Benign Prostatic Hyperplasia (BPH)

At NUH Urology Centre, Benign Prostate Hypertrophy (BPH) is a common urological condition seen often by our team of doctors. BPH or commonly known as prostate enlargement,  is a non-cancerous enlargement of the prostate gland. It is one of the most common urological problems in elderly male, with 60% incidence for those above 60 years old.

Common symptoms include:

• Difficulty in starting urination (Hesistency)
• A weak urinary stream
• Interruption of the stream (‘Stopping’ and ‘Starting’ effect)
• Sensation of incomplete bladder emptying
• Urgency (The person has difficulty postponing urination)
• Frequent urination
• Waking up frequently at night to urinate (Nocturia)

Patient may present late with complications of BPH. Some of these complications include:

• Acute urinary retention
• Urinary tract infectious (UTIs)
• Bladder stones
• Bladder damage
• Kidney damage

Causes of the condition

The prostate gland increases in size with age. The exact cause for the growth of the prostate gland is not known, but it could be contributed by the changes in the balance of the sex hormones as men ages. If the growth is significant, it will obstruct the urine flow.

Diagnosis and Treatment Options

BPH is diagnosed through a combination of medical history taking, physical examination and digital rectal examination.

In mild BPH, there is no significant blockage of the bladder and the symptoms are not bothersome. Most of these patients can be managed with an adjustment in their fluid intake, regular exercise, and a proper diet. In moderate BPH, the blockage of the bladder is not severe but the symptoms are bothersome. Medication can be used to treat these cases to either relax the bladder outlet or help shrink the prostate, to improve the flow of urine.

In severe BPH, the blockage is severe and patient is unable to empty the bladder completely. Surgery will be considered. The gold standard for surgical treatment for BPH is TURP (transurethral resection of the prostate).

What is Transurethral Resection of Prostate (TURP) and how does it work?

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In TURP, the obstructing part of the prostate gland is removed using a special instrument called the resectoscope that is inserted via the urinary passage.   This procedure is done under General Anesthesia or Regional Anesthesia. The amount of prostate tissue removed will depend on the size of the prostate gland. This is an in-patient procedure with an average length of stay of 3 days.   With the introduction of a new PlasmaKinetic Bipolar technology, TURP can be done as a day surgery case. We are the first centre in South East Asia to perform TURP as a day surgery.

Indications for TURP

• Acute / Chronic Urinary Retention
• Recurrent urinary tract infections
• Hematuria (Blood in the urine)
• Bladder stone
• Renal insufficiency
• Bladder diverticulum/diverticula
• Failed medical therapy
• Patient preference

Transurethral Needle Ablation (TUNA) - New clinic procedure to treat BPH

For years, surgery - TURP (transurethral resection of the prostate) has been the gold standard for treating obstructive BPH. Patients with mild or moderate symptoms can choose to be on medication to relieve the symptoms. Medication can be expensive and not all patients on medication experience significant voiding improvements.

NUH is now offering a minimally invasive procedure that can be performed under local anaesthesia – Transurethral Needle Ablation of Prostate Gland (TUNA). We are the first centre in South East Asia to offer this procedure in an outpatient setting. To date, about 80 patients have successfully undergone the procedure.

TUNA has been practised widely in the United States in recent years and it has been demonstrated to be safe and effective in relieving the symptoms of BPH with good clinical outcome at 5-year follow up.

How does TUNA work?

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Using radiofrequency waves, two needles are inserted into the prostate. The heat generated causes the prostate gland to shrink.   The procedure takes 20-30 mins. Patients will be discharged a few hours later with a urinary catheter (i.e. to have a tube inserted into the urinary bladder to drain the urine).   So far, all our patients were discharged on the same day and their urinary catheter were removed within three to five days after the procedure.

Who is suitable for TUNA?

Patients with mild or moderate bladder obstructive symptoms who
 

a. Are not able to tolerate the side effects of medication (which can include giddiness, lethargy and transient drop in blood pressure)

b. Do not wish to continue with long term medical therapy because of cost consideration

* Please note that patients who have prostate cancer and conditions like bladder stone, recurrent urinary tract infections, are not eligible for TUNA.

The main difference between TUNA and TURP

• Can be done under local anaesthesias
• Shorter procedure time
• Lower risk of complications (e.g. incontinence, retrograde ejaculation)
• Less invasive with minimal blood loss
  

Our experience with TUNA

Our experience with TUNA has shown it to be a safe clinic based procedure. Patients treated with TUNA have shown statistically significant symptomatic relief from bothersome symptoms. We know from experience that not all patients on medication experience significant voiding improvements. Some men face undesirable side effects and prefer a different management rather than remaining on long-term medication. TUNA fills a void between medical therapy and TURP by being a compromise between the limited efficacy of drug treatment and the invasiveness of surgery.
 

While TUNA may not necessarily reach the same efficacy as TURP, it has the advantages of low treatment related morbidity. It is not for TUNA to compete with medical treatment or TURP but rather to include it as one of the treatment options for suitable patients with enlarged prostate. We proposed TUNA as a second line treatment when medical therapy fails to improve a patient’s obstructive and irritative symptoms. In addition, TUNA can be considered for patients who wish to avoid surgical treatment or who are not fit for surgery. It can be also proposed to patients who wish a rapid treatment in an outpatient management or wish a preserved sexual function.

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