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Prostate embolization in BPH.

Surgery in BPH (Benign prostatic hypertrophy)

In patients with BPH, symptom-relieving pills are tried first. However, in a significant proportion of patients, these pills are not sufficient or cause important side effects and thus, symptoms may increase over time and an intervention may become necessary. The most commonly performed procedure insuch patients is the TURP (transurethral resection of the prostate). In this treatment, the prostate is accessed by inserting a tube through the urethra (urine channel) and the part of the prostate that narrows the urethra is cut away and pushed into the bladder in pieces. These pieces are then passed out through the catheter in the urethra over time. Following TURP surgery, the patient can go home after a few days in hospital. TURP is a successful method of relieving prostate complaints, but has important side effects. Of these, retrograde ejaculation is the most common one. Retrograde ejaculation is the flow back of semen into the bladder during orgasm. The semen accumulated in the bladder is then passed out in the urine during the next voiding. Another common side effect after TURP is bleeding. Bleeding may continue for several weeks, although it decreases gradually after the procedure.


Following TURP, besides these two common side effects, the following problems may also develop:


Impotence: In some patients, a decrease in erectile function may occur after TURP. This is more common in patients who had erection problems before the procedure.

Urinary incontinence: Urinary retention problems may occur after TURP due to ongoing bladder problems or damage to the sphincter muscles during operation.

Urethral strictures: After TURP, the scar tissue formed in the urethra may contract later and the patient may have difficulty in urinating. In this case, it may be necessary to expand the strictures repetedly via the urethra by special methods.

Infertility: If retrograde ejaculation occurs, pregnancy is not possible in the normal way because the semen does not come out during sexual intercourse.

If the prostate is overgrown, ie above 75-80 g, standart TURP is usually not sufficient. The recommended method in such patients is "open prostatectomy". In this surgery, an incision is usually made from the lower part of the abdomen and a large portion of the prostate is removed. In open prostatectomy, side effects such as infection, bleeding, impotence, and urinary incontinence are even more common than TURP. Therefore, the application of nonsurgical treatments is of greater importance, especially in patients with large prostates.

Because of these side effects, many patients do not want to undergo surgical operation even if they have severe symptoms. Therefore, alternative interventions are becoming popular. These interventions are done by urologists or interventional radiologists. 

Alternative interventions done by urologists:

The biggest problem in TURP is that the surgeon cuts away the prostate tissue where important structures are present including the urethra, sperm channels and sphincters. As a result of this  traumatic operation, these structures are broken down and important complications may develop such as retrograde ejeculation, urethral narrowing, impotence and incontinence. In an attempt to reduce this trauma, following interventions have been developed by urologists:

1. Laser prostate excision:

The standart TURP procedure is done by using different lasers. Many types of lasers are used for this purpose including Holmium laser, Green light laser, Yag laser and diode laser. In laser excision, the prostate tissue is broken down by burning and evaporation instead of mechanically cutting, as in the standart TURP. As a result, bleeding is less and hospital stay is shorter. However, the prostate tissue including the sperm channels, urethra and sphincters are still traumatically destroyed and thus the same complications as TURP occur such as retrograde ejeculation, urethral narrowing, impotance and incontinence.

2. Aquablation:

In this procedure, the prostate tissue is mechanically destroyed by a high pressure water infusion, instead of cutting. Since there is no thermal effect, the procedure creates less trauma to the prostate tissue. However, the prostate tissue is still mechanically broken down and as a result, similar side effects such as retrograde ejeculation, urethral narrowing, impotance and incontinence may be seen although to a lesser extent.

3. Urolift:

In urolift procedure, several stitches are surgically put across the urethra and the outer surface of the prostate. As a result, the prostate around the urethra are squeezed and the narrowed urethra is enlarged. Although this procedure may be effective in the short term, symptoms may recur in the long term because the stitches may break off or the prostate tissue may grow again between the stitches. Besides, this procedure may not be effective if the prostate is larger than 80 grams or BPH is caused by median lobe hypertrophy.  

4. Rezum (vapor ablation): 

This procedure is another type of ablation of the periprostatic tissue. In the past, it was thought that instead of mechanically removing the prostate as in TURP, it may be less traumatic to ablate the prostatic tissue around the urethra to reduce the side effects. For this purpose, ablation with heating (microwave, RF) or alcohol have already been tried with a modest success. In rezum, this is done by puncturing the urethra and infusing a puff of hot vapor into the prostate tissue around the urethra. The tissue is destroyed by heating and shrinks by time. This shrinkage results in gradual enlargement of the urethra and improvement of symptoms.

Ablation of the periprostatic tissue has a similar effect to TURP surgery with less side effects. Rezum has been reported to be associated with less side effects compared to TURP procedure. However, there are two limitations of the rezum procedure: first, the urethra is traumatized by puncturing with a needle multiple times and second, during the operation, the doctor sees inside the urethra but not around the urethra where the vapor is given. Thus the extent of the vapor ablation are not well controlled and predictable. Besides, heating a tissue at high temperatures may be quite traumatic to structures such as urethra, sperm channels and sphincters. For these reasons, the Rezum procedure may still be prone to complications. 

Alternative interventions done by interventional radiologists:

These procedures are done by interventional radiologists specialized in image-guided minimally invasive procedures. The most common procedure is embolization. The other less known but more promising procedure is percutaneous cryoablation. These treatments are typically done with local anesthesia and conscious sedation and there is no trauma to the penis, urethra, sperm channels and sphincters. Therefore, complications like retrograde ejeculation, impotance, incontinance and urethral narrowing are not seen. 



In TURP procedure, urethra, sperm channels and sphincter muscles may be harmed.
Similar to TURP in laser also, urethra, sperm channels and sphincter muscles may be harmed.
In aquablation, side effects are similar to those seen in TURP procedure.
In stapling, recurrence may occur as prostate may regrow among the staples or they may break off.
In Rezum, multiple punctures to urethra are done and the vapor heating is not well controlled.
In embolization, side effects are mild but the procedure is not very successful.

Interventional oncology in cancer management

Prof Saim Yilmaz, MD

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