BPH (Benign Prostatic Hyperplasia) and Greenlight Laser - PVP

The Greenlight laser (PVP, or photovaporization of the prostate) uses a special (green) wavelength of laser light, which immediately vaporizes and removes enlarged prostate tissue.

It combines immediate symptom relief and dramatic flow-rate improvements with minimal side effects and fast operative and recovery times. Anything you could possibly find fault with any of the other treatments (bleeding, scarring, impotence, delayed symptom relief, lengthy recovery), doesn’t happen (or happens much less) with the PVP. Any improvement in symptoms the others could provide, the PVP can provide better, and with far less risk.

Seed implantation is an effective treatment for men with localized prostate cancer. Seed implantation requires no surgical incision and offers men a short recovery time. Brachytherapy is an outpatient procedure. Patients go home the same day as their treatment. Recovery usually takes only a day or two. Additionally, most men return to their normal activities a few days after treatment. Physicians recommend waiting about two weeks before resuming sexual activity.

What Is a Prostate?

The prostate, found only in men, is a doughnut shaped gland lying just under the base of the bladder. The pee channel, or urethra, runs through the hole in this doughnut. This urethra, then, runs from the tip of the penis through the prostate up to the bladder. Although this is all one tunnel, there are different landmarks along the way to tell exactly where one is in the channel - within the shaft of the penis, or within the prostate, or bladder.

What does the prostate do?

The prostate is like a switching station in a train yard. It decides what fluid is going to come out the penis. So, when you have sex, the prostate shuts off the bladder neck, letting sperm come down the "track". And, when you pee after sex, the prostate is shutting down the sperm tubes, and letting only the bladder eliminate down this "track".

A small portion of a male's ability to stay dry (not leak urine) lies in the smooth muscle of the prostate. Most of this sphincter function (the ability to stay dry), however, lies in the lower bladder neck. The prostate also produces some of the fluid that makes up your ejaculate. The sperm made by your testicles is stored in the sperm sacs behind your prostate, until you climax. Before you climax, the sperm from the testicles is mixing in the sperm sac with thickening fluid made by the prostate's sacs themselves. This thickener gives the sperm mass or bulk, so that when you have an orgasm, the contraction of the sperm sacs and prostate throws the thick fluid down the urethra, propelling it forcefully forward, like a snowball, in hopes that it will hit the female's cervix, and eventually fertilize her egg to create a pregnancy.

Prostate Growth

Your prostate starts to grow with the surge in testosterone (male hormone) that occurs with puberty. Growth of the prostate is slow, but continuous, from then on. Your bladder starts life with a fixed amount of muscle capacity or strength. When called on for more strength, your bladder probably has some reserve that it can dip into, but essentially viewing your bladder's strength as somewhat fixed will help you understand how the bladder reacts to growth of the prostate over time. At birth, the your prostate and bladder are in perfect harmony. The bladder certainly has enough firepower to push all of its urine out the urethra when you feel you have to pee.

The relationship of the bladder with the prostate, though, constantly but slowly changes as the prostate slowly enlarges throughout life. It may take some time for the prostate's enlargement to be recognized or have an effect on the bladder's function. Generally it is accepted that men start to notice the symptoms of enlargement of their prostate around age 60. You should realize that two variables play a role in how severely and when men will notice these symptoms. The two variables are: bladder strength and prostate size. Some men have huge prostates and don’t notice them at all. The only thing that can be said for such men is that they must have naturally strong bladders that don’t perceive their bigness of prostate as a problem. Conversely, there can be men with small prostates who have every symptom that others would only get with a big prostate. Their problem may be that they were born with a generally weak bladder (one of limited strength) which could not cope with even the slightest enlargement of the prostate. So the relationship between prostate size and bladder strength is important to understanding symptoms of a blocking prostate.

To make things even more confusing, men's prostates grow at different rates. This means that there may be an average size for a man's prostate at age 50, but that there will also be men with prostates drastically smaller than that at age 50, and an equal number of men with prostates much larger at that age, when prostates would generally not be expected to be so big. A patient with a big prostate by age 50 must have an annual growth rate that is faster than that of his peers, to have achieved a bigger gland in the same amount of time. Such is the randomity of life. If that 50 year old with the huge prostate happens to also have a strong bladder, he may remain blissfully unaware of his big-ness for quite some time. But, if he has a weak bladder, he'll have symptoms at an early age.

How Does Enlargement of the Prostate Cause Symptoms?

A man with an enlarged prostate may notice that he goes to the bathroom more often, gets up at night to go, has a slow stream that takes time to start, isn’t forceful and doesn’t stop cleanly. He'll notice a start-stop pattern of voiding, and will go in spurts rather than with a continuous flow. He'll notice that when he does get the sense he should go, he has to go immediately (urgency), or else risk wetting himself. Any or all of these patterns may be seen. Symptoms ignored for a long time will lead eventually to complete blockage - unable to void at all - called retention, which requires a trip to an emergency room for a catheter to drain the blocked bladder until the prostate can be further treated.

All of these symptoms appear and worsen gradually as the man gets older

Early in life, your prostate and bladder start out having a perfectly harmonious relationship. Say that your bladder is born with the ability to generate 10 push-ups worth of bladder energy ("bladder energy-generating ability" isn't officially measured in units of "push-ups". We are making up this fake unit of measure just for purposes of this example). For the most part, your bladder can generate 10 push-ups worth of energy and not much more (your bladder has a fixed strength). Prostate growth starts with puberty. Early in life, (say from puberty to age 35-40), before much prostate enlargement has had chance to occur, those 10 push-ups are still more than enough to completely empty one's bladder. After going to the bathroom, the bladder is completely empty and so has plenty of space (and, thus, plenty of time) to hold more urine before it becomes full and has to empty again. So urination is more efficient and less frequent, with emptying that's complete and a flow that's strong.

Now, say that, slowly, over time, your prostate gets bigger, and takes on mass, so the hole in the doughnut, once wide open, is getting smaller and closing as the bulk of the prostate presses in on the doughnut hole from all sides. Where your bladder could once use all 10 push-ups of energy to eliminate the urine, it now finds it must first spend two push-ups just to open your closing prostate, and then only has 8 push-ups left to empty itself. Say that as time goes by (and the prostate enlarges even more), it takes 4 push-ups to open the prostate, leaving only 6 push-ups to empty. You can see, as this goes on, that more and more of the bladder's fixed reserve of strength must be spent in simply opening the prostate, leaving less and less energy to empty your bladder. Each time you go to the bathroom, you void slightly less than the time before. By doing this, you have more urine remaining in the bladder after you’ve just emptied. You are soon full again and have to go more and more frequently. Your stream will slow as the big prostate takes all the force out of it. When you get the urge to go, you've got to go, urgently! While you once used to be able to delay going till it was convenient, you now can't wait. When you have to go, you are really full, and have no more storage space left. If you don't soon go, you will simply leak to vent the high pressures building in the bladder. You are operating off the top half of your bladder, which is never truly empty.

How Can I Prove My Prostate Is Causing My Symptoms?

Flexible Cystocopy

The bladder tries to cope with the enlargement of the prostate. When it was healthy, the lining of the bladder appeared absolutely smooth. However, the blocked bladder's muscles will be visibly separated into very dramatic bundles when viewed with a telescope (cystoscope). These bundles are called trabeculations, and the spaces between them are sacculations. Actually, with the bladder needing to generate high pressures to empty, the lining of the bladder slips out between the muscle bundles and creates these pouches (sacculations). This would be similar to squeezing a handful of wet sand at the beach. As the pressure in your hand increases, the sand has no choice but to escape thru the spaces between your fingers. The bladder lining has no choice but to escape the high pressures of the blocked bladder by slipping between the bundles of muscle, thus forming sacculations. This appearance is only seen with high pressure voiding, such as when your prostate is too big for your bladder. So, cystoscopy is a simple test to show not only that a prostate is enlarged, but also physical evidence (in the changed appearance of the bladder) that the bladder is being overwhelmed by that prostate. Prior to any treatment, most patients would have a flexible cystoscopy to prove that it is the prostate causing their symptoms. Cystoscopy gives patients valuable information needed to decide their future. This procedure is easy, quick and painless. It is often performed with a television camera attached to the eyepiece so both the urologist and the patient can look together at a monitor to see the changes described above. Patients resume normal activities immediately afterward.

What Is The Best Treatment For An Enlarged Prostate?

Historically: (early treatments: open surgery, TURP, alpha blockers)

A brief review of the history of treatments for enlargement of the prostate will tremendously help with your understanding where therapy stands today. One of the earliest treatments for enlargement of the prostate was open surgery through an eight inch incision in the lower belly to core out the inner, blocking tissue of the prostate. This was called a suprapubic (SPP) or retropubic prostatectomy (RPP) (and should not be confused with open surgery to remove the whole prostate when the diagnosis was cancer - open radical prostatectomy). When the patient did not have cancer and simply had a huge prostate, this supra/retro pubic prostatectomy was done. In it, the blocking tissue was shelled out of the capsule of the gland, clearing the once blocked channel. This was very invasive and needed a considerable post-op recovery period. Obviously patients would rather grow their prostates very big before they felt having this procedure was worth the risk. Many patients with "not-that-bad" sized prostates suffered for years before having this surgery. When telescopes were then developed, which could be passed up the pee channel under anesthesia to trim out the blocking prostate (TURP or transurethral resection of the prostate), patients who had refused having a big incision with the open surgery were happy to have another surgical option. There is a limit to how much tissue even the most skilled surgeon could ever remove through a telescope, so with really big prostates, open surgery was still favored. The TURP, however, did allow men to have an option other than waiting for their prostate to get super-huge and then having the open procedure. For many years, TURP remained unchanged and uncontested as the "gold standard" of therapies for enlargement of the prostate. It was not that TURP didnt have its own problems, but rather that it produced reasonably good results with reasonably little risk compared to what else was available at the time.

TURP became very popular, and drug companies, seeing how many men actually were having the procedure, developed medicines to treat enlargement of the prostate hoping to capture a piece of the market. The initial medicines were minipress, followed by Hytrin, Cardura and most recently Flomax and Uroxatrol. These are all alpha blockers, which relax smooth muscle. The prostate does contain some smooth muscle, so the theory is that by relaxing this smooth muscle fraction of the prostate, the hole in the doughnut becomes less tight, and allows for a better urine flow and better emptying, translating into decreased frequency. These medicines didn’t work as good as trimming (TURP). They couldn’t possibly. Since the problem with big prostates came from their bulk or mass, only a solution that lessened that mass could ever really hope to be successful. These medications never lessened the mass of the prostate, so, understandably, their benefits never approached those of a TURP. They were, however, easy to take and appealed to those who were against having a procedure.

The problems with TURP were numerous. The tissue bled as it was cut, so visibility decreased as the procedure progressed, and this ultimately limited the amount of tissue that could be removed. To stop the bleeding during the procedure, high levels of electric energy were used to cauterize the bleeding tissue. Since your body is 70% water, and water conducts electricity, its not surprising that trimming with electricity (TURP) caused post operative impotence (loss of erections), scar tissue (bladder neck contractures) and loss of ejaculation. It is now very clear that electricity electrocuted the tissue that remained. The true extent of the side effects of electricity was not really recognized until recently, with the advent of the Greenlight Laser, which is able to remove even more tissue than TURP but uses light rather than electricity, and, amazingly, has very few of these side effects.

The popularity of the TURP was maintained by its being less invasive than the open surgery, and more effective than the medications of its day. Everything does need to be compared to its historical surroundings to best understand its popularity. I don’t think there is any reason to perform a TURP today, when easier more effective treatments exist.

Avodart/proscar

We had mentioned how alpha blockers merely relaxed prostates, and how that didnt really change the true root cause of the problems from prostates, which stemmed from their "big"ness, bulk or mass. On alpha blockers or not, the size of your prostate remains the same, (and your prostate continues to grow). A novel approach is used in the drug proscar (and more recently, avodart). These drugs selectively block the action of testosterone within the prostate. Remember that we said the prostate growth started with the increase in testosterone that occurs with puberty? In the absence of testosterone prostates dont grow. If you remove testosterone, already grown prostates will shrink (somewhat).

The problem with these medications is they are much more effective at preventing prostate growth than erasing growth that has already occurred. To be truely effective, then, they would have to be started before there is appreciable growth of the prostate, just on the hunch that a particular patient is certain to get enlargement of the prostate in the future. (We really aren't certain who will or won't get enlargement of the prostate, or, further, who with a big prostate will even have symptoms from it, so we'd have to treat every man in the hopes of helping those who would really need it. This would mean giving the medications to lots of men who would never have needed it). These medications can have some side effects, such as decreased sex drive and enlargement of the breast tissue, so giving them early to many to prevent growth in a few is not only wasteful but dangerous. Again, the popularity of such medications can best be understood by understanding their historical surroundings. They had a certain appeal, considering the risks of TURP and open surgery - the other treatment options available at the time. Though they still have a place in the treatment of enlarged prostates, given the more effective therapies that currently exist, they have much less appeal today.

The Newer Treatments

Weeding Out Ineffective Alternatives

In the 1990's, one could tell that man was searching for a replacement for the TURP as the "gold standard" for treatment of prostate enlargement. Practically every year there was a "great new discovery" that promised to "revolutionize" treatment. One by one, newer treatments were hyped as contenders for TURP's title of " gold standard treatment", and, one by one, they all failed. The list of less effective alternatives to TURP includes:

• Microwave (TUMT, CoreTherm, TherMatix, and Prolieve)
• Thermotherapy (AquaTherm)
• Needle Ablation (TUNA )
• Interstitial Laser Coagulation Indigo)
• HoLAP (holmuim laser prostatectomy)
• TUVP (vaportrode)
• Balloon Dilatation
• Prostate Stents
• HIFU (high intensity focused ultrasound)
  

Microwave (TUMT, CoreTherm, TherMatrix, and Prolieve), thermotherapy (AquaTherm), needle ablation/laser coagulation (TUNA and Indigo) and HIFU (high intensity focused ultrasound) can only treat small to medium sized glands, and leave the cooked tissue lying within the prostate, where it causes prolonged inflammation and irritation, until it sloughs on its own (this may take several weeks, during which the patient has irritative voiding symptoms). Microwave and ablation techniques might be tempting for very private patients to consider because they usually require either no anesthesia or light sedation, so they can be discreetly performed in an office setting. They aren't effective at removing bulky tissue, so patient's gland size is a very important consideration.

HoLAP (holmuim laser prostatectomy) is very similar to the Greenlight PVP, except HoLAP uses a weaker wavelength of light that only penetrates 1-2 mm, compared to Greenlight's 3mm depth of penetration. Three millimeters of penetration provided only by the PVP is the ideal depth, allowing for both precise yet rapid vaporization. The HoLAP is therefore much slower, so the operative times are much longer, and surgeons using the HoLAP will shy away from big glands because the combination of slower rate of vaporization with large amounts of tissue to be vaporized will lead to very long operative times, with lengthy anesthesias. The HoLAP does work, it should just be considered the younger, weaker brother of the PVP.

TUVP (vaportrode) uses very high electricity settings to prevent the blood loss seen with the conventional TURP. Even though laser can remove more tissue quicker and with practically no bleeding, TUVP is occassionally still an excellent choice under certain circumstances. I personally prefer to use TUVP to treat retention occuring after brachytherapy (radioactive seed implant for prostate cancer). Here the laser light of the PVP can reflect off the metallic seeds, decreasing its effectiveness. (This is the only situation in which I'd ever prefer to use anything other than PVP/laser.) Balloon dilatation caused tearing of the prostate which ultimately healed with scar tissue - resulting in worsened blockage (so this was removed from market quickly after being introduced). Prostate stents got calcified by all the minerals normally present in urine (and never made it to market).

Not surprisingly, most patients find the large number of possible treatment options very confusing, and can't begin to distinguish one proceedure from another. Even doctors, who are used to sifting through scientific studies and weighing data, may have trouble keeping up with all the treatment options, and find it difficult to advise their patients. Microwave, TUNA, thermotherapy and other minimally invasive therapies all require compromises be made by the patient and/or physician. With PVP, there are no compromises, patient's symptoms are drastically reduced and flow rates are significantly improved.

Greenlight Laser - PVP: The Solution

The Greenlight laser (PVP, or photovaporization of the prostate) uses a special (green) wavelength of laser light, which immediately vaporizes and removes enlarged prostate tissue. It combines immediate symptom relief and dramatic flow-rate impovements with minimal side effects and fast operative and recovery times. Anything you could possibly find fault with any of the other treatments (bleeding, scarring, impotence, delayed symptom relief, lengthy recovery), doesnt happen (or happens much less) with the PVP. Any improvement in symptoms the others could provide, the PVP can provide better, and with far less risk. I have treated many patients (from other urologists) who had failed to improve after having microwaves, TURP's, Indigos, TUNA's or other treatments. The main cause of failure has been inability of those therapies to handle anything larger than a mild to moderately enlarged prostate. All of their failures had residual tissue causing their symptoms to persist, and all the failures were easily converted to successes by vaporizing the remaining tissue with the PVP. The PVP is the only therapy that can deliver consistently excellent results, regardless of prostate size (its especially good for BIG glands) with minimal risk and recovery.

The PVP Procedure

PVP Procedure During the Procedure: The PVP laser probe is passed to the prostate under direct vision through a cystoscope inside the urethra (pee channel). The light pulses are directed towards the prostate tissue. The laser quickly vaporizes and removes the prostatic obstruction without significant bleeding. This is usually done in a surgicenter under general anesthesia as an outpatient. Laser produces consistently excellent symptom relief regardless of gland size.

There is no limit to the amount of tissue that can be removed safely in one setting. This laser can remove 2 grams of tissue per minute, so even very large prostates can be easily and quickly treated.

The average operative time is normally less than 60 minutes.PVP is not bloody (patients on blood thinners technically can have a laser without stopping their blood thinners, but we usually do stop blood thinners for a few days before the procedure, just to be safe). The tissue is vaporized by the laser and never gets a chance to bleed, so visibility is never lost during the procedure. The laser is very precise, since its done under direct visualization, and the lack of bleeding allows for even greater precison.

The urine may be red for about 24 hours after the proceedure, but the amount of blood actually lost is always negligible. No PVP's have ever come even close to needing a transfusion, even with the biggest of prostates Most patients do go home with a catheter, but this is more for safety rather than because they actually need one (Many patients are so blood-free, they don't get a catheter at all). All catheters are always removed early the next morning. Patients report dramatic improvement in emptying immediately after having a PVP. Over weeks to months, any pre-op frequency will resolve as his bladder realizes it can now empty completely again, and has more room for storage - just like before the prostate ever started growing. Long term follow-up data indicate that the dramatic improvements in symptoms, urinary flow rates and bladder emptying have been durable over a 5-year follow-up period.

Although patients do still have a prostate (now hollow after a PVP), which will continue to grow, the laser is so effective at vaporizing out all the blocking tissue, most patients would need almost another lifetime to re-grow what bulk the PVP just removed.

I have performed many PVP procedures and none of my patients have had problems with post-op bleeding, impotence or bladder neck contractures. The extremely low incidence of these in large published series supports my personal experience. The laser is light, which is not conducted, ie.its not electricity. The nerves that run down the outside of his prostate to help his penis create an erection are unaffected by the laser light shining on the inside of his prostate during the proceedure. If electricity were used (TURP, Vaportrode) the current would arc through the conductive water in the prostate tissue over to the nerves and would likely eventually palsy them, causing post-op impotence. The laser beam only penetrates 3 mm into the tissue under it. The tissue under the 3mm depth is not electrocuted, so scarring and bladder neck contractures are much less common than with TURP.

All PVP's are outpatients (unless the patient is 80+ years old and/or has other medical problems, in which case his procedure is done as a 23 hour stay for observation, but even he will still go home the next morning catheter free and voiding better immediately. Notice that the PVP works so well that many 80+ yr old males, even with very big prostates, have had the procedure done. That is a great unsolicited testimonial as to just how effective and easy to tolerate the procedure is, and how mild the recovery period is afterward!!!).

Retrograde ejaculation is the term given when sperm, at the time of ejaculation, goes backward (or retrograde) into the bladder, rather than forward down the urethra, as usual. Retrograde ejaculations has nothing to do with the ability to get an erection or to have an orgasm. After a conventional TURP, the bladder neck could be considered damaged (electrocuted). It is in the fixed open position, static, and no longer opens and closes as it once did. (Remember in the opening of this section we described the prostate's function as being that of a switching station in a train yard? The prostate decides which "train" (sperm or urine) will come down the "track"(urethra). Well, after a TURP, this dynamic, active ability of the bladder neck is lost and the bladder neck is set to permanently direct only the urine down the urethra. As a result, the sperm, during an ejaculation, chooses going backwards (the path of least resistance) rather than forwards.

On the other hand, retrograde ejaculation, after a PVP, seems to have a different mechanism, and thus a different incidence, and course. The PVP is laser light which penetrates only 3mm and isnt conducted, so the incidence of scar tissue after PVP is extremely low. The bladder neck is unscarred and seems to retain its dynamic abilities post-op. The retrograde ejaculation that does occur post PVP seems instead to be due to the prostate's now being perfectly hollowed out. The hollowed out space within the prostate seems to dampen the velocity of the sperm coming into it from the sperm sacs. Sperm simply hits the open space, losing its forward momentum, and just sits there, rather than being forced forward or backward (Normally, the mass or bulk of the prostate "herds" the sperm forward). Some men's cavities seem to shrink quickly post-op, so they don't lose their forward ejaculation, while others, after PVP, have their cavity shrink over the next year, resulting in the 10% return of forward ejaculation noted over time. This percentage may improve with longer follow-up. No matter what the mechanism, the risk of ejaculatory disturbance after PVP is much less than seen with TURP.

I am firmly convinced PVP is a major advancement in the surgical treatment of the enlarged prostate.

What's Best for the Patient?

During my years of practice, I have constantly tried to provide "what's best for the patient". The interesting thing is how "TIME" can change one's perspective on that. Very early in my career, I had several 70 year old patients, with obviously huge prostates, who said their symptoms were lessened with medications and refused surgery. I felt they had very big prostates and didn’t see how they could be as improved with pills as they claimed, but accepted what they told me. I also was leary of trying to trim such big prostates via TURP, feeling that I couldn’t really get enough tissue out, and was thus likely to stir up a hornet's nest of trouble if I tried. I also felt that I didn't really have the heart to push those patients to have open surgery just on my belief that their large glands surely had to be giving them more symptoms than they were letting on. So I did not treat these patients except with medications, and I had the opportunity to see, over the last decade, whether they and I were correct in taking this non-operative course. It turns out, we weren't.

Invariably, these men with really huge prostates got that way by growing prostates at faster rates than others. So, when advances in modern medicine prolonged their lives, it also gave them more time to grow even bigger glands, which eventually outstripped the ability of their bladders to cope, sending them into retention. I thought I was doing them a favor by not operating when their large prostates were first discovered. Instead, I was unknowingly creating worse problems later by delaying definitive treatment. Several of these patients had heart attacks in their 80's, went into retention, and were started on blood thinners for their medical problems. Suddenly I was faced with having to trim a now bigger prostate on a patient who just had a heart attack and was now on blood thinners. Obviously, things would have been better had I trimmed their prostates earlier. Situations like these made me realize the need for both patients and myself to face reality. I can understand how patients would like to avoid having either a TURP or an open procedure. I also understand how ignoring real problems makes them worse. PVP resolves this dilemma.

Another interesting thing to consider is that if a man lets his prostate get very enlarged without seeking treatment, and only comes to treatment when he has finally gone into retention (ie his bladder has just quit and he needed to go to the emergency room to have a catheter placed to drain it), he may find his bladder permanently ruined, unable to ever return to normal voiding. Though the PVP can remove the blockage, his voiding will never be forceful, and his frequency will never resolve. Any procedure under those conditions will merely make him catheter free. That is the best outcome he can hope for. This argues in favor of early treatment, or, at least, not failing to treat enlargement when it is recognized. Hopefully, once patients learn PVP is minimally invasive and very effective, they will no longer delay needed treatment and "ruined bladder" scenarios will be a thing of the past.

Since PVP is so minimally invasive and very effective, it would be nice for patients to know that treatment of big prostates should not be avoided and scenarios like the "ruined " bladder are easily completely avoided.

Greenlight PVP and PSA

Thankfully, now, the Greenlight PVP gives patients an easy-to-tolerate, very effective, low risk procedure to avoid all those downsides. The PVP is so easy and effective, it really does lend itself as a solution to other scenarios that previously had none. Most patients agree that the man who gets up many times a night, has a slow stream, and urgency is getting "run" by his prostate. The big size of his prostate is running his life, controlling him. When his prostate demands, he must comply, its nice then that this patient can have a PVP and regain control of his life. Right? We also know that men get PSA's (prostate specific antigen - a blood test to screen for prostate cancer) every year. PSA's can be elevated by cancer, but also, more commonly, by enlargement of the prostate and by silent infections in the prostate. These silent infections in the prostate can't be cleared with antibiotics. They usually climb thru the pee channel to live embedded in the enlarged prostate tissue that surrounds it. This is the tissue that would be vaporized in a PVP proceedure. A patient's PSA will drop after a PVP due to elimination of prostate bulk and particularly due to the elimination of this centrally infected tissue. This infected tissue can cause a high PSA level at any time, and usually this would require a biopsy to rule out the presence of a cancer. These silent infections are common and many men are on "PSA rollercoaster" because of this. Their PSA goes up and down, without their control. Many of these men have had to have several prostate biopsies to confirm that no cancer is present. Hopefully, it turns out that none is present. But if that is the conclusion of the biopsies, then isn't that patient being "run" by the benign enlargement of his prostate just as obviously as the man with all the voiding symptoms? Shouldn't we consider that one of the newer symptoms of an enlarged prostate?

Since the PVP can easily vaporize this area of the prostate (the central area around the urethra where the infections are embedded) easily, and with minimal discomfort, risks and side-effects, how many false positive PSA's and negative biopsies should we let a patient have before recommending he have a PVP? This is a very interesting question. This is a whole new slant on how a prostate could be "symptomatic" and control a patient, without even affecting their voiding, and how a patient could regain control over this with a PVP. Having a PVP to lower your PSA is usually something that is considered and discussed more and more by the patient with his urologist as they see that his PSA is falling into this type of pattern. This is a very new consideration, but is also an exciting new route for these patients to effectively get off their "PSA rollercoaster".

Some patients come in with a high PSA, and, in the course of an ultrasound-guided biopsy (to rule out prostate cancer), it is documented they indeed dont have prostate cancer and do have not only significant benign enlargement but also evidence of chronic infection. If these patients additionally have obstructive voiding symptoms, their having a PVP will solve their voiding problems, lower their current PSA, and get rid of two sources of false PSA elevations (enlargement and infection).

My Experience

The first Greenlight Laser came to this area in January 2005. By word of mouth, happy satisfied patients increased the demand for the procedure to such a degree that there are now three lasers in operation. Initially, when all of the area's 14 practicing urologists were sharing one machine, it was easy to look at the log book and see who had the most experience. By August 2005, that log showed 600 cases had been performed, and, of those, I had performed 100. (The next highest level of experience was a colleague who had performed 50). I perform, on average, three PVP's a week. I have great experience with applying the therapy to extremely large glands. I really believe in the PVP procedure and am firmly convinced it is a major advancement in the surgical treatment of the enlarged prostate.

Before	After

Not surprisingly, patients have uniformly had exceedingly positive things to say about the PVP. Most cite their appreciation of how easy the procedure was, how quickly they saw improvement, how strong their flow now is, and how nice it was to get a good nights sleep or no longer need to keep track of where the nearest bathroom is. Post-operative side effects, if any, have been minimal and transient. Patients usually feel well within several days of the procedure, but full recovery can take several weeks. Some blood in the urine is common during the recovery process. This is harmless and rarely requires treatment. Many of our previous patients have offered to gladly share their experiences with anyone considering the procedure. Word of mouth in the community has been so favorable, that several new patients now come in weekly specifically to discuss having the procedure.

Patient's Comments About the PVP

Arthur Kay (age 79) had a PVP for enlarged prostate 9/2005:
"My stream is so much stronger, I go better and now I can even sleep through the whole night without waking. I used to call you 'Doctor', now I call you 'friend'. Everything is great. Couldn't be better. This and my angioplasty were the best things I ever did for myself."

John Keenan (age 68) had a PVP for his enlarged prostate 2/2006:
"I'm very pleased with the results. I rarely get up at night anymore. Before the laser I used to get up several times nightly. I used to have poor flow. Now I feel I could put out a fire from across the street!"

Post-Op PVP Instructions

You did have your prostate vaporized, so there is a surface inside you cannot see that has been changed. It is not near as raw as with the conventional old fashioned TURP resection...but the normal surface has been temporarily changed and will not return to normal immediately. Laser surgery is amazingly bloodless, but seeing some blood on occasion would not be out of the ordinary. The prostate surface may take from two weeks to one month to seal completely. If you lift, strain or have sex in the first 3 weeks post-op, you will likely see blood in the urine. It may be that you see no blood, until the 30-th day…any variation is possible. If you do see blood, it is usually a sign you lifted, did too much, strained etc., so, if you "see it", get off your feet, rest, drink lots of water. The main thing is to try to get any bleeding to stop before returning to normal activities. The other thing is, if you do bleed and you don’t heed these measures, you just make your condition worse and may get a clot that blocks your ability to pee, thus you'll have to go to the emergency room to get that out. But this could really only happen if you ignored all the signs. Hence this is info you want to know.

Colace is an over-the-counter stool softener that prevents constipation. Constipation can be a cause of straining that may cause blood in the urine. So, get take colace if needed. Take any laxative you need.

So when can you go back to work?

It varies, but as long as you don’t lift or strain at work, maybe in three days. You can walk/drive/take stairs/lift a fork immediately post op, but don’t do anything more than that for three days. After 3 days you can return to your regular daily activities. No lifting, straining or sex for three weeks. What if you do lift or strain normally at work? Either get light duty or stay off work for 7 days.

Some men are on proscar or flomax or other prostate meds (cardura, uroxatrol, hytrin) before a PVP. Should they continue them post op?

I like to continue prostate meds for one month after laser, then stop them completely. If you run out quicker than one month, don't worry, just stop them without getting a refill.

Laser is a significant improvement over TURP (the old fashioned trimming). Even though its clearly better, you still did have surgery and a little bit of common sense will keep you from having any problems. As technology makes invasive surgery less and less invasive, patients will feel less and less like they actually had anything done, thus creating a new source of problems: doing too much too soon because they actually couldn’t believe how "great" they felt. Some mistakenly feel that if they "feel great", the post op instructions don’t apply to them, and abandoning the suggestions opens them up to the possibility of creating problems for themselves they could have otherwise avoided. The price of progress!!! Don't let that happen!

Laser patients have been doing so well post-op, they generally have not needed to come in to the office for routine post-op checks. I have started to make their follow-up "phone follow-up". I'll normally call a patient in follow up at day 4 and then again around day 14. Of course, you are welcome to call me any time you have a concern. The secretaries have been instructed to bring the rare patient who does have a post-op problem in for a visit at the next available opening if needed. Though infrequent, these instances are followed closely until resolved. The majority of patients do not need post-op visits and go right back to their yearly check-ups. Eventually everyone gets back on schedule with their yearly PSA and office visit.

Feel free to call me (302-266-7577) anytime with questions or concerns. Thank you for allowing me to participate in your care.