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What are the treatment options for benign prostatic hypertrophy (BPH)?

Q: Is it advisable to surgically treat BPH (benign prostatic hypertrophy) at the age of 91? Is TURP still better at this age or you advocate PVP/ HOLEP treatment? What are the anaesthetic risks? How long does the surgery take and is there a lot of bleeding? If laser is effective, then where is it available in Delhi? I have tried the Tamsulosin, but it hasn't worked, plus it makes me dizzy.

A:The indications for surgical intervention include acute urinary retention, failed voiding trials, recurrent gross hematuria, urinary tract infection, and renal insufficiency secondary to obstruction. In addition, failure of medical therapy, a desire to terminate medical therapy, and/or financial constraints associated with medical therapy may be indications to proceed with a surgical intervention. However, TURP has a significant risk of morbidity (18%) and mortality (0.23%). In current clinical practice, most patients do not present with obvious surgical indications; instead, they often have milder lower urinary tract symptoms and, therefore, are initially treated with medical therapy. A wide variety of surgical procedures are available and these include the following minimally invasive treatments for BPH. Most minimally invasive therapies rely on heat to cause destruction of prostatic tissue; however, this heat is delivered in a limited and controlled fashion with the hope that the complications associated with TURP may be avoided. They also allow for the use of milder forms of anaesthesia, which translates into less anaesthetic risk for the patient. Heat may be delivered in the form of laser energy, microwaves, radio frequency energy, high-intensity ultrasound waves, and high-voltage electrical energy. Delivery devices are usually similarly passed through a working sheath placed in the urethra, although they are usually of a smaller size than that needed for TURP. Devices may also simply be attached or incorporated into a urinary catheter or passed through the rectum, from which the prostate may also be accessed. 1. Transurethral incision of the prostate (TUIP) has actually been in use for many years and, for a long time, was the only alternative to TURP. It may be performed with local anaesthesia and sedation. 2. Photoselective Vaporization of the Prostate (PVP) Lasers deliver heat to the prostate in a variety of ways – a) They may be used to directly evaporate, i.e., melt away prostate tissue. They may also be used in a manner in which the laser is not actually in direct contact with the prostate but delivers heat energy into the prostate, resulting in cell death of the prostate tissue or b) Lasers may be used in a knifelike fashion to directly cut away prostate tissue (Holmium Laser Enucleation of the Prostate (HoLEP). 3. The use of microwave energy, termed transurethral microwave therapy (TUMT), delivers heat to the prostate via a urethral catheter or a transrectal route. 4. Transurethral needle ablation of the prostate (TUNA) involves using high-frequency radio waves to produce heat, resulting in a similar process of thermal injury to the prostate 5. High-intensity ultrasound energy therapy delivers heat to prostate tissue, with the subsequent process of thermal injury. 6. Water-induced thermotherapy is a relatively new procedure in which heated water is circulated through a balloon in the prostatic urethra, thus initiating a process of thermal destruction of prostate tissue. You need to discuss this with the surgeon as the modality chosen will depend on the experience and expertise of the treating doctor. The facility is available in most major hospitals including Sir Ganga Ram Hospital, AIIMS, Apollo Hospital, Batra Hospital etc.

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