Dr. Dan Sperling, a leading expert in targeted ablation of prostate tumors, has adapted his innovative focal laser technology to treat Benign Prostatic Hyperplasia, commonly known as BPH.
What is Benign Prostatic Hyperplasia?
Benign Prostatic Hyperplasia is a normal non-cancerous enlargement of the prostate gland that occurs as men age. It is caused by a very gradual change in the types of tissue that make up the three prostate zones. It tends to begin around age 40, and the risk of BPH increases as a man grows older.
Statistically, 20% of men in their 50s experience BPH; 60% of men in their sixties have it, and by age 90 it is estimated that 90% of men have BPH.
The prostate gland is comprised of three zones: The Peripheral Zone (PZ), the Transitional Zone (TZ), and the Central Zone (CZ). BPH arises in the transitional zone. According to the American Urological Association, in young men the TZ occupies about 20% of the gland, but as it enlarges from midlife onward, it can cause the entire gland to increase in size. Because the TZ surrounds the urethra (the passageway through the prostate for urinary flow out of the bladder), as it gradually enlarges, it can cause a narrowing of this passage, causing problems with urination.
What are the symptoms of BPH?
Common BPH symptoms include:
- Difficulty starting urination
- Interruptions of urine flow
- Weak force of stream
- Dribbling after urination
- Sense of urgency even when the bladder is not full
- Inability to empty bladder completely
- Sleep disruption due to need to urinate
- Straining of pelvic muscles leading to injury or risk of infection
- Urinary tract infection (due to incomplete bladder emptying)
- Bladder stones (due to incomplete bladder emptying)
- Kidney damage (due to increased pressure caused by urinary obstruction)
IMPORTANT: These symptoms can be caused by conditions other than BPH. If any of these symptoms become troubling, see a doctor for diagnosis.
How is BPH diagnosed?
In addition to a complete medical history, there is a special questionnaire called the International Prostate Symptom Score (I-PSS) that screens for BPH and other possible prostate conditions, including infection, inflammation and prostate cancer. To rule out other prostate diseases, the doctor might conduct any or all of the following tests:
- Blood test, including PSA, free PSA or PSA density
- Urinary flow test
- Post-void residual volume test (any urine left in the bladder after urination)
- Urodynamic studies (user of a urinary catheter to introduce water into the bladder to measure internal pressure and bladder contractions)
- Cystoscopy (insertion of a thin tube with a lens and light for visual inspection of the urethra and bladder)
- Imaging using a contrast dye to reveal aspects of the urinary system
- 3T multiparametric MRI of the prostate (this type of MRI when interpreted by an experienced radiologist can clearly show BPH). The MRI scan below shows how well the prostate zones can be seen:
How is BPH treated?
For many patients, changes in behavior (e.g. reduced fluids before bedtime, dietary changes to exclude bladder irritants) will reduce symptoms. There are also medications that can make urination easier to begin, or to shrink the prostate gland. These can relieve symptoms for many men. However, when symptoms become too problematic, other interventions may become necessary. Conventional approaches to enlarging the urethral passage include:
- Transurethral Resection of the Prostate (TURP) – A surgical procedure done under anesthesia in which the surgeon uses a narrow instrument inserted into the urethra through the penis in order to scrape away excess prostate tissue with tiny instruments. Usually involves 1-3 days in the hospital. Some patients refer to this as a “reaming out.” Healing may take up to 3 weeks or more. Side effects: difficulty controlling urine stream, erectile dysfunction, retrograde ejaculation (semen flows backward into the bladder), urinary blockage, and infertility.
- Transurethral Microwave Thermotherapy (TUMT) – A minimally invasive, 1 hour outpatient procedure that uses an antenna inserted into the urethra through the penis to generate sufficient heat to destroy overgrown tissues without damage to healthy tissues. Depending on prostate anatomy, not everyone is a candidate. May take time to produce results as dead cells are broken down and reabsorbed by the body.
- Transurethral Needle Ablation (TUNA) – Uses a needle inserted through the urethra to deliver radiofrequency energy to destroy tissue. It is usually done as an outpatient procedure under local, general or spinal anesthesia. Patients wear a catheter to allow the urethral lining to heal. Possible side effects: blood in urine, painful urination, difficulty urinating, risk of infection.
- Indigo laser therapy – A needle with a laser delivery system at the tip is introduced through the urethra. It can be done outpatient under local or regional anesthesia. The type and strength of laser energy used causes coagulation (clumping and scarring) of small volumes of tissue, which are eventually passed off through the urethra. While there are very few side effects, patients wear a catheter for several days to a week so the passage of dead tissue does not obstruct urine flow. Improvement in symptoms may occur over 6-12 weeks.
- Laser vaporization therapy, often called Green Light Laser or KTP laser – A cystoscope is used to introduce a laser fiber that generates a different type of laser energy that vaporizes, rather than coagulates, prostate tissue. It is done outpatient under anesthesia. Side effects may be similar to TURP, though with less severity; healing is shorter than with TURP.
How does the Sperling Prostate Center treat BPH?
The Sperling Prostate Center offers a unique new FDA-approved approach to treating BPH. With the same kind of MRI-guided focal laser ablation (FLA) used to treat individual prostate cancer tumors, Dr. Dan Sperling has developed a patient-friendly outpatient treatment that eliminates BPH in a single treatment with minimal-to-no side effects.
Focal laser ablation for BPH (FLA-BPH) permanently relieves BPH-related urinary symptoms by reducing the enlarged TZ (transition zone) tissue causing urinary blockage. This process is called debulking because it diminishes the bulky BPH tissue. The ablation is done with the type of laser that coagulates, not vaporizes, tissue. By ablating targeted areas of the transitional zone near but not touching the urethra, FLA-BPH creates strategic tissue shrinkage by generating harmless scar tissue that will be reabsorbed by the body. There are no residual urinary or sexual side effects because the treated areas are contained well within the prostate gland away from other healthy tissues and structures. However, depending on the location and extent of the heat ablation, some patients may wear a catheter for several days to protect the urethra as post-treatment inflammation diminishes. The urinary symptoms of BPH begin to diminish within a few weeks as the resulting scar tissue is reabsorbed by the body.
FLA-BPH is performed under real-time 3T multiparametric MRI guidance. Unlike all other treatments for BPH, which are transurethral (access the urethra through the penis), FLA-BPH is done using rectal access so there is no risk of urinary irritation or infection.
A local anesthetic to numb the entire prostate area is administered and the patient lies prone on a table that slides into the MRI tunnel (also called the bore). The area to be treated is calculated based on the detailed MRI scans that clearly show where the BPH is constricting the urethra. A hollow needle guide is inserted into the prostate through the rectum. This allows a very small laser fiber optic to be placed precisely at the center of each area to be treated.
When the fiber is correctly placed, the laser is activated for a brief time, usually 2-3 minutes. During the ablation, a special type of software shows temperature changes in the tissue being treated, and confirms that there is no heat damage to surrounding tissues. Following ablation, the MRI is used to confirm each area that was ablated.
When sufficient tissue has been destroyed, the laser fiber and needle guide are removed. Any further treatment confirmation occurs with another MRI scan, if needed. The patient gets dressed, and the treatment is done.
NOTE: prostate anatomy differs from one man to another. Depending on the size of the gland at the time of treatment, and the extent and degree of laser power, some patients will be discharged with a urinary catheter placed temporarily while post-treatment inflammation diminishes. Dr. Sperling will discuss this with individual patients.
There are no long term side effects from FLA-BPH (as there are with traditional TURP and intraurethral ablation procedures) because the urethral lining is better preserved. Furthermore, baseline erectile function is preserved because the TZ is within the prostate and not adjacent to the neurovascular bundles that control erection. Finally, the side effect called retrograde ejaculation (semen flowing backward into the bladder) that can occur after TURP or Green Light laser does not happen after FLA-BPH, because the structural anatomy of the urethra and seminal vesicles is not affected. NOTE: Minimal transient (short term) side effects may occur as with any transrectal procedure, but these tend to resolve quickly.
Advantages of FLA-BPH
- No general or spinal anesthesia, only local numbing
- Real-time MRI guidance
- Nothing inserted into the penis or urethra
- One-time treatment with excellent results
- No residual side effects
How Dr. Sperling developed FLA-BPH
In an interview, Dr. Sperling described how he adapted FLA for treatment of BPH.
“The first patient who told me that his urinary problems had disappeared within several weeks after I treated his prostate cancer with focal laser ablation was a cardiologist in his early seventies. He had been diagnosed with BPH, and had a history of annoying symptoms. He called me because he was amazed that he was urinating like he did when he was in his twenties, and asked if it was related to his cancer ablation.
“I thought it was very possible, because the tumor I treated was in the area called the transition zone, close to where the urethra passes through the prostate, but not directly against it. I researched what is called ‘debulking the prostate’ which can be done with other types of ablation, such as cryo [freezing]. There were reports in the literature that many men who had a whole-gland cryo for prostate cancer were cured of their BPH. I know that FLA also results in scar tissue, just as it does with cryo of HIFU, which the body harmlessly reabsorbs and excretes as waste. I reasoned that as the tissue shrank after treatment, it relieved pressure on the urethra, and the literature bore this out.
“However, he was not the only patient who had similar results. In fact, among the hundreds of men I’ve treated, I would say about a quarter of them have reported improved urinary flow, even when I treated smaller tumors in the peripheral zone. In my pre-treatment evaluations with patients, I would discuss this possibility with men whose urinary symptom scores were unfavorable. In my follow-ups, I was encouraged by what patients were reporting as far as better urinary function.
“The more this occurred, the more I thought about the side effects of other BPH treatments, like retrograde ejaculation, transurethral infections or blockage, even ED. We know that the laser creates less blood products due to essentially cauterizing the blood vessels by heat, and there is less hematoma (build-up of fluid). Because treatment is outside the urethra, I’m not affecting that delicate lining. I’m simply debulking the tissue that’s causing pressure on the urethra. My patients are very happy.”
Are you suffering from BPH?
Contact the Sperling Prostate Center today to schedule a consultation and find out if FLA-BPH is the right treatment for you.
1 Geneva Foundation for Medical Education and Research. Source