Question: What’s worse than aging-related prostate enlargement that blocks urine flow?
Answer: Going through a TURP to treat the blockage, only to find out after that you have prostate cancer.

For men, a common side effect of aging is an enlarged prostate gland. You may not even be aware that this is happening until you start having trouble peeing. This occurs if this noncancerous increase in prostate size called benign prostatic hyperplasia (BPH) causes the urethra to narrow. This passage from the bladder toward the penis goes right through the center of the gland, so as the gland volume grows, the urethra is squeezed. As a result, a sense of urgency may become more frequent, but starting urine flow and/or complete bladder emptying often gets problematic.

Widening the passage

There are a number of treatments for blocked urine flow. Medication is a common first effort to help Mother Nature along. However, if prescription drugs don’t help, there are procedures that involve removing or destroying prostate tissue in order to widen the passage. The generic term is Transurethral Resection of the Prostate, or TURP. TURPs involve inserting small cutting instruments or ablation devices through the tip of the penis into the prostate while the patient is under anesthesia. Methods that vaporize the tissue away (certain types of laser) or destroy it with steam do not preserve tissue for analysis. However, those that cut tissue away and remove it have the advantage of preserving the tissue for further analysis.

Analyzing removed prostate tissue

The benefit of being able to analyze the bits of tissue that are removed is similar to a needle biopsy. The actual prostate cells are routinely examined under a microscope to check for prostate cancer (PCa).

This extra step matters because aging also brings more risk of prostate cancer due to genomic breakdown within aging cells. Normal cells can mutate and become cancerous. When PCa is diagnosed as a result of a TURP, it’s called incidental PCa. It’s like, “Well, your TURP was successful. Oh, by the way, you have prostate cancer.” You can imagine a patient’s dismay. Here he is, recovering from a TURP procedure that already came with risks like bladder injury, blood in urine, ED, pain when peeing, etc.—and now learns he also has prostate cancer, and may require treatment for that! Finding out after the fact sucks. In fact, statistics show that this happens in as many as 10% of TURP cases.^[i]

Finding out ahead of time

Thus, for men about to have a TURP, it’s wise to rule out PCa, especially if their PSA is high or rising, or they had an abnormal digital rectal exam (DRE). Knowing beforehand if PCa is present allows the treatment plan to be modified so that both the urinary blockage and the cancer can be addressed in one treatment rather than two separate procedures. In the traditional diagnostic pathway, men considering a TURP who are suspected of having PCa will usually have a 12-14 needle transrectal ultrasound (TRUS) guided biopsy before their procedure. In itself, this is an unpleasant, possibly painful procedure that comes with its own risks of infection or other side effects.

However, there’s an alternative to such invasive biopsies. It’s called in-bore MRI-guided prostate biopsy. This is the most efficient, least invasive type of prostate biopsy because it’s precisely targeted under image guidance. At the Sperling Prostate Center, we perform the biopsy inside the bore (tunnel) of our powerful 3T magnet, which reveals suspicious areas. By directing a minimum number of needles into the heart of the lesion, we gain maximum diagnostic power since that’s where the most dangerous cells lurk. Our 3T multiparametric MRI (mpMRI) has the added benefit of providing a visual portrait of the size, shape and location of the lesion. This is a plus in terms of planning a potential treatment that controls the cancer, opens the urethra, and preserves urinary and sexual function.

A recent multi-center study compared two groups of men scheduled for a laser-type of TURP. All men had symptoms of bladder flow blockage; all had suspicion of PCa based on elevated PSA and/or abnormal digital rectal exam, and all men had a multiparametric MRI (mpMRI) of the prostate before a TURP procedure. Then men were assigned to one of two groups:

1. In-bore MRI-GB (57 patients) – those whose mpMRI revealed a suspicious lesion underwent an in-bore MRI guided biopsy
2. mpMRI + TRUS-GB (60 patients) – those whose mpMRI was negative for suspicious lesion underwent a conventional TRUS guided biopsy

There was no significant difference between the two groups in their respective rates of incidental PCa following TURP procedures. The authors concluded that a routine mpMRI scan plus in-bore biopsy (if indicated by scan results) before TURP leads to a low rate of incidental PCa as well as “avoiding unnecessary standard TRUS-GB biopsies.”^[ii]

Our Center’s 3T mpMRI can help rule out PCa before a patient has a TURP. In addition, we offer an alternative to transurethral resection of the prostate. Our minimally invasive, outpatient Focal Laser Ablation for BPH does not “carve out” or “ream out” the urethra. Instead, by strategically placing a laser fiber to destroy and thereby shrink the tissue that’s blocking the passage of urine out of the bladder, the urinary problems from BPH naturally resolve as the body reabsorbs the harmless post-ablation scar tissue. For more information, visit our website.

NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.

References

[i] Matanhelia DM, Groghan S, Nason GJ, O’Connell CO, Galvin DJ. The Management of Incidental Prostate Cancer Following TURP. Ir Med J. 2019 Feb 14;112(2):866.
[ii] Porreca A, D’Agostino D, Vigo M, Corsi P et al. “In-bore” MRI prostate biopsy is a safe preoperative clinical tool to exclude significant prostate cancer in symptomatic patients with benign prostatic obstruction before transurethral laser enucleation. Arch Ital Urol Androl. 2020 Jan 14;91(4):224-229.