J. Nicholas (Nick) Warner, M.D.
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Enlarged prostate, also called benign prostatic hyperplasia (BPH), is a common condition as men get older. By age 60, about 30% of men show moderate to severe symptoms of BPH; by age 80, it is 50%. An enlarged prostate gland can cause uncomfortable urinary symptoms, such as a weak urine stream, urine stream that starts and stops, frequently getting up at night to urinate, and inability to void the bladder.
There are many different treatment options for BPH, ranging from behavior medications to surgery. A minimally invasive option is bipolar enucleation of the prostate, or BipoLEP. If you are considering treatment, here's what you need to know.
The prostate is a small organ that sits at the bottom of the bladder. The urethra, the tube the drains the bladder, runs through the middle of the prostate.
Early in a man’s life, the prostate is roughly the size of a walnut or a small tangerine. Often around 50, the prostate increases in size. For some men, this change closes off the urethra and makes it more difficult for the bladder to empty.
The prostate has two parts. The adenoma is the inner part that surrounds urethra. It is the part of the prostate that grows as men get older. The capsule is the outer part of the prostate and does not change in size over the course of life. A good analogy is to think of an orange. The orange peel represents the capsule, and the fruit represents the adenoma.
Removal of prostate tissue
One treatment for BPH is called enucleation of the prostate. Using the orange analogy, the goal of this option is to remove the fruit (the adenoma) from the inside while leaving the peel (the capsule) behind. This technique results in a wide-open channel for the urine to pass out of the bladder.
There are different ways to perform a prostate enucleation:
- Through a large open incision called a simple prostatectomy
- Through small incisions and using a surgical robot
- Through the urethra without any incisions called transurethral
History of transurethral enucleation
In 1983, the first transurethral enucleation was performed in Japan. However, once the tissue was freed from the prostate, an incision still had to be made to remove the tissue. Imagine peeling an orange and leaving the pieces floating in the bladder.
The procedure became more common when the morcellator was invented in the late 1990s. This medical device is used to cut tissue into smaller pieces during a minimally invasive surgery. This allowed the prostate tissue to be removed through the urethra.
Bipolar enucleation of the prostate
Transurethrally enucleation can be performed with two different of energy sources. It can be completed with a holmium laser. This is called holmium laser enucleation of prostate, or HoLEP.
Another option is with bipolar energy, called BipoLEP. BipoLEP is appropriate for patients who have larger prostates, usually over 80 milliliters, or in urinary retention and unable to void their bladders without a catheter. Also, patients who have been offered an open surgery because their prostate is "too big" may benefit from BipoLEP.
BipoLEP is typically performed in the clinic. The patient is given a spinal anesthetic to numb everything from the waist down. During the procedure, a urologist inserts a specialized scope into the urethra. Using bipolar energy on the scope, all adenoma tissue is enucleated. The tissue is cut into smaller pieces and then easily removed through the urethra. This procedure leaves the capsule intact and restores the urinary flow through the urethra. The procedure takes 45 minutes to two hours, depending on the size of the prostate.
Unlike similar surgical procedures performed for prostates, BipoLEP does not require abdominal incisions. The result is faster recovery, lower risk of infections and patients can recover at home. Patients' catheters can be removed the day after the operation in most cases. In contrast, open or robotic surgeries require catheter use for seven days.
A BipoLEP procedure can be performed on any size prostate, so it can help a wide range of patients. Finally, enucleation is a complete removal of the adenoma, giving longer-lasting results compared to other surgical options.
Patients need to limit strenuous physical activity for two weeks and drink plenty of fluids. Most can resume normal activities after two weeks, but may still see occasional bits of tissue or bleeding with heavy activity.
Most instances of urinary incontinence improve in the first three months after the procedure. Side effects are generally mild and comparable to other treatments. The risk of bleeding and infection is low. Patients with smaller prostates have a higher rate of scar tissue formation after this procedure.
Talk with your primary care provider and make an appointment if you are having trouble urinating and are looking for treatment strategies.