Which BPH treatment is right for you? With all of them—even watchful waiting—there’s a risk of complications. Be your own advocate; learn as much as you can. Before committing to one of these treatments, you owe it to yourself to find answers to some basic questions, including: What are the odds that my symptoms will improve?

*How long will the effects of the treatment last—will I need to do this again? *What are the risks of complications, and which complications are likely to result?

Symptom Improvement. The top row of table 10.3 shows your best odds for symptom improvement lie in the TURprocedure. But even the TURis not an ironclad guarantee; the ranges for all of these are pretty wide. One surgical rule of thumb: Generally, the worse your symptoms before treatment, the more dramatic the improvement—if the treatment works.

Incontinence. As the third row of table 10.3 indicates, over the short run, the risk of uncontrollable urine leakage is extremely rare, even with surgery.

However, over time, BPH itself can cause incontinence; that’s one long-term risk of watchful waiting. And men taking alpha blockers or finasteride may run some risk of incontinence over the long run.

Impotence. Discussed in the table.

Need for Future Treatment. The ranges indicated in the fifth row of table 10.3 are so wide because doctors really don’t know the long-term success of some treatments. Some men who opt for nonsurgical treatment wind up getting surgery later to relieve bothersome symptoms. And some men who do get surgery may need it again after several years if the prostate grows back.

Loss of Work and Activity Time. The sixth row of the table includes time spent at the doctor’s office and in the hospital.

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Similar to the suprapubic operation in terms of anesthesia and recovery, the retropubic approach is preferred by many surgeons because it allows better access to the prostate and a more accurate approach to the urethra.

What Happens

In retropubic prostatectomy, surgeons go directly through the top of the prostate, rather than through the bladder—first making an incision in the lower abdomen, and then separating the abdominal muscles. Instead of opening the bladder, the surgeon moves it aside, and there, beneath the pubic bone, is the prostate.

A small incision is made in the outer capsule of the prostate, and (as in suprapubic prostatectomy) the surgeon’s index finger is inserted to remove the overgrowth of prostate tissue compressing the urethra. To avoid the development of epididymitis, many surgeons go ahead and perform a vasectomy during this procedure. The prostate tissue removed during surgery is then sent to a pathologist for examination.

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Early on, however, erections are not sufficient for traditional vaginal penetration. One common reason for this is the venous leak—even though the arteries are doing their job and filling the penis with blood, producing a partial erection, the veins aren’t keeping the blood trapped inside the penis. To improve this situation, many men find that if they attempt sexual activity standing up, they’ll be able to achieve a much firmer erection. (The blood has to travel all the way back up to the heart, and this takes longer if a man is standing up than if he’s lying down.) Sexual activity can continue either while a man remains standing, or while he’s kneeling. Also, it may help to attempt entry from behind; the vagina opens more easily if a woman is bending forward.

Another way to combat venous leak is for men to place a soft tourniquet at the base of the penis before they begin foreplay or sexual stimulation. The purpose of the tourniquet is to keep blood in the penis, once the stimulation causes the arteries to dilate and penile blood flow to increase. The tourniquet doesn’t impede blood flow into the penis; it just keeps it from going back out. (A material called Coban works well for many patients. This is a transparent tape that can be cut into strips one-half inch to three-quarters of an inch wide. It does not stick to hair, and it can be bought in most drugstores.)

The return of sexual potency has a lot to do with the patient’s age and stage of the tumor. For some men, it can take as long as four years for full potency to return. For others, intercourse is possible just a few weeks after surgery. In any case, you don’t have to wait for the penis to become erect on its own. If you are not having erections yet, you may wish to try a vacuum erection device (see below).

Finally, it’s worth repeating that almost all men who can’t obtain an erection after radical prostatectomy still have normal penile sensation and are able to achieve a normal orgasm. Therefore, even if your body can’t produce an erection, it will still be possible for you to restore sexual function. There are three basic approaches, discussed below.

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LHRH agonists shut down production of LH and FSH. Here’s how they work: LHRH is a small protein, built of ten blocks of amino acid. A synthetic substance called an LHRH-analog, or agonist, made by changing one of the ten blocks, works by inhibiting LH (the hormone that tells the pituitary gland to make testosterone). The hypothalamus acts like a lighthouse, sending out LHRH in signal pulses—like Morse code in flashes of light—to the pituitary gland. LHRH agonists work by providing prolonged signals—by turning on the light and keeping it on, instead of just sending flashes. So these drugs trick the pituitary; because the pituitary receives no flashes, or pulses, it thinks no signal is being sent—and it doesn’t make LH.

These drugs don’t work right away. In fact, for about a week after a man begins taking an LHRH agonist, his testosterone level kicks into overdrive. This is called a “flare,” and it happens because the constant LHRH signal initially stimulates LH production. But by about ten days, testosterone falls into the castrate range. For the first few weeks, doctors often prescribe another drug, such as flutamide, to block this surge.

The most commonly prescribed LHRH agonists are leuprolide (Lupron) and goserelin (Zoladex). In large studies, researchers have found that these LHRH agonists are equivalent to treatment with DES or surgical castration in their ability to lengthen the time until the cancer progresses, and to prolong survival. These drugs are given in monthly injections.

To sum up: LHRH agonists are basically equivalent in testosterone-lowering and lifespan-lengthening results to DES, which is basically equivalent to surgical castration.

The chief advantages of LHRH agonists are that they avoid the need for surgery, and that they don’t cause breast swelling as often as treatment with estrogen. Also, they don’t have the risk of cardiovascular complications that can accompany estrogen treatment.

Side Effects. Like surgical castration, however, LHRH agonist treatment does cause hot flashes, loss of sex drive, and impotence. Other disadvantages include the need to get monthly shots, and the tremendous expense—LHRH agonists cost hundreds of dollars a month.

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As a general rule, men with organ-confined cancer or men with cancer that has penetrated the prostate but still was removed in its entirety (men who had “negative surgical margins”) and Gleason scores of 6 or less should not receive radiation therapy after radical prostatectomy.

The best candidates for radiation after radical prostatectomy are men who have positive surgical margins—but cancer that has not yet reached the pelvic lymph nodes and seminal vesicles. However, even this is not a crystal-clear decision; not all of these men are going to need radiation. For many of these men, the radical prostatectomy will be enough to control the cancer. One option is for men to have regular PSA tests and begin radiation treatment only if the PSA starts going up.

And there’s yet another consideration: Not all of these men with rising PSAs are going to be helped by the radiation, because of the problem with distant metastases we mentioned above. So what you and your doctor need to determine is, why is the PSA going up? Is it local recurrence of cancer, or the presentation of distant metastases?

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