra to visualize the prostate. The iTind device, resembling a wire brace around a champagne cork with three prongs, is then placed through the bladder and guided into the prostate using the cystoscope. The prongs of the device are positioned strategically within the prostate. Reshaping the Prostate: Once positioned correctly, the metal twine of the device is untwisted, causing the prongs to expand and create pressure on the prostate tissue. This pressure creates grooves within the prostate over the next few days, reshaping it and relieving the symptoms of BPH. Device Removal: After five to seven days, the device is retrieved using the cystoscope. It's designed to be removable, so there is no permanent metal left in the patient. Overall, the iTind procedure offers a quick and minimally invasive alternative for treating BPH compared to traditional surgical methods like transurethral resection of the prostate (TURP) or open prostatectomy. It aims to provide symptom relief while minimizing the risks and recovery time associated with more invasive procedures.
    Reply to: Sexual preservation for BPH prostate surgery – Important for men of all ages
  • Dr. Kevin Zorn
    Dr. Kevin Zorn Urologist, Montreal, QC 18 February 2024 Steinberg Urology Montreal
    REZUM indeed stands out as a unique procedure among MIST (Minimally Invasive Surgical Therapies), particularly because it can be performed in an office setting. Here are some key points about REZUM: Office-Based Procedure: REZUM can be conducted in an office setting, which offers several advantages, including convenience for patients and potentially lower costs compared to procedures done in a hospital setting. Anesthesia: Unlike some other procedures, REZUM typically does not require general anesthesia or spinal anesthesia. This can reduce the risks associated with anesthesia and eliminate the need for an anesthesiologist to be present during the procedure. Quick Procedure: The REZUM procedure is usually completed relatively quickly, with patients typically spending less than an hour in the clinic. This can further contribute to the convenience and accessibility of the treatment. Post-Procedure Care: While REZUM offers many benefits, there are some considerations for post-procedure care. One such consideration is the need for the treated tissue to absorb, which may require some time for the patient to experience the full effects of the treatment. Catheter Placement: Additionally, a catheter is typically required for at least seven days after the procedure. While this may be an inconvenience for some patients, it is often necessary to ensure proper healing and to manage any temporary urinary symptoms that may occur after the procedure. Overall, REZUM offers a minimally invasive and convenient option for treating prostate issues, particularly for patients who may prefer or require an office-based procedure without the need for general anesthesia. As with any medical procedure, it's important for patients to discuss the potential benefits and considerations with their healthcare provider to determine the best course of treatment for their individual needs.
    Reply to: Sexual preservation for BPH prostate surgery – Important for men of all ages
    • Dr. Dean Elterman MD, MSc, FRCSC
      Dr. Dean Elterman MD, MSc, FRCSC Urologist, Toronto, ON 18 February 2024 University Urology Associates
      Here are some key points: Symptoms of UTIs: Common symptoms of UTIs include frequent urination, urgency, dysuria (painful urination), discomfort in the bladder or suprapubic area, cramping, hematuria (blood in urine), cloudy urine, and unusual odor in urine. However, it's important to note that not all of these symptoms may be present in every case, and some individuals may experience different symptoms with each UTI episode. Gender Differences: The anatomy of the urinary tract differs between men and women, with women having a shorter urethra, making it easier for bacteria to reach the bladder. As a result, women are more prone to UTIs, and experiencing one or two UTIs per year may not be considered abnormal. In contrast, UTIs are less common in men, and even one UTI may be considered abnormal. Factors such as an enlarged prostate in men can contribute to UTI risk by interfering with complete bladder emptying, providing a conducive environment for bacterial growth. Asymptomatic Bacteriuria: Some individuals, particularly postmenopausal women, may have bacteria in their urine without experiencing any symptoms (asymptomatic bacteriuria). In such cases, treatment with antibiotics may not be necessary unless symptoms develop. Factors Contributing to UTIs in Men: In men, factors such as incomplete bladder emptying due to an enlarged prostate can increase the risk of UTIs by allowing stagnant urine to serve as a medium for bacterial growth. This highlights the importance of proper bladder emptying and urinary tract hygiene in preventing UTIs. Overall, understanding the differences in UTI presentation between men and women, as well as the factors contributing to UTIs in each gender, is essential for accurate diagnosis and effective management of UTIs. It also underscores the importance of tailored approaches to UTI prevention and treatment based on individual characteristics and risk factors.
  • Dr. Kevin Zorn
    Dr. Kevin Zorn Urologist, Montreal, QC 18 February 2024 Steinberg Urology Montreal
    MIST (Minimally Invasive Surgical Therapies) is an FDA-approved treatment option designed for men aged 30 to 80 years old. One of the procedures falling under the MIST umbrella is called REZUM. Here's how the REZUM procedure works: Procedure Overview: REZUM involves the placement of a rigid cystoscope into the prostatic space. Device Used: A single disposable gun is utilized, which contains a small one-centimeter needle under motorized direction. Steam Injection: Once the needle is in position, a button on the gun is pressed to dispense steam into the prostate. Over a period of nine seconds, 0.42 milliliters of steam is delivered into the prostate, which equates to just under 250 calories in nine seconds. Injection Placement: Injections are administered every centimeter, with approximately eight injections delivered to a 4-centimeter prostate (four injections per side). This steam induces atrophy and shrinkage of the prostate. Procedure Duration: The entire procedure typically takes around five minutes to complete. Applicability: REZUM can be offered to men with prostates of all sizes and shapes. Success Rate: The procedure boasts an over 80% success rate, catering to both healthy individuals and patients who may be deemed too unhealthy to undergo anesthesia. Volume Reduction: Studies have shown that REZUM can result in a 30% reduction in prostate volume. Overall, REZUM offers a quick, minimally invasive alternative for treating prostate issues, with promising success rates across a wide range of patients. It's important for individuals considering this procedure to discuss its suitability with their healthcare provider based on their specific medical condition and needs.
    Reply to: Sexual preservation for BPH prostate surgery – Important for men of all ages
  • Dr. Kevin Zorn
    Dr. Kevin Zorn Urologist, Montreal, QC 18 February 2024 Steinberg Urology Montreal
    REZUM therapy is a minimally invasive procedure used to treat benign prostatic hyperplasia (BPH) by injecting steam into the prostate to reduce its size and alleviate urinary symptoms. While it can be effective in improving symptoms, as with any medical procedure, there can be potential side effects and downsides to consider. One potential downside of REZUM therapy is the discomfort or burning sensation that may occur during and after the procedure as the treated tissue sloughs off. This discomfort is a result of the thermal energy used to inject steam into the prostate. However, it's important to note that this discomfort is usually temporary and typically resolves within four to six weeks following the procedure. Additionally, in cases where REZUM therapy is used for men with chronic urinary retention, a catheter may need to be kept in place for a longer period, typically between three and four weeks. While this may be inconvenient for the patient, it is often necessary to ensure proper healing and recovery. Overall, while there are potential side effects and downsides to REZUM therapy, many men find it to be an effective and less invasive alternative to traditional surgical treatments for BPH. As with any medical procedure, it's essential to discuss the risks and benefits with a healthcare provider to determine the best course of treatment for individual needs.
    Reply to: Sexual preservation for BPH prostate surgery – Important for men of all ages
  • Dr. Kevin Zorn
    Dr. Kevin Zorn Urologist, Montreal, QC 12 December 2023 Steinberg Urology Montreal
    BPH is a condition where the prostate gland enlarges, causing compression of the urethra and obstructing the flow of urine. When medications are not effective or are poorly tolerated, surgical intervention may be recommended, and TURP is one of the established procedures for this purpose. The TURP procedure involves the use of a small metal loop, often powered by electricity, to remove the excess prostate tissue. The loop is essentially a cutting tool that can vaporize or cut away the obstructive tissue in the transition zone. The electrical current passing through the loop helps to achieve this, and as you described, it can be likened to a hot knife cutting through butter. While TURP is an effective treatment for BPH, it is important to note that there are alternative surgical approaches and technologies available, such as laser prostatectomy and transurethral needle ablation (TUNA). These procedures may offer different advantages and considerations depending on the patient's specific situation and the surgeon's expertise. The mention of potential bleeding and the need for postoperative hospitalization and irrigation aligns with the typical postoperative care associated with TURP. This procedure has been a standard of care for many years, and advancements in surgical techniques continue to refine and improve outcomes for patients with BPH. It's worth noting that the choice of surgical intervention is often individualized based on the patient's overall health, the size of the prostate, and other factors. Patients considering surgical options for BPH should have thorough discussions with their urologists to understand the potential benefits, risks, and expected outcomes of the chosen procedure.
    Reply to: Sexual preservation for BPH prostate surgery – Important for men of all ages
    • Dr. Dean Elterman MD, MSc, FRCSC
      Dr. Dean Elterman MD, MSc, FRCSC Urologist, Toronto, ON 12 December 2023 University Urology Associates
      benign prostatic hyperplasia (BPH), offering insights into its prevalence, impact on urinary function, and the role of the prostate in male reproductive health. You accurately describe BPH as an enlargement of the prostate, which is a gland involved in the male reproductive system and contributes to semen production. Your explanation of how, with aging, the prostate may grow and lead to the narrowing of the urethra, impacting urine flow, is informative and accessible. Highlighting the shape of the prostate as a doughnut and its location just below the bladder adds a visual element that aids in understanding the anatomical context of the condition. The narrowing of the central hole as the prostate enlarges, squeezing the urethra, is a succinct way to explain the mechanical aspect of BPH and its impact on urination. The statistics you provide about the prevalence of BPH among aging men, with 50% of 50-year-old men experiencing an enlarged prostate by the time they reach 80, offer a perspective on the widespread nature of this condition. Additionally, the mention of genetic factors and the potential influence of diet, particularly weight, on prostate growth adds valuable context to the discussion. Your concluding statement about the "luck of the draw" emphasizes that, to a large extent, the development of an enlarged prostate is influenced by factors beyond an individual's control, contributing to a better understanding of the condition. Overall, your explanation provides a well-rounded and accessible overview of BPH, making it easier for individuals to grasp the basics of this common age-related condition.
  • Mr. Jackson Sayers BSc.,
    Mr. Jackson Sayers BSc., Kinesiologist, Vancouver, BC 13 September 2023
    Great information Dr Kevin Zorn, Urologist, Montreal
    Reply to: Sexual preservation for BPH prostate surgery – Important for men of all ages
    • Dr. Dean Elterman MD, MSc, FRCSC
      Dr. Dean Elterman MD, MSc, FRCSC Urologist, Toronto, ON 12 December 2023 University Urology Associates
      The consideration of various treatment options and the classification into first, second, and third line treatments is a helpful way to approach the management of prostate-related symptoms. The emphasis on first-line treatments involving behavioral and lifestyle modifications is crucial. Addressing factors such as fluid intake, coexisting medical conditions like diabetes, and the impact of medications on symptoms is a sensible and comprehensive approach. Lifestyle modifications may also include dietary changes and exercises that can contribute to overall prostate health. The introduction of medications, specifically alpha receptor blockers, as a second-line treatment option is well-explained. These medications work by relaxing the smooth muscle in the prostate, which can help alleviate symptoms such as difficulty urinating. This class of medications is commonly prescribed for conditions like benign prostatic hyperplasia (BPH) to improve urinary flow. Your description aligns with the step-wise approach often taken in clinical practice, where less invasive or conservative options are explored before considering more invasive interventions such as surgery. This approach allows for personalized care tailored to the severity of symptoms and the individual needs of the patient. It's important for men experiencing prostate-related symptoms to consult with healthcare professionals for a thorough evaluation and discussion of available treatment options. The decision-making process should involve considering the impact on quality of life, potential side effects, and individual preferences to arrive at the most suitable course of action.
    • Dr. Kevin Zorn
      Dr. Kevin Zorn Urologist, Montreal, QC 12 December 2023 Steinberg Urology Montreal
      Indeed, one of the strengths of TURP is its widespread availability and acceptance as a standard treatment option for BPH. The equipment for TURP is commonly found in urology practices, making it easily accessible for patients who may require surgical intervention. However, as you mentioned, there are some limitations and potential complications associated with TURP. The time constraint during the procedure is crucial due to concerns about fluid absorption, which can lead to electrolyte imbalances. Managing the fluid balance is an important aspect of the surgical process to minimize the risk of complications. Postoperatively, the bleeding associated with TURP can be more significant than in some minimally invasive procedures, which may impact recovery and hospitalization requirements. It's important for patients to be aware of these potential postoperative effects and discuss them with their healthcare providers. The impact on sexual function, specifically the potential for a lack or loss of ejaculation, is another important consideration. Patients should be informed about potential changes in sexual function as part of the preoperative discussion, allowing them to make informed decisions about their treatment. As with any medical procedure, the choice of TURP or alternative interventions should be based on an individualized assessment of the patient's condition, preferences, and potential risks and benefits. Open communication between healthcare providers and patients is crucial to ensure that individuals are well-informed about their treatment options and can actively participate in the decision-making process.

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