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Prostate: new light on laser therapy: for the millions of males living with benign prostatic hyperplasia (BPH), a new laser treatment is proving a promising alternative to more invasive surgery.

Like 40 percent of men in their mid-50s, John Fitzgerald successfully coped with the symptoms of an enlarged prostate, known as benign prostatic hyperplasia (BPH).

"I had all the classic symptoms," admits Fitzgerald, who for six years kept his condition in check with medication. "However, as the condition progressed, it became increasingly worse."

By age 61, the symptoms became so bothersome, interfering with his daily life, that Fitzgerald began investigating his further options.

"I was just lucky enough to be in the right place at the right time," says Fitzgerald. "I asked my young physician, "If this was your dad, what would you tell him?'"

The physician suggested meeting with Dr. James Lingeman at Methodist Hospital in Indianapolis. A world-renowned urologist, Dr. Lingeman performed the first kidney stone lithotripsy procedure in the U.S. and was now performing a new laser treatment for BPH called holmium laser enucleation of the prostate (HoLEP).

After an initial visit with Dr. Lingeman and undergoing diagnostic tests, Fitzgerald underwent the HoLEP procedure three weeks later, returning home that same day. "The recovery time was just a few days," says Fitzgerald. "I took no postoperative analgesics, experienced no real discomfort, and knew within 36 hours that the problem was completely resolved."

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To learn more about the procedure, the Post spoke with Dr. James Lingeman, volunteer clinical professor of urology at Indiana University School of Medicine and director of research at Methodist Hospital Institute for Kidney Disease.

Q: How common is BPH among American males?

BPH is very common among men as they grow older. By age 70, about 50 percent of men have BPH symptoms. Basically, BPH is an overgrowth of the periurethral prostate gland that becomes hyperplastic, resulting in abnormal enlargement of the tissue. The enlarged gland then centrally compresses the urethra, where it passes through the prostate, causing obstruction to the flow of urine.

Q: Is BPH linked to prostate cancer?

No. They are separate and generally arise from different places in the prostate.

Q: How is the BPH diagnosis confirmed?

The diagnosis is suggested by the development of urinary symptoms and confirmed by physical exam and diagnostic tests, including x-rays, ultrasound, and endoscopy or cystoscopy of the urinary tract.

We assess patients' symptoms in two primary ways. One, we categorize them using a scoring system called the American Urological Association Symptom Index that lists a series of seven questions with a numeric score of 0 to 5. A highly validated instrument, the index allows us to create a score of urinary symptoms. A score of 7 or less would represent mild symptoms, while a score between 7 and 15 represents significant symptoms: a score of 15 and over represents severe symptoms.

The second scoring system is what we call "bother." Many men have urinary symptoms that do not "bother" them very much. If symptoms do not bother them, we leave individuals alone unless they've got some absolute indication for intervention, such as they cannot urinate.

Q: What are conventional treatments?

There are four basic categories of treatment for BPH. One is to do nothing--"watchful waiting." In many, if not most, men, the symptoms of BPH are mild and not of sufficient bother to the individual that anything needs to be done, and those patients can be merely watched. Interestingly, in various placebo-controlled randomized clinical trials, men who received nothing (placebo) had some improvement in urinary symptoms over time, so doing nothing is not necessarily bad. Assuming a patient has symptoms and significant bother, we use three active forms of intervention: one category is medication, a second category is thermal therapies of various sorts, and a third category is surgical therapies. Each one works significantly better than the previous one.

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Q: What medications are used?

Medications come in two general groups. One group of medications for BPH are the alpha-blockers--the most popular in the United States is Flomax, but others are available. Alpha-blockers appear to reduce muscle tone in the region of the bladder and prostate and improve urinary symptoms significantly and rapidly, sometimes within a few days or, at most, weeks. While a popular treatment approach, this group of drugs does not actually change or shrink the prostate.

A second category of medicines includes what are termed the 5a-reductase inhibitors, including Proscar and Avodart. These medications help shrink the prostate by about 30 percent overall in a large population of men. Some men obviously respond better than others.

Alpha blockers and the 5a-reductase inhibitors can also be given together, because some data suggest that using the drugs together is better than using either one alone. The advantage of medications is that they are simple to administer and are low-risk medications. They do have some sexual side effects, but they are generally well tolerated. About two thirds to three quarters of men will benefit from the medications.

Q: Would you describe thermal therapy?

The next treatment category is thermal therapy, or various forms of heat applied to the prostate. In the United States, the most popular approach is something called transurethral microwave thermotherapy (TUMT) of the prostate. TUMT is performed in the office where a catheter is inserted, usually under local anesthesia. The microwave antenna in the catheter is applied in the vicinity of the prostate and the prostate is basically heated. The procedure takes about an hour. How TUMT works is the subject of considerable debate and controversy, but nonetheless it is effective in perhaps two thirds to three quarters of men treated with it. Reviewing the medical literature, the effect of microwave therapy and other thermal therapies is the same or perhaps slightly better than medication. However, treatment is more involved--in that a catheter is usually left in for a few days after the procedure. These procedures are considered quite safe and minimally invasive. Other forms of microwave therapy include transurethral needle ablation (TUNA) of the prostate and indigo laser therapy. It typically takes several weeks to several months for a patient to get a maximum response to the treatment because, again, the tissue is heated and has to gradually heal.

Q: When is surgery used?

The third category is the surgical therapies, which are the most effective but also the most intrusive. The classic procedure is transurethral resection of the prostate (TURP). This operation dates back to the 1930s and '40s and is one of the first minimally invasive operations performed in medicine. During this procedure, we insert a thin, tubelike telescope through the urinary opening. An attachment that carries an electric current is used to scrape out BPH tissue and create a channel. A common and effective operation, it has some risks, including risk of bleeding. It also can only be done for prostates up to a certain size. The normal prostate is approximately 25 grams. TURP can be done, depending on the skill of the surgeon, for prostates weighing 75 to 100 grams. Over that size, it is considered a difficult and more risky procedure. In the United States and around the world, if the prostate is over 100 grams, patients with BPH are treated with open surgery in which tissue is removed through a lower abdominal incision. That operation works well to remove very large prostates, but is associated obviously with an incision, a significant hospital stay, and about a 30 percent risk of a blood transfusion.

In recent years there has been interest in laser technology.

A laser heavily promoted in the United States termed the "green light laser" is actually a KTP laser. Basically, with this laser, you core out a channel much as you do with TURP. It is a popular treatment in that it is associated with very little risk of bleeding and it generally works pretty well for small- to medium-sized prostates, but you can't remove very much tissue with it. As the prostate gets larger, it becomes more difficult to treat it adequately with this laser.

At Methodist and a few other places around the country, we use what is called the holmium laser. With this laser, we can endoscopically remove all BPH tissue.

Q: How is the holmium laser surgery performed?

We look through the urinary opening with a telescope. The easiest way to think of it is shelling an orange from the inside out. You know how there's a point of separation between the fruit of an orange and the rind or the peel? Imagine that the BPH tissue is the fruit of the orange. As BPH tissue enlarges, it compresses the original prostate out into a shell with the BPH in the middle. Using the laser and the telescope, you can separate the enlargement of the BPH from the original prostate, because it's not the original prostate that is the problem here; it is the BPH tissue that has enlarged over time. Once detached from the prostate, the enlarged pieces of BPH tissue (called lobes) float up into the bladder where they are removed with a morcellating device. The morcellating device cuts the BPH tissue into small pieces that can be removed through the urinary opening.

Q: What are the results to date using the holmium laser for BPH?

At Methodist, we started doing this operation in June of 1998. We recently entered the 1,000th patient in our database, and we have not had to retreat anybody for regrowth of BPH in ten years, so it seems to hold up quite well. The procedure provides a very thorough clean-out, so I would anticipate that it would be associated with very good long-term outcomes.

Q: Who would be an ideal candidate for the holmium treatment?

The beauty of the holmium laser is that you can treat a prostate of any size--small, medium, or large. However, the larger the prostate, the greater the advantages of HoLEP over other approaches. The ideal candidate for the HoLEP procedure is a man with a prostate over 100 gm whose physician has told him he needs to have it removed with open surgery. We can essentially accomplish the identical operation endoscopically; the patient can be treated on an outpatient basis or, at most, an overnight hospital stay. We leave a urinary catheter in place overnight, then remove the catheter the next morning. Within a few days, the patient can return to regular activity.

Q: Is there a significant difference in recovery times between procedures?

With the TURP operation, there is the risk of bleeding afterwards, so patients are typically placed on restricted activities for six weeks after the surgery. Using the laser, I recommend that patients take it easy for a week, then they can resume normal activities.

When I was in New Zealand learning how to do this procedure ten years ago, I asked physicians there what their policy was about men treated with this procedure. It was February, which is their summer. On a Tuesday, I was watching surgeons do the HoLEP procedure, and they said that if this fellow wanted to make a tee time and play golf that weekend, he could. We would never allow that before when we did TURP. The shorter convalescence with HoLEP makes a huge difference with the patients, particularly for professional people. I treat many physicians, pilots, and people with busy careers and lives who don't want to be tied down. It's great for them.

Q: What about pain?

There is remarkably little discomfort afterwards. The procedure is done under anesthesia, so there is no discomfort during the procedure and very little, if any, discomfort afterwards. Now, when the catheter comes out, there may be some burning and stinging for a few days, but it is minor.

Q: Do you think this procedure is eventually going to take over?

It sounds so wonderful, so how come everybody isn't doing it? The problem is that it is hard to learn to perform. I went to New Zealand to spend time with the two very inventive fellows who developed this very elegant surgical technique. I have done many of them. But physicians feel there is a significant learning curve to the procedure, so adoption has been slow. The procedure has not been heavily promoted by industry, as opposed to other techniques. The laser fiber that we use for this procedure is reusable, so it is very inexpensive. The morcellator that we use is reusable, so there are not a lot of expensive disposable costs, which is good for hospitals and patients, but bad for companies.

Q: Are you investigating the use of holmium laser therapy in other conditions?

Originally, the holmium laser was developed for kidney stones, and we were one of the first facilities in the United States to use it. We use it every day for kidney and ureteral stones. That is a very nice feature when the patient has BPH and associated bladder stones, which is common--a condition that Ben Franklin had, I think. It's very easy for us to fragment and eliminate the bladder stones at the same time we treat the prostate with the laser because it's the same technology.

The laser originally came into use in the early '90s for stones, and it has been a mainstay of our stone treatment ever since.

Q: Is the procedure covered by Insurance?

It is FDA approved, and it is covered by Medicare and other insurance companies.

Q: If men are interested in learning more, is there a central source?

Probably the most appropriate thing for people who want further information would be contact us. The web site address is methodisturology.com. Also, our phone number is 317-962-2485.

by Patrick Perry, M.P.H.
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Publication:Saturday Evening Post
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Date:Mar 1, 2008
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