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Exploring Alternative Prostate Treatments

Surgery New, minimally invasive procedures may promise benign prostaic hyperplasia patients less risk of long-term repercussions.

November 30, 1998|MARTIN LASDEN | SPECIAL TO THE TIMES

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.

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