AUA Summit - Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH)

Out of the Closet: BPH Sufferers Find Relief in a Variety of Treatments

Clothing may make the man, but at the end of the 19th century, accessories were what counted most for men with benign prostatic hyperplasia (BPH). No finery did more for men suffering from enlarged prostates than bowler hats, walking sticks or umbrellas. For stashed discreetly in the hat bands or hollow cane-shafts were one of the few means of relief for a man suffering from BPH-related restricted urine flow: a catheter.

BPH, an enlargement of the prostate, is a common condition in men more than 50 years old. The growing organ compresses the urethra and causes an obstruction of urine, making it difficult to empty the bladder completely. A century ago, reasonable treatments—such as transurethral resections of the prostate—weren't available. But that didn't stop physicians from attempting to treat this ailment. Centuries passed as doctors tried a number of different treatments, such as the notion advanced by Pennsylvania's William J. White in 1893 that the removal of testicles in normal men would shrink their prostates. Other approaches proved more promising. In September 1891, Southern Pacific Railroad physician George Goodfellow, of Tucson, Arizona, removed prostate tissue through an incision made in the perineum—the area between the scrotum and rectum. While this procedure isn't documented, Goodfellow has been credited with the first perineal prostatectomy. New York City's Eugene Fuller originated the suprapubic procedure—where the prostate is removed through an incision made through the lower abdomen and bladder. Nearly a century after reporting six successful cases, he was memorialized with the AUA's Eugene Fuller Award in 1985. Hugh Hampton Young, a urologist at Johns Hopkins Hospital accumulated even better results. He used a perineal incision to remove the prostatic mass, but he also pushed the gland upward from the rectum to ease and complete the excision, thus distinguishing his approach and making the removal more complete. This innovative maneuver was one of many by Young, who came to be known as the "Father of American Urology."

On October 8, 1902, Young, who had honed his perineal approach by developing a specially crafted "tractor" to draw out the prostate, used his technique on Hawaii patient Samuel Alexander. Previously, Alexander had visited Baltimore and, upon talking with Young, requested that he perfect his technique and encouraged him to refine the procedure. Alexander was an inspiration to Young, who later wrote, "My indebtedness to him is great.” Others, such as Britain's Terence Millin, added their own techniques. Millin perfected and popularized today's retropubic operation in 1945, pursuing an abdominal cut directly into the prostate.

But not all prostatectomies involved incisions. In introducing his "punch" procedure, April 1, 1909, Young produced an endoscopic alternative to "big" operations for small tissue. Using his own remodeled urethroscope, Young made an incision into the urethra, caught the obstruction and sheared off the enlargement with a snug cutting tube. Once the enlargement had been removed, his patient urinated freely.

Producing less pain and fewer complications than open surgeries, Young's punch procedure gained many fans, though none as celebrated as James Buchanan "Diamond Jim" Brady. Brady found in Young an intrepid surgeon who would take on his chronically inflamed prostate in an April 12, 1912 procedure. Even a stormy post-operative course wouldn't mar Brady's generosity; he made a donation that founded the James Buchanan Brady Urological Institute at Johns Hopkins. Young was its first director. Others added their own twists to the transurethral procedure. New York City's Maximillan Stern launched the present-day "resectoscope" in 1926, using a moveable tungsten wire to whittle away the obstruction, thus creating the basis for today's transurethral resection of the prostate. In South Carolina, Greenville physician Theodore M. Davis used his engineering background to improve Stern's resectoscope and control bleeding by perfecting the electric current supply and adding today's double foot switch to create seamless cutting-to-coagulating surgery. New York City's Joseph F. McCarthy fashioned a lens system, with ACMI, that widened the visual field considerably. He also used a bakelite sheath and moved the cutting window to the tip of the instrument, leading modern Stern-McCarthy resectoscopes. Innovations in lens systems continued to improve and in the 1960’s Harold Hopkins introduced his rod lens system which greatly enhanced visualization. This was combined with fiber optics to carry light to create the first modern endoscopic system.

More recently bipolar resectoscopes have been developed to get around certain complications as a result of the inability to use saline irrigation with the traditional monopolar systems.

There have been multiple energies that innovators have used in the "war against the prostate" with variable success. Greenlight (532 nm wavelength) laser vaporization is quite durable. Transurethral microwave thermotherapy has some utility whereas prostatic balloon dilation, indigo laser ablation and others did not enjoy long-term durability. Holmium laser enucleation is a durable procedure with a long learning curve that has not had wide adoption so far.

Rezum is a relatively new technology where radiofrequency-heated water vapor is injected into the prostate transurethrally. Urolift is a minimally invasive procedure – implants that lift the prostate up and out from the urethra are implanted with a device transurethrally. Its five-year data looks very satisfactory for moderate symptoms.

But such innovations weren't the only advances in BPH treatment. By the mid 1970s, Israeli investigators led by Dr. Marco Caine were describing the importance of adrenergic receptors in the disorders of voiding. This resulted in the early use of alpha adrenergic blocker drugs, then on the market mainly to treat hypertension, to treat BPH. By the 1990s doctors had added newer and more specific drugs to their arsenal. "Alpha adrenergic blockers," such as tamsulosin, impede prostate and bladder muscle tension to promote better urination. Androgen suppressors, such as finasteride, shrink the prostate by blocking the conversion of testosterone into dihydrotestosterone, a player in BPH. Other classes of drugs such as phosphodiesterase inhibitors, on the market for erectile dysfunction, have also been found to have a positive effect on prostatic obstruction.

But these drugs have drawbacks. They aren't cure-alls. Yet, until scientists can prevent BPH by finding its cause, doctors are left to attack its symptoms. Fortunately, with increasingly elegant treatments, today's sufferers can hang up their bowler hats and save their walking sticks and umbrellas for strolling in the rain.

Rainer Engel, MD
Kevin Pranikoff, MD