Greenlight Photoselective Vaporization of the Prostate (PVP)
Urology Group designated as Greenlight Center of Excellence
What happens as the prostate enlarges and causes blockage? Why do men have to pee at night?
The prostate enlarges in all men and is an inevitable consequence of aging. As the prostate enlarges, it crowds the urinary pathway and causes difficulty with urination in one out of four men.
As the prostate causes obstruction and blocks the urinary pathway, the bladder has to work harder to push urine past the obstruction.
At the same time that the prostate begins to enlarge, there are two other changes that may take place. The bladder gets smaller, so that it does not hold as much urine, and with smaller bladder capacity, men notice that they have to go more frequently. They may also have urgency, which is the sense of the need to go with less time to postpone urination.
The third change that takes place is the body holds on to fluid during the day, and then the kidneys get rid of the excess fluid at night. Increased frequency of urination at night can develop, because not only are the kidneys making more urine, the bladder holds less, so there is the need to go more often.
Of these three changes - the enlarged prostate blocks in the urinary pathway, the bladder gets smaller, and nighttime fluid production increases – the first step is to treat obstruction along the urinary pathway
Do pills always work for treating the enlarged prostate?
When treatment for the enlarged prostate (BPH) is required, there are a variety of choices available. For many men, drug therapy provides excellent treatment. However, for some men, ongoing treatment with medication is not the answer. Some men have bothersome side effects related to the pills they take for the enlarged prostate. Proscar and Avodart, pills which reduce the size of the enlarged prostate, can interfere with sexual function in a subset of men. The alpha-blockers – Hytrin, Cardura, Flomax, Uroxatral and Rapaflo– work by relieving the grip of the prostate as it crowds the urinary pathway. Possible side effects include dizziness, lightheadedness, nasal stuffiness, and retrograde ejaculation (retrograde ejaculation describes the circumstance where a man has an orgasm but the ejaculated fluid flows back into the bladder
rather than out through the tip of the penis). In addition to these potential side effects, another drawback to drug therapy for some men may be cost.
When is it time for a procedure for the enlarged prostate?
Indications for BPH treatment include urinary retention, large postvoid residual (the amount of urine left behind in the bladder after voiding) which can interfere with kidney function, bleeding, recurrent urinary infection, and bothersome voiding symptoms. When pills are not working or when they cause side effects, different types of intervention are available.
What types of procedures are available?
A recent review lists over a dozen types of procedures available to treat BPH. Older procedures, no longer used, include transurethral needle ablation (TUNA) and transurethral microwave of prostate (TUMT). Current standards for intervention for the enlarged prostate include Urolift, Rezum, different types of laser coagulation of the prostate, transurethral resection of the prostate (TURP), including button TURP, and photo selective vaporization of the prostate (Greenlight Laser PVP). The Greenlight laser procedure has proven itself as an effective and minimally invasive procedure available for managing BPH.
How do the procedures get rid of obstruction?
In the TUMT, TUNA, Rezum and laser coagulation (not photo vaporization) procedures, heat is used to coagulate (shrink) the enlarged portion of the prostate so that over the next several months, the enlarged portion of the prostate reduces in size. Once the enlarged portion has reduced in size, there is less crowding of the urinary pathway, which can eventually lead to improved urination. These procedures do not actually remove any of the enlarged and obstructing portions of the prostate.
In green light laser PVP the obstructing portions of the prostate that block the urinary pathway are removed. This actual removal of the blockage distinguishes GLL from the other procedures that coagulate the prostate. With vaporization (removal), the urinary pathway is opened up which leads to more immediate improvement in urinary flow.
How is green light laser done?
With the GLL procedure, the actual enlarged portion of the prostate is melted away, under direct vision, which opens up the blocked portion of the urinary pathway.
An instrument called the resectoscope is introduced through the urethra, the urinary pathway in the penis. The resectoscope is a fiber optic instrument used to look into the bladder.
During the procedure, the enlarged portions of the prostate are melted away.
After removal of the blocking portions of the prostate, the urinary pathway is opened.
What are outcomes and what is the recovery after surgery?
When the urinary pathway is unblocked, the bladder can do a better job of emptying the urine to the outside. Most men notice improved force of urination, and a better sense of empty. Also, once the bladder muscle does not have to work as hard to push against a blocked pathway, the bladder muscle loses some of the thickening which developed when it had to work harder, and as the bladder muscle becomes less thick, and regains elasticity, it can improve its storage capacity, and hold more urine, which translates into less frequency and urgency.
Prostate procedures in the past were burdensome for patient recovery, with its attendant risks of bleeding, incontinence, and erectile dysfunction (ED), as well as the need for a one- to five-day hospital stay and significant restrictions on activity for a six-week postoperative period. With GLL, the procedure is much less invasive.
The risk of general complications, such as heart and lung problems, is the same as for any other operation.
Greenlight laser has the following advantages: outpatient or overnight procedure, less chance of bleeding, faster return to activities and reduced time period of catheterization.
The procedure is typically done in an outpatient setting with a regional or general anesthesia. Most men are asked to stop one week in advance any mediations that can promote bleeding, such as aspirin, and anti-inflammatory medications (i.e., Advil, Nuprin). If men are on Coumadin, which is a blood thinner, this should also be stopped one week in advance. Men are typically sent home several hours after the procedure. Men have a catheter in for several days. Postoperatively, men may notice for the first 6-8 weeks urinary frequency (the need to urinate more often), urgency (the need to urinate promptly once the urge is felt), and dysuria (burn or discomfort with urination). They may see blood, which may develop on an intermittent basis over several weeks. Increased fluid intake is recommended during the first several weeks, preferably water, to promote increased urinary output. Strenuous exercise and heavy lifting, including bike riding,
running on treadmills, working with vibrating equipment (e.g., riding a tractor mower), and engaging in sexual intercourse should be avoided for two weeks.
For most patients, the Greenlight laser procedure typically does not interfere with sexual function and men are still able to have an erection and orgasm the same as they did preoperatively. Of note, most men develop retrograde ejaculation, also known as “dry climax”. Orgasm occurs but no fluid is ejaculated. Rather the semen back washes into the bladder and is voided out with the next urination. Some men note the sensation of climax is lessened when there is retrograde ejaculation.
For many of the men who have GLL, they can stop the medication they previously used to address urinary bother.
After intervention to relieve the obstruction is carried out, it may take some time for the bladder to regain some elasticity to then allow lessening of frequency and urgency.
Some men have a bladder that does not store well, which means it has low storage capacity, and even after GLL, they are still bothered with frequency and urgency. In that case, additional strategies are available to improve bladder storage, as outlined in the overactive bladder newsletter.
Take Home Message
A useful framework to assess the above information is to determine how much difficulty the underlying condition, the enlarged prostate, causes, and then to look at the options that are available to help, along with the burdens that go along with those efforts to help.
When the enlarged prostate has caused enough trouble that it needs attention, the green light laser is an attractive minimally invasive outpatient procedure which provides significant improvement in the majority of men typically with a low risk of adverse effects and offers the added advantage of a prompt return to normal lifestyle.Print Page
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