Monday, June 2, 2014

Faculty Spotlight: Stephen Schatz, Innovative Treatments of BPH

Benign prostatic hyperplasia (BPH) and associated lower urinary tract symptoms (LUTS) are incredibly common.  Approximately 40% of 50-year old men with have histologic evidence of BPH at autopsy, this number increases to 80% for 80-year men.  Over the same time period, mean prostate volume increases from an average baseline of 15-25 grams at age 50 to 25-40 grams at age 80.  In addition, the percentage of men with moderate-to-severe LUTS increases with age.[1]  When LUTS are bothersome, treatment options for BPH include medication and, when medications fail, surgery.

Stephen Schatz, MD
The traditional surgery for BPH is the transurethral resection of the prostate (TURP).   This operation has long been considered the "gold standard" for symptom relief.  But now, instead of chipping away at the prostate, says urologist Stephen Schatz, "we are doing far more procedures using either bipolar electrosurgical vaporization or laser vaporization techniques."  Essentially, vaporization destroys prostatic tissue using a high-energy source that coagulates as it destroys, preventing bleeding.

"Vaporization techniques are demonstrated to be safer than traditional TURP, with results that are entirely comparable" in terms of the durability and degree of symptoms relief, and retreatment rates are quite low.[2]  

With vaporization, the only significant downside is temporary worsening of irritative urinary symptoms (frequency, urgency and burning) immediately afterward.  But, Schatz says, "I have found this always gets better, and the long-term improvement is profound in most men.  It's a great alternative to long-term medical treatment," which takes longer to achieve an effect and does not provide as great a relief of symptoms.

Although Schatz performs all the surgical procedures, he prefers bipolar vaporization.  "I can see the prostate clearly as I work, without bleeding obscuring my view," he says.  Immediately afterwards, he adds, "the urine is almost always clear."  Only about 5% of patients stay overnight.  In addition, the rates of erectile dysfunction lower than with TURP because there is no electricity arcing outside the prostate and potentially injuring the cavernous nerves.

For men with BPH and low-risk prostate cancer...

Schatz and colleagues are even able to use vaporization on men with low-risk prostate cancer in Johns Hopkins' active surveillance program who are significantly bothered by LUTS.  "We continue to follow them regularly with biopsies and PSA tests," he says, "but the cancer doesn't get in the way of their treatment."

For men with very large prostate...

Schatz performs a simple prostatectomy - enucleation of the prostate, going in through a skin incision and through the bladder - robotically.  In a case series of more than 50 patients, Johns Hopkins urologists have reported outcomes that are comparable to the results from open surgery, but with clear decreases in perioperative blood loss.

For men who are poor candidates for surgery...

Schatz and interventional radiologist Mark Lessne are conducting a multicenter trial comparing prostatic artery embolization with traditional TURP, using very rigorous outcome measures, measuring prostates and performing urodynamics before and after, and tracking quality of life indices to see how patients respond.  The angiography procedure, done through the femoral artery, takes less than three hours and has "essentially no blood loss and no absorption of any fluids," Schatz says.  Symptoms improvement comes gradually as prostate tissue dies.  Click on the following link to see our prior blog entry on prostatic artery embolization.

Schatz suspects that within a few years, this treatment will be offered to men who "may not be candidates for even minimally invasive surgery, but who have significant symptoms not helped all that much by medications."

This blog entry is extracted and modified from the "Johns Hopkins Urology: News for Physicians from Johns Hopkins Medicine," Spring 2014.

[1] Roehrborn, Claus G., MD.  Benign Prostatic Hyperplasia : Etiology, Pathophysiology, Epidemiology, and Natural History [Book] Campbell-Walsh Urology, chapter 91, Pages 2570-2610.e10 Copyright © 2012, 2007, 2002, 1998, 1992, 1986, 1978, 1970, 1963, 1954 by Saunders, an imprint of Elsevier Inc.
[2] Teng J1, Zhang D, Li Y, Yin L, Wang K, Cui X, Xu D.  Photoselective vaporization with the green light laser vs transurethral resection of the prostate for treating benign prostate hyperplasia: a systematic review and meta-analysis.  BJU Int. 2013 Feb;111(2):312-23. doi: 10.1111/j.1464-410X.2012.11395.x. Epub 2012 Nov 13.

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