If your brother , your husband or your father or grandfather had urinary obstruction and needed a prostate operation to relieve the stoppage of water, where should he go to find a fully-trained Urologist and the best equipment for the job? Photo:supplied

Is your first thought   Puerto Rico, or perhaps somewhere in the USA  like Florida where you can find top rated hospitals like  the Mayo Clinic, Cleaveland Clinic or perhaps to Baptist Hospital. BUT  HANG –ON!!  Have you forgotten Bougainvillea Clinic, yes The Purple Palace, right here in Road Town?

Bougainvillea Clinic now has the GreenLight XPS laser, the newest and most advanced GL Laser in the world; more powerful, more efficient and safer than any other model of  green light laser that came before. None of the above hospitals have better than the XPS GL laserfrom American Medical Systems, now being used at Bougainvillea Clinic, right here in the BVI.  With the help of Dr. Dwayne Thwaites, urologist who was fully trained in USA, Bougainvillea Clinic is rapidly expanding the range of state of the art operations that can be done on the prostate, bladder and kidneys.

Recently, at Bougainvillea Clinic, Dr. Thwaites used the XPS green Light Laser to vaporize the part of the prostate that was causing obstruction in three patients. Each patient had a different degree of obstruction , covering the range of indications for surgical treatment for BPH (Benign Prostatic Hyperthrophy)- one patient had incomplete relief of symptoms from medical therapy so he requested surgical treatment, the other had  recent complete obstruction that required an indwelling catheter for relief and the third had longstanding obstruction with formation of several large, hard bladder stones, thus needing pulverization of the stones with Lithotripsy in addition to the GLL prostatectomy.

Why do men get stoppage of water?  

More scientifically, this is call obstruction of urination and is usually caused by an enlarged prostate gland. The prostate is part of the male reproductive system. Only men, not women, have prostates .This gland is located at the bottom of the bladder , and   the urinary passage(urethra)  actually passes through the middle of the prostate gland.  The normal  prostate in young men is about the size of a walnut or golf ball and weighs  20-25 grams: less than one ounce. As men reach their 40’s the prostate gland begins to enlarge and gets firmer. Both the muscular and the glandular elements of the prostate enlarge. Prostates may reach up to 150 gm ( about  5 oz.)  with increasing age. This enlargement is usually a benign process, so we call it Benign Prostatic Hypertrophy (BPH) but less frequently it can be malignant (prostate cancer). As the prostate enlarges,  it tends to squeeze and obstruct the urinary passage, but since the enlargement  of BPH occurs in a variable manner  the degree of obstruction is not directly related  to the size of the prostate only.Ssome men with a relative small prostates  can have marked symptoms ( if the enlargement is mostly around the urethra) whereas some men with huge prostates can have relatively few complaints, particularly if the enlargement occurs slowly and is further away from the urethra.

What are the symptoms of BPH?

Early symptoms of BPH are increased frequency of waking up to urinate at nights,  having to go as soon as the urge is felt, dribbling of urine after voiding ( post-void dribbling), hesitancy ( having to wait and to strain) when trying to pass urine.  Later there is  incontinence before getting to toilet,  incomplete emptying of the bladder ( having to go again soon after) and finally complete obstruction.  As the degree and duration of obstruction increases, the bladder gets more muscular in order to push out the urine but eventually the bladder muscle  can get tired and give up, allowing chronic retention. Sometimes the distended bladder may reach as high as the umbilicus with several liters of urine. Finally the urine backs up into the kidneys and may lead to kidney failure. Longstanding stagnation and retention of urine   also leads to bladder stone formation and  to bladder and kidney infections.

How is  BPH treated?

Some men can cope with mild symptoms of BPH without treatment. Natural supplements like saw palmetto can give relief to mild symptoms. Alpha-blocker drugs like Hytrin and Flomax are quite good at relaxing the smooth muscle element  of the prostate and bladder  thus improving symptoms quickly        (within hours to days)  but tend to become less effective with passing years, as the glandular element of the prostate becomes the predominant cause of the obstruction.  Drugs like Proscar and Avodart  prevents the conversion of testosterone to dihydrotestosterone (DHT) in the body. Since DHT is involved in the enlargement of the glandular element of the prostate, these drugs can shrink the prostate but this effect take 3-6 months to become noticeable.  Because these drugs effectively block important action of testosterone there may cause be reduced sex drive and performance. They also have to be taken for life to continue relief of symptoms.

Surgical treatment for BPH is indicated when symptoms are resistant to medication or when medication causes unacceptable side effects. Over the years types of operations have changed for the better. First there was the open prostatectomy whereby  an incision was made into the lower abdomen and into the anterior capsule of the prostate  so that  the middle part of the prostate can be  enucleated. A catheter is left in place for 7-10 days and the patient has to stay in hospital for several days.  This is a bloody operation, frequently requiring blood transfusion . Also, the bladder has to be irrigated for the first 24-48 hrs to remove blood clots.

Next came Trans-Uretheral-Resection –of the Prostate (TURP) with electrical cautery. This is a much better operation, with no abdominal incision but still relatively bloody, requiring at least overnight stay in hospital, irrigation of the bladder for 12-24 hrs and leaving a uretheral catheter in place for several days.

Now it’s the advent of Laser prostatectomy, which is also done trans-uretherally.

So why is the Green Light Laser surgery for stoppage of water so fantastic?   Firstly, there is relatively little bleeding during this procedure, the surgeon can see more clearly what he/she is doing, so it is safer and with fewer  potential complications.  The operation is quicker, especially with the more powerful XPS laser.  As the GLL vaporizes the prostate tissue it also coagulates and stops bleeding. In fact, the operation could be safely performed on patients who are taking blood thinners like warfarin. There is usually no need to irrigate that bladder to remove clots after the procedure,  or to  give a blood transfusion .The patient can usually be discharged home on the same day of the operation. A uretheral catheter is usually left in overnight  only but sometimes the surgeon may decide not to leave a catheter in at all. The man can resume normal activities more quickly.  Adequate surgery  brings immediate and permanent relief of urethral obstruction , although in practice  there is a need for repeat operation in about 20 % of patient after many years. GLL prostatectomy has the fewest side effects than the other forms of surgery..

Did I hear somebody say  “ yes that’s fantastic but, Dr. Vanterpool why does  Green Light Laser Prostatectomy procedure cost so much?” Well firstly, the GreenLight XPS laser machine is the most modern and advance laser for prostatectomy available, costing  substantially more than US$100,000, and each procedure requires a non-reusable laser fiber costing  $1,500 ( that’s the way the makers program the equipment) and of course we must take into account the cost of other equipment used during the procedure, and the number of highly trained health care staff. Yet at Bougainvillea Clinic, our price for this procedure is compare very favorably the few other places in the Caribbean that have this technology.

Furthermore, compared to the cost of buying  the combination of say Flomax plus Avodart and remembering to take these pills every day  for the rest of one’s life, will show that the Green Light procedure is quite cost effective.

Dr. Heskith Vanterpool, Medical Director, BC