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Prostate Diseases Treatment and Care

Urology: Urinary & Reproductive Disease Diagnosis & Treatment

Urology treats urinary tract diseases in all genders and male reproductive issues, covering the kidneys, bladder, prostate, urethra, from infections to complex cancers.

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Management of Benign Prostatic Hyperplasia (BPH)

Prostate Diseases

The goal of BPH treatment is to improve quality of life (QoL) and prevent complications such as urinary retention, kidney damage, and bladder stones. Treatment is individualized based on prostate size and patient preference.

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Medical Therapy

  • Alpha-Blockers (e.g., Tamsulosin, Alfuzosin, Silodosin): These drugs relax the smooth muscle at the bladder neck and prostate capsule. They work quickly (within 48 hours) to improve flow but do not shrink the prostate. Common side effects include retrograde ejaculation and dizziness.
  • 5-Alpha-Reductase Inhibitors (e.g., Finasteride, Dutasteride): These block the conversion of Testosterone to DHT. They shrink the prostate by 20-30% over 6 months and reduce the risk of urinary retention. They are often combined with Alpha-blockers (Combination Therapy) for maximal effect.

PDE5 Inhibitors (e.g., Tadalafil): Relaxes pelvic smooth muscle and improves vascular perfusion. Excellent for men with both BPH and Erectile Dysfunction.

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Surgical Therapy

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Liv Hospital prioritizes Minimally Invasive Surgical Therapies (MIST) and Endourology.

  • Transurethral Resection of the Prostate (TURP): The historical “Gold Standard.” An electrosurgical loop is used to “chip away” the inner prostate tissue from the inside out. Bipolar TURP uses saline, reducing electrolyte complications.
  • Holmium Laser Enucleation of the Prostate (HoLEP): The modern “Platinum Standard” for large prostates (>80g). A high-powered laser is used to separate the entire adenoma from the surgical capsule (like removing the fruit from an orange peel) and push it into the bladder, where it is morcellated. It offers less bleeding, complete removal, and shorter catheter time than TURP.
  • Water Vapor Therapy (Rezūm): A needle injects sterile steam into the prostate. The thermal energy destroys cell membranes, causing the lobe to shrink over the course of 3 months. It preserves ejaculation in 95% of men.
  • Prostatic Urethral Lift (UroLift): Tiny implants are placed to pull the obstructing lateral lobes apart physically, opening the channel like curtain tie-backs: rapid recovery, no sexual side effects.

Aquablation: Robotic waterjet resection. Uses a high-velocity water jet to ablate tissue under ultrasound guidance—Heat-free, preserving ejaculation in many cases.

Management of Prostatitis

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  • Antibiotics: Since the prostate has a blood-tissue barrier, lipophilic antibiotics (Fluoroquinolones, Trimethoprim-Sulfamethoxazole) are required for extended durations (4-6 weeks for chronic bacterial prostatitis) to ensure deep tissue penetration.
  • Multimodal Therapy for CPPS:
    • Alpha-blockers: To relax pelvic tension.
    • NSAIDs: For inflammation.
    • Neuromodulators: (e.g., Amitriptyline/Gabapentin) for neuropathic pain.
    • Pelvic Floor Physiotherapy: Crucial for releasing “trigger points” in the pelvic floor muscles (levator ani), which mimic prostate pain.

Management of Prostate Cancer

Treatment is strictly stage-dependent and involves a multidisciplinary team.

Localized Disease (Low to Intermediate Risk)

  • Active Surveillance: For low-risk cancer (Gleason 6), immediate treatment may cause more harm than good due to side effects. We monitor the patient with serial PSA, DRE, and MRI/Biopsy every 1-2 years. Curative treatment is initiated only if the cancer shows signs of progression.
  • Radical Prostatectomy: Surgical removal of the entire prostate, seminal vesicles, and often pelvic lymph nodes.
    • Da Vinci Robotic-Assisted Laparoscopic Prostatectomy: Liv Hospital employs the latest robotic systems. The 3D magnification enables Nerve-Sparing, in which the delicate neurovascular bundles responsible for erections are gently peeled from the prostate to preserve function. It also offers better urinary continence outcomes and less blood loss compared to open surgery.
  • Radiation Therapy:
    • External Beam (IMRT/SBRT): Using a linear accelerator to target the prostate with high-energy photons. SBRT (Stereotactic Body Radiation Therapy) delivers the full curative dose in just five sessions (CyberKnife).
    • Brachytherapy: Implantation of radioactive seeds (Low Dose Rate) or temporary catheters (High Dose Rate) directly into the prostate.

Focal Therapy (The Middle Ground)

Prostate Diseases

For patients with a single, visible tumor on MRI who wish to preserve function. Technologies like HIFU (High-Intensity Focused Ultrasound) or NanoKnife (Irreversible Electroporation) are used to ablate only the cancer, sparing the rest of the gland and preserving continence and potency.

Advanced/Metastatic Disease

  • Androgen Deprivation Therapy (ADT): Also known as “Chemical Castration.” Drugs (LHRH agonists like Leuprolide or Antagonists like Degarelix) shut down testosterone production, starving the cancer cells.
  • Next-Generation Anti-Androgens: Drugs such as Abiraterone, Enzalutamide, Apalutamide, or Darolutamide bind androgen receptors directly in the cancer cell nucleus with high affinity.
  • Chemotherapy: Docetaxel or Cabazitaxel is used for hormone-resistant disease.
  • Radioligand Therapy (Theranostics): Lutetium-177 PSMA therapy targets cancer cells anywhere in the body via the PSMA receptor and delivers beta radiation directly to the tumor cell’s DNA. This is a revolutionary precision treatment for metastatic CRPC.

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Prof. MD. Selçuk Şahin Prof. MD. Selçuk Şahin Urology
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FREQUENTLY ASKED QUESTIONS

What is the "Retrograde Ejaculation" side effect?

This is a common side effect of Alpha-blockers and prostate surgeries (TURP, HoLEP). Usually, the bladder neck closes tightly during orgasm to force semen out of the penis. Treatment relaxes or removes the bladder neck tissue, so semen takes the path of least resistance backward into the bladder. It is medically harmless (the semen is urinated out later) but causes a “dry orgasm” and infertility.

Both offer similar long-term cure rates for localized cancer. The choice depends on the side-effect profile and patient age. Surgery carries risks of immediate incontinence and ED (which usually improve over time) but removes the organ for pathology. Radiation avoids surgery but can cause long-term bowel irritation (proctitis) or progressive ED years later. Younger men often choose surgery; older men often choose radiation.

for glands larger than 60-80 grams? HoLEP is superior. It removes the entire adenoma (like peeling an orange), whereas TURP creates a channel in the middle (like coring an apple). HoLEP has a lower recurrence rate, removes more tissue, causes less bleeding, and allows for shorter catheter times. For small prostates, both are excellent options.

The “Trifecta” represents the ideal surgical outcome that surgeons aim for: 1. Cancer Control (Negative Surgical Margins/Undetectable PSA), 2. Urinary Continence (No pads needed), and 3. Potency (Ability to have erections). Robotic surgery has improved our ability to achieve the Trifecta by allowing precise dissection.

Historically, giving testosterone to men with a history of prostate cancer was forbidden (“adding fuel to the fire”). However, recent data suggest that in selected men who have been cured (undetectable PSA for a period of time) and are suffering from severe low-T symptoms, replacement therapy may be safe under strict urological supervision (“Saturation Model”).

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