Contrary to what many think, prostate enlargement is something natural for men – which intensifies with age – and does not always require surgical intervention. It should also not be seen as a synonym for cancer. Few cases must be resolved surgically and, today, there is even a technique that can preserve the patient's ejaculatory capacity, the Urolift.
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In recent years, different technologies have improved the quality of life of men who need prostate surgery, reducing recovery time, for example. In this field, robotic surgeries are very promising, which give the surgeon a three-dimensional view of the region.
To understand the reason for prostate enlargement and learn about the newest techniques for this type of procedure, FreeGameGuide spoke to urologist and oncologist Bruno Benigno, a specialist in robotic surgery.
Why does the prostate begin to enlarge after a certain age?
In the male body, the prostate is an organ that is present in both the urinary system and the male genital. Basically, the gland is a kind of connector. Furthermore, it is responsible for producing a substance that feeds sperm, seminal fluid.
To fulfill its functions, the prostate is directly influenced by the hormone testosterone. This begins to be produced at puberty and reaches its peak when the individual turns 21 years old. In the gland itself, testosterone is converted into an enzyme 100 times more powerful than itself, dihydrotestosterone (DHT).
“All men’s prostates grow due to the conversion of testosterone to DHT. But there are other factors that can accelerate growth, for example, metabolic syndrome”, explains Benigno. This occurs, for example, when the patient has a sedentary lifestyle or is sleeping poorly. Both behaviors, when continued, contribute to this growth.
In general, “the main reason why the prostate grows is the biological effect of testosterone. However, there are other substances, such as insulin [when chronically increased in the blood] that can function as a growth factor”, he adds.
What is an enlarged prostate?
Talking about prostate enlargement is a very generic expression, as it does not allow comparisons. In a healthy man up to 30 years of age, the prostate is the size of a walnut, weighing between 25 and 30 grams. It is worth remembering that, in urology, each gram is equivalent to one cubic centimeter of prostate. Therefore, both sizing methods are accepted.
“Over time, the prostate grows and usually grows at a rate of 0.7 to 1 gram per year”, explains the doctor. Despite the estimate, this is a highly variable rate and must always be understood within the patient's context.
Now, a large prostate can be defined as one that weighs more than 60 grams. A very large, hyperplastic one weighs more than 100 grams. “The prostate can reach gigantic volumes, weighing 300 to 350 grams. These are rarer paintings”, he comments.
Does every prostate enlargement require treatment?
It is very common for people to think that all enlarged prostates must be resolved on the operating table, but this is not necessarily true. Surgical intervention depends, among other factors, on the symptoms reported by the patient and the intensity of these complaints — when it is known that it is not a malignant neoplasm.
“Not every prostate enlargement will lead to the need for treatment. This need occurs when the prostate grows and this growth leads to the narrowing of the channel that passes through the prostate, the urethra”, explains the doctor. “Treatment is based not only on the size of the prostate, but on the intensity of the symptoms”, he reinforces.
In general, there are three categories of symptoms related to an enlarged prostate:
- Light;
- Moderate;
- Intense.
In most cases, drug or surgical treatment is only indicated for those individuals with moderate to severe symptoms. In these circumstances, the man may have a recurrent infection, impaired renal filtration, stones in the urethra or difficulty urinating, for example.
For mild cases, treatment consists of proposing a change in the individual's lifestyle. This can be translated as sleeping better, adopting a physical activity routine and having a balanced diet. These interventions “are very effective for men with large prostates and mild symptoms,” says Benigno.
How can the prostate grow?
A curiosity that is directly linked to the need for surgical intervention is the direction in which the prostate grows:
- Inwards: tends to narrow the urethra, triggering different types of symptoms;
- Outside: usually keeps the channel wide and does not cause urinary symptoms.
How do you know if it is a benign or cancerous growth?
Another myth related to the prostate is that every growth is a case of cancer, which is not true. Even a man can have a small prostate and get cancer of the gland. “Size has no correlation with the risk of having cancer or not,” points out Benigno.
However, knowing whether or not the patient has prostate cancer is essential to define which treatment will be adopted. To answer this question, you need to investigate the image – including age and family history.
Clinical investigation tends to begin with the PSA (Prostate Specific Antigen) test. In it, it is worth observing whether the indicator is too high and how fast it is growing. The urologist can also perform a physical examination, as the prostate normally has a soft consistency and is softened. Ultrasound and MRI may also be considered. Finally, a biopsy is done.
How does enlarged prostate surgery work?
When the doctor finally rules out the risk of cancer, it's time to understand how benign prostatic hyperplasia will be corrected. For surgical interventions that expand the canal, it is essential to understand the size of the gland.
Prostate weighing 80 to 90 grams
For prostates of these dimensions, surgery is usually performed from the urethra and basically consists of enlarging the canal. Scraping can be done with a scalpel or with the help of a laser — the green laser. Furthermore, the Urolift is a new option on the Brazilian market, but common in other countries, such as the United States.
Unlike scraping, the new technique uses a type of forceps that does not harm the tissue, while at the same time opening the channel from the inside. “It’s quick, takes less than 20 minutes and can be done with light sedation”, explains Benigno. In these circumstances, the patient is discharged on the same day and, in an unprecedented way, is able to preserve ejaculation. “This is not possible with other existing techniques”, he says.
However, the technique, which arrived in Brazil in August, presents a greater risk of retreatment, that is, at some point the patient may need to resort to the procedure again. Another limitation is the price, as the material alone costs around 25 thousand reais.
Prostate weighing more than 90 grams
For larger prostates, urethra-initiated interventions or Urolift are not available. In these cases, the main strategy involves abdominal surgery. The most traditional is to make an incision below the navel to the pubis, where the surgeon will remove the inside of the prostate.
The procedure can be less invasive when a microcamera is used. In these circumstances, the video equipment enters through the navel and holes are made in the area to accommodate the clamps. More recently, this type of video surgery has been updated with the help of a robot.
In robotic prostate surgery, the healthcare professional also does not need to open the patient's abdomen, just introduces the camera and the robotic forceps — a kind of miniature hand, which gives the doctor greater mobility. In this case, it is possible to have a 3D view of the region and a higher level of definition, which improves the success rate of the procedure.
