Dr. Julia M. Willingham, MD

Medication can relieve mild to moderate symptoms of BPH, such as frequent urination, incomplete bladder emptying, a weak urine stream, and straining while urinating. However, other forms of treatment may be more appropriate if an individual has pain with urination, frequent urinary tract infections, or is unable to urinate. The size of the prostate and the severity of their symptoms will determine the type of treatment they need. If the prostate is not very large, doctors will likely recommend a transurethral procedure. This minimally invasive technique involves the insertion of a scope into the urethra. The most common transurethral procedures for BPH are:

• Transurethral incision of the prostate or TUIP, where the surgeon uses the scope to make small cuts in the area of the prostate that meets the bladder. These cuts will open up the pathway for urine and allow it to flow with more ease.
• Transurethral needle ablation or TUNA, where needles are inserted through the scope and into the prostate. The needles use radiofrequency waves to destroy excess prostate tissue.
• Laser prostate ablation, where lasers pass through the scope to melt away the part of the prostate causing urine blockage.
• Transurethral resection of the prostate or TURP, where the inside of the prostate is trimmed and removed one tiny piece at a time using the scope.

If the prostate is too big for a transurethral procedure, an individual may need a simple prostatectomy, which can be done in one of three ways: laparoscopic, robotic, or open. During a laparoscopic simple prostatectomy, a surgeon makes several small incisions on the belly. Then they insert a long tube with a camera into one of the cuts and surgical instruments into the others. Using the camera to see inside the belly, they carefully removes the enlarged part of the prostate. Robotic simple prostatectomy uses the same techniques as the laparoscopic method, but the surgery is done with the help of a robot. For men with very large prostates, open simple prostatectomy may be the best treatment option. This surgery differs from the other approaches in that it requires a much larger incision.

Most transurethral treatments for BPH, like TUIP, TUNA, and laser prostate ablation, are done in the doctor's office or outpatient surgery center. TURP and simple prostatectomy, however, need to be performed in the hospital and require an average stay of one to three days. Patients should wait a week before doing any strenuous activities after a TUIP, TUNA, or laser prostate ablation, and about four to six weeks after a TURP or simple prostatectomy. Although these treatments improve BPH symptoms for most patients, it is important to be aware of the risks involved, such as urine control issues, tightening of the urethra, and erectile dysfunction.

SNS surgery has two parts. The first part is an evaluation phase, during which it is determined if neurostimulation is effective treatment option for patients. Patients lie on their stomachs while a temporary electrode lead, through which electrical signals will travel, is inserted into their lower back. A permanent lead may also be used, and it would remain in place should the trial period prove successful. The lead is connected to an external neurostimulator. The procedure takes approximately one hour and may be performed in a doctor's office, hospital, or surgical center. After the procedure, patients are required to keep a log of their toilet habits over approximately two weeks, and they may need to limit their activities during this time. If patients' symptoms do not improve after the trial, they may repeat the test phase or discuss other treatment options with their doctors.

If the trial stimulator is effective, patients will undergo the second phase of SNS surgery, which is permanent implantation. In the second stage of surgery, the temporary lead (if used) will be replaced with a permanent lead. Then the sacral nerve stimulator will be implanted subcutaneously (under the skin) in the upper buttock. Patients should be able to return home the day of their procedure.

If patients are sore after surgery, their doctors may give them medication. The sacral nerve stimulator will be programmed after the procedure, and when it is turned on, patients should feel a sensation similar to pulling, tapping, tingling, or pulsing. Patients will need to work with their doctors during follow-up appointments to determine the most effective settings for the stimulator. Patients will be given instructions on how to adjust it themselves at home. The stimulator is powered by a battery that will last approximately five years, after which it can be replaced.

Lithotripsy is a procedure used to break up small stones. Shock wave lithotripsy, the most common type of lithotripsy and least invasive way of treating stones, does this using high-powered sound waves. This procedure can treat many types of stones in the body, but it is most frequently used for urinary stones, such as kidney and bladder stones.

Shock wave lithotripsy can be done in one of two ways. Conventionally, this procedure is performed when someone is sitting in a tub of water, and the sound waves travel through the water to their body. A more recent alternative is to send the shock waves through cushions while a patient is lying on a table. Although shock wave lithotripsy is not surgery and requires no cutting, the patient will be given anesthesia before the procedure. Their body should be able to pass the broken-up urinary stones naturally in their urine after treatment. For other types of stones, another minimally invasive procedure may be required to remove stone fragments left by shock wave lithotripsy.