Stents are tubes, implanted and left in place to hold open a space that otherwise would collapse or be compressed—in this case, in the urethra where it’s choked by the prostate. The tubes are not visible and can be implanted quickly, in outpatient surgery that lasts about fifteen minutes. They are a good option for older men who are too ill to be eligible for other procedures. They’re also a major addition to the meager range of alternatives formerly available to these men. Until recently, this consisted mainly of bladder catheters, left in place indefinitely, whose presence in the body over time leads to urinary tract infection, sepsis, bladder stones, and even kidney damage.
With the stents, there’s no need for a urinary catheter, and the procedure can be performed under local anesthesia. There’s hardly any bleeding during or after the operation, minimal recovery time, and sexual function is not impaired.
The stents come in several models. The newest ones are made of nickel-titanium alloys, which are flexible and have an intrinsic memory—they expand when heated, and become flaccid and increasingly malleable when cooled. They’re easy to install and, when positioned correctly, will expand when irrigated with warm water. If it becomes necessary to remove them, these stents can be irrigated with cold water, which cause them to contract and become malleable again. They’re designed to be incorporated into the body, to meld with the epithelial tissue lining the urethra—a feat that takes the body about three to six months to accomplish, as the tissue knits a thin blanket of cells to cover the tube. Why is this coverage necessary? It’s like greasing a pan before cooking so nothing will stick to it—except the “grease” here is the body’s own cells. (During this time, bicycle riding and other activities that put pressure on the perineum should be avoided.)
One drawback of the stents is that no prostate tissue is removed and sent to a pathologist for examination. Also, the possibility exists that, over time, the epithelial tissue lining the urethra could do such a good job of covering the tube that it might overgrow the stent, and surgery to correct this may be needed. Stents aren’t a good option for men with BPH in the middle lobe; the site of enlargement interferes with the coverage of epithelial cells.
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Do you have BPH? There are some telltale symptoms. These include: A weak urinary stream, hesitancy in starting to urinate, and difficulty maintaining and stopping the stream (this can include a small amount of “dribbling” afterward). Also, many men with BPH have to urinate ffequentiy, especially at night, and often with a strong sense of urgency. If not treated, these symptoms can lead to some serious problems, including urinary retention—when the bladder stays completely or partly full—and even kidney damage.
Men who have any of these symptoms should see a doctor to determine exactiy what the problem is. It’s important to know if you have BPH. It’s equally important to make sure you don’t have a more serious condition such as prostate cancer, urinary tract infection, bladder cancer, bladder stones, a neurogenic bladder (a bladder affected by a neurological disease), or a urethral stricture (scar tissue that blocks the urethra); all of these can mimic BPH.
The doctor’s evaluation will include a detailed medical history, a physical, including a digital rectal exam; a urinalysis (examination of urine for bleeding and infection); and blood tests to check the level of PSA (an enzyme produced by the prostate) and to evaluate kidney function. Depending on your symptoms, you also may need other tests including a measurement of urinary flow rate (uroflowmetry), a check for residual urine in the bladder, an evaluation of the upper urinary tract with ultrasound or X-rays, cystoscopy (a “periscope” view of the urethra and bladder), and, for some men, bladder pressure tests to rule out neurological conditions.
After the diagnosis of BPH has been confirmed, the next step is to decide, with your doctor, what to do about it.
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When cancer invades bones, they become brittle. Brittle bones break. Therefore, men with metastatic prostate cancer are prone to broken bones (called pathologic fractures). Most susceptible are bones that bear much of the body’s weight, in the hip and thigh. Sometimes, doctors can take steps to protect bones at risk—putting pins in the hip bone to strengthen it, for example. Such steps are a good idea when a bone has a large chunk of cancer (greater than three centimeters in diameter) that takes up at least half of the bone’s outer shell.
Other Complications
Urinary Tract Obstruction
If you’re having any of these symptoms—weak urine flow; hesitancy in starting urination; a need to push or strain to get urine to flow; intermittent urine stream (starts and stops several times); difficulty in stopping urination; “dribbling” after urination; a sense of not being able to empty the bladder completely; or not being able to urinate at all—it’s probable that the cancer has become extensive enough to block your urinary tract. Several procedures are available to ease these symptoms, including a TUR procedure or the placement of stents.
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Doctors have long known that hormones play a major role in the life of the prostate. In 1786, an English surgeon named John Hunter became the first to demonstrate in animals that a radical operation, castration, caused the sex accessory tissues, including the prostate, to shrink.
But it wasn’t until the 1930s that anyone discovered why this happened. At the University of Chicago, a trio of investigators discovered that removing the testes shut down production of testosterone. And, when shots of testosterone were injected back into castrated animals, these tissues were restored to normal size and function. This Nobel Prize-winning research included another valuable finding—that castration also could shrink prostate cancer.
The researchers were able to achieve the same effect chemically; they found they could shut down testosterone with doses of female hormones called estrogens. Estrogens blocked a signal, transmitted in the brain by the pituitary gland, called luteinizing hormone (LH), which stimulates testosterone. The oral estrogen, called DES (diethylstilbestrol), is what’s known as a chemical castrator; it causes impotence.
For now, hormonal therapy means one of two main choices: Surgical castration, a “one-shot effect”; or chemical castration, a lifetime of medication.
Impotence is likely with almost every kind of hormone therapy; 90 percent of men on hormone therapy lose sexual drive and the ability to have an erection. In the future, however, new hormone treatments (discussed later in this chapter) may prove effective without causing impotence.
For a time, hormone therapy does control prostate cancer. But what some doctors used to believe—that prostate tumors are nourished only by hormones, that hormone starvation will stop the cancer from spreading—is, unfortunately, not the whole story. Ultimately, hormone therapy will not stop the disease’s progression.
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Radical prostatectomy is certainly not a new cure for prostate cancer; it’s been around since 1904. There are two versions of this operation—the perineal approach, and the retropubic approach. The radical retropubic prostatectomy used to be notorious among surgeons for the extreme bleeding that went along with it, and both of these procedures used to have two devastating side effects— impotence and incontinence.
That picture has changed. The last fifteen years have seen dramatic improvements to the retropubic approach, based on new understanding of the prostate’s anatomy. The development of new techniques has lessened the awful blood loss, and the operation has become far safer for patients. And, with what surgeons call “a bloodless field,” it’s now possible for them actually to see what they’re doing—a major improvement! In the process, critical structures can be looked for and saved that previously were unrecognized and damaged as surgeons blindly felt their way. More precise techniques have reduced the likelihood of troublesome urinary incontinence to about 2 percent (and even those 2 percent aren’t incontinent all the time). New anatomical discoveries also have made it possible for surgeons to preserve potency in the majority of men.
And perhaps most exciting, better understanding of the anatomical terrain means surgeons can now remove more tissue along with the prostate than anyone ever thought possible—which improves the operation’s chances of cutting out all the cancer.
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