Enlarged Prostate Treatment Options, Kidney Stones and ED

Enlarged prostate treatment options are no longer a choice between lifelong tablets and a major operation. For men with benign prostatic hyperplasia (BPH), the options run from medicines through day-care implants and water vapour therapy to laser enucleation and robotic surgery, and open surgery is rarely needed. The same shift has reached kidney stones, erectile dysfunction and male infertility, where lasers, endoscopes and regenerative techniques have replaced incisions and guesswork.

This article sets out how Dr. Yajvender Pratap Singh Rana (Dr. Y P S Rana), Senior Director - Urology, Uro-Oncology, Andrology and Kidney Transplant, BLK-Max Super Speciality Hospital, New Delhi, India, matches each of these treatments to the patient in front of him. It is part of a series that begins with advances in urology, uro-oncology and kidney transplant.

Enlarged prostate treatment options: matching the method to the man

BPH is a non-cancerous enlargement of the prostate, the gland that surrounds the urethra below the bladder. As it grows it narrows the channel, causing a weak stream, frequency and incomplete emptying. Dr. Rana's governing principle is selection: identify the patient, and treat his symptoms in the way that leaves him most satisfied with the fewest side effects.

The typical patient, and why medicines often disappoint

The scenario he described is common. A man of about 50, not old, has bothersome urinary symptoms and a prostate of around 46 g that is obstructing, and he is unhappy with medical treatment.

Alpha-blockers, the first-line medicines that relax the muscle of the prostate and bladder neck, work but carry side effects that matter to younger men. Silodosin can cause retrograde ejaculation, in which semen passes backwards into the bladder instead of out through the penis. Alfuzosin can cause postural (orthostatic) hypotension, a fall in blood pressure on standing, and not every man tolerates it. Younger men usually want to keep their sexual function, including normal ejaculation, so for them the side-effect profile drives the decision.

Dr. Rana's view is that such patients should not be left with their symptoms for long. They need treatment.

UroLift, Rezum and other day-care procedures that preserve ejaculation

The most recent options are not surgery in the traditional sense. They are small outpatient or day-care procedures, and Dr. Rana described them as helping many of his younger patients who want to preserve sexual function.

• Prostatic urethral lift (UroLift). Small implants are placed through a cystoscope to clip the enlarged lobes apart and hold the prostatic channel open. As the tissue settles, the prostate stays in that open shape and symptoms improve.
• A temporary prostate implant. A small metallic device is placed into the prostatic urethra, where it expands and compresses the obstructing tissue. It stays for five to six days and is then removed, after which the channel remains open. Dr. Rana considers this a good option for a young man and called the device very simple to implant.
• Water vapour therapy (Rezum). A fine needle delivers water vapour into the prostate tissue, which then shrinks.

TURP and laser enucleation (HoLEP): the standard of care

For most men who need a definitive operation, Dr. Rana regards two families of procedure as the standard of care.

• Bipolar transurethral surgery, either bipolar transurethral resection of the prostate (TURP) or bipolar enucleation, in which the obstructing tissue is shelled out using bipolar current.
• Laser enucleation, using the holmium laser (HoLEP) or the thulium laser (ThuLEP).

Laser enucleation is an advanced and sophisticated technique, but it usually leaves the patient with retrograde ejaculation. Dr. Rana therefore positions holmium laser enucleation for men above 60 to 70 who are not concerned about preserving ejaculation and accept the trade-off. Indicative prices for these operations are listed on the TURP cost page and the HoLEP cost page.

Treatment for a very large prostate

Size is no longer a reason for open surgery. "None of your patient will require a open surgery in this era," Dr. Rana told the audience. For glands larger than about 200 g, in the range of 250 to 300 g, his team may perform robotic simple prostatectomy, removing the obstructing tissue through small ports. He has also routinely treated glands of around 300 to 350 g with holmium laser enucleation, including 300 g in a single session.

Kidney stone treatment without an incision

In Dr. Rana's practice, kidney stones of every size are treated without an incision: in 15 years he has not made one for a stone patient. Lasers and endoscopes do the work, and, where the anatomy is difficult, the robot.

Stones are never a silent disease

He was equally blunt about timing. A stone that causes no pain today is not harmless. Stones are a metabolic disease: they increase in size, obstruct the urinary tract and damage the kidney. Leaving a stone untreated because the patient is comfortable is, in his words, ignoring the patient. Every stone needs medical attention, and early treatment is the best treatment. Guidelines do allow small kidney stones that cause no symptoms to be watched with periodic imaging, treating those that grow, obstruct or become painful.

RIRS: kidney stone removal with a flexible ureteroscope

For stones in the kidney and ureter, the workhorse is retrograde intrarenal surgery (RIRS). A flexible ureteroscope is passed up through the natural urinary passage into the pelvicalyceal system (the collecting chambers of the kidney). The stone is fragmented with a laser, and the fragments are caught in a basket and removed.

The advantages, as he listed them, are "no holes, no cut, no blood", and the patient usually stays only one day. He described RIRS as the safest procedure for removing kidney stones. Stones of around 2.5 to 3 cm can sometimes be cleared this way. With the thulium fibre laser, he described RIRS as a very rewarding operation for the patient; the holmium laser is also used to fragment stones.

PCNL for a heavy stone load

Some patients arrive with both kidneys full of stones. These can be treated with percutaneous nephrolithotomy (PCNL), in which the kidney is entered through a small track in the back. In the case Dr. Rana showed, clearing the stones required three separate punctures, with all the stones removed through the kidney tracts.

Robot-assisted pyelolithotomy for difficult anatomy

Bony deformities can make standard stone access difficult. For one such patient with a very large stone, his team performed robot-assisted pyelolithotomy, opening the renal pelvis through two or three small ports and removing all the stones. Prices for endoscopic stone surgery are listed on the kidney stone surgery cost page.

Erectile dysfunction: a stepwise ladder

Erectile dysfunction is a very common male problem, and Dr. Rana treats it as a ladder. Counselling and medicines come first, then injections and regenerative therapies, and a penile implant only when everything else has failed.

Shock wave therapy for erectile dysfunction

Low-intensity shock wave therapy uses a device that works like a miniature version of the lithotripter used to break kidney stones. About 2,000 shocks are delivered into the corpora cavernosa, the erectile chambers of the penis. Sessions are repeated either once a week for six sessions or twice a month for three months.

The mechanism is neoangiogenesis: the shocks stimulate growth factors, and new blood vessels form within the erectile tissue. Dr. Rana put the success rate at around 65 to 70%, with a caveat that runs through all of his andrology practice: careful patient selection. The best candidates are men with borderline erectile function and well-controlled diabetes. European Association of Urology guidelines support shock wave therapy mainly for mild vasculogenic erectile dysfunction.

Platelet-rich plasma (PRP) for erectile dysfunction

For PRP, about 5 ml of the patient's blood is taken and centrifuged, and roughly 1 ml of the platelet-rich concentrate is injected into each corpus. Sessions are given once a week for three sessions. Dr. Rana put the response at around 60% of patients, again in carefully selected men: well-controlled diabetics with vasculogenic erectile dysfunction, meaning dysfunction caused by impaired blood flow. PRP is not a good treatment for neurogenic erectile dysfunction, caused by nerve damage. Dr. Rana explained that both PRP and shock wave therapy work through the same mechanism of new blood vessel growth. European Association of Urology guidelines regard PRP for erectile dysfunction as experimental and recommend its use only within clinical trials.

Intracavernosal injections

Intracavernosal injections remain a reliable on-demand option. Patients are taught to inject a measured dose of medicine into the penis themselves, and an erection follows.

Penile implants: the last resort

When conservative treatments fail, a penile prosthesis restores function. The device Dr. Rana described has three components: two cylinders placed inside the erectile chambers, a reservoir filled with saline, and a small pump. Pressing the pump moves fluid from the reservoir into the cylinders and produces an erection.

None of his patients receives an implant up front. It is reserved for men with neurogenic problems, a completely fibrosed penis, end-stage penile arterial insufficiency, or no response to injections. A recurring group is men who had open radical prostatectomy elsewhere, including patients from Africa, and lost erectile function and sometimes continence. Implants restore erectile function for them. Recovery of erections after modern robotic surgery is covered in erectile function and continence after robotic prostatectomy. Indicative prices are on the penile implant surgery cost page.

Male infertility: microsurgery for obstructive azoospermia

For men with obstructive azoospermia, Dr. Rana's team performs microsurgical vasoepididymal anastomosis, and he put the chance of sperm appearing in the ejaculate after this surgery at around 35 to 40%. Azoospermia means no sperm in the ejaculate. In obstructive azoospermia, the testes produce sperm but a blockage prevents it from reaching the ejaculate. The first step is to confirm the diagnosis and establish that spermatogenesis inside the testes is good. If it is, the operation joins the vas deferens to the epididymis under the microscope to bypass the blockage.

How these options fit together

Across the prostate, stones and sexual medicine, Dr. Rana's practice follows three rules.

1. Select the patient, then the technology. A 50-year-old with a 46 g prostate and a 70-year-old with a 300 g gland need different operations.
2. Treat early. Symptomatic BPH should not be left untreated for long, and stones damage the kidney when left alone.
3. Escalate in steps. In erectile dysfunction especially, the implant is the end of a ladder, not the first rung.

The same principles shape his approach to kidney failure, covered in kidney transplant for international patients. Questions doctors raised during the session are collected on the Live Discussion page, and more on the specialty is on the urology hub.