The Patient’s History and Clinical Information

The patient is a 63 year-old male diagnosed with benign prostatic hypertrophy.

The patient’s history includes hemorrhoids, sinusitis, steatotic hepatopathy with multiple hepatic cysts and HbsAg+, hypercholesterolemia and slight hyperglycemia, benign extrasystolic arrhythmia, anxiety syndrome, obesity, venous insufficiency of lower limbs, right inguinal hernia and slight left inguinal hernia.

The onset of urological symptoms (reduction in urinary flow) dates from nearly 15 years ago. The first uroflowmetry showed a medium grade cervicourethral obstruction. A subsequent urography and micturition cystourethrography showed narrowed and compressed prostatic urethra, and an extended bladder is in mid-position, with moderately thickened walls. Subsequent uroflowmetry tests showed a medium/ severe obstruction.

As the micturition symptoms persisted, with frequent urges, difficulty with flow, etc., the patient again consulted a medical services specialist, who diagnosed a prostatic adenoma with clinical symptoms of first degree benign prostatic hypertrophy. The specialist prescribed cycles of therapy with the alpha-lytic Unoprost (Terazosin).

Since then, the patient had annual checkups by the same specialist, including abdominal and transrectal ultrasounds, to follow up the condition of the prostate, which demonstarted gradually increasing in size, volume and weight. The patient’s PSA value was also monitored annually.

Due to the progressive increase in the gland , the urologist doctor suggested a surgical solution (TURP). As the patient is a particularly anxious person, he has had further medical consultation to avoid surgery.

The second opinions received are as follows:

The first urologist that the patient consulted does not agree with the requirement to have surgery. The second urologist does not feel that surgery is urgent, but advised for open surgery instead of TURP. The third urologist agrees on the choice of open surgery due to the size of the prostate with no delay, given the patient’s age, in order to avoid bladder complications and to improve quality of life.

The patient is currently being treated with Omnic 0.4 mg (Tamsulosin) and Avodart 0.5 mg (Dutasteride).

The patient reports the following symptoms: frequent urgency to micturate, sometimes extreme, weak flow with partial emptying of bladder, nocturia (1-2 times per night), feeling of tension and spasm in perineal area.

He had suffered two episodes of urine retention, which were resolved with antibiotics and large quantities of water, but no catheter was required.

The patient has never experienced burning during micturition or had fever. His urine is clear with tested negative in urine cultures.

The medical treatment decreased the severity and frequency of the symptoms.

However, the patient has retrograde ejaculation, with almost no sperm after ejaculation, even in presence of urges and he achieves a satisfactory erection for his age.

Online Doctor Consultation – Medical Questions:

1) Would you advise surgery or treatment with medication?

2) Do you consider TURP or open surgery as most appropriate?

3) Given the patient’s fear of the surgery, are there any other alternative therapies than those mentioned above that do not involve significant side effects?

Expert Report and Opinion

CHIEF COMPLAINT: lower urinary complaints marked by urgency, nocturia X 1-2, variable decreased force of stream with a sense of incomplete bladder emptying, perineal discomfort marked by “tension and spasm”.

Patient is a 63 year old male with progressive urinary symptoms which began with a decreased urinary stream. Patient complained of frequent urgency and poor flow. He was started on cycles of alpha blockade (terazosin). He had two episodes of urinary retention each of which resolved with antimicrobial therapy without catheterization. He now complains of frequent urgency, a poor force of stream, incomplete bladder emptying, nocturia X 1 – 2, and perineal discomfort. He is currently taking tamsulosin 0.4mg and dutasteride 0.5 mg daily. He has sexual side effects (retrograde ejaculation). On his current urologic regimen the patient says his symptoms are acceptable.

LABS/IMAGING: No positive urine cultures have been reported.

Post void residuals have been variable. PSA’s have trended upward. Percent free PSAs have always been high. Prostate volumes over time have increased.

MEDICAL HISTORY: obesity, hyperglycemia, hypercholesterolemia, benign extrasystolic arrhythmia, venous insuffieciency of lower extremities, + HbSAg, steatotic hepatopathy with multiple hepatic cysts, sinusitis, hemorrhoids, bilateral inguinal hernias, anxiety syndrome.

MEDICAL OPINION/DISCUSSION:

While the patient’s symptoms are “acceptable” to him, I think that there are several unanswered issues which may pose medical problems.

His PSA is high while on a 5 alpha reductase inhibitor. 5 alpha reductase inhibitors halve the value of PSA. So, in effect, his PSA is 2 times that which is reported. No biopsy of his prostate has ever been done. I am not convinced that one can assume that a high percent free PSA rules out prostate cancer or attributes his high PSA to the volume of his prostate. A biopsy of his prostate is indicated prior to the consideration of any procedure.

It is not known whether the patient empties and stores his urine at safe pressures. Does he generate high pressures to void? Does he have bladder decompensation and over-activity during filling on cystometry? what is his renal function? Should any of these items be true, then the argument for surgery is more persuasive.

It is concerning that he twice went into retention. His post void residuals may be increasing with time. His history of retention is the single most compelling reason to go forward with surgery at this time.

Ideally the patient should have a prostate biopsy and be studied uro-dynamically on his current therapy and a cystoscopy.

In the absence of prostate biopsy, properly performed urodynamic studies, and cystoscopy it is impossible to offer a definitive opinion as to advise surgery or not. Certainly, if one were to monitor him conservatively (i.e, no surgery) he needs to be monitored very closely with checking of his post void residuals, urine cultures, and monitoring of his upper tracts with either creatinine levels or ultrasonography. In case that a surgery is required he would probably achieve a superior result with an open procedure (suprapubic or retropubic simple prostatectomy) rather than any procedure done transurethrally. I do not believe there is any suitable alternative procedure that would provide him with as good of a result or provide him with as good durability.