73-year-old Man with Sensation of Incomplete Bladder Emptying and a Need to Strain to Urinate Treated with Urolift at New York Urology Specialists
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BPH Treatment: 73-year-old Man Treated at New York Urology Specialists
NP is a 73-year-old man with complaints of nocturia (waking up to urinate) 3-5 times per night, a sensation of incomplete bladder emptying, urinary urgency, and a slow urine stream as well as frequent urination during the day for the past 10 years. The patient reports no blood in the urine. The patient does report urge incontinence. Involuntary leakage of urine when he is unable to make it to the toilet in time occurs 1 to 2 times a week. The patient was previously treated with Avodart (dutasteride) for 1 year and Flomax (tamsulosin) which did not help. The patient reports that he stopped the medications due to a lack of efficacy.
AUA symptom score of 25. PSA = 1.9 (adjusted for Avodart use PSA = 3.8)
A thorough evaluation was performed which included bladder and prostate ultrasound, uroflow measurement, and bladder post-void residual urine volume measurement. The patient was found to have a relatively small prostate, 25 ml; peak urinary flow of 19 ml/sec, and a mean flow of 11 ml/sec. He had an elevated post-void residual of 114 ml.
Clinically, the patient appeared to have high-pressure voiding with incomplete bladder emptying likely due to obstruction by the prostate.
Cystoscopy revealed lateral lobe hypertrophy of the prostate (moderately obstructing prostate); 2+ trabeculations of the bladder suggesting long-term obstruction and high-pressure voiding. Urodynamic studies confirmed very high-pressure voiding and delayed sensation.
Treatment options were discussed with the patient given that he failed treatment with medications. The patient was given a choice of a minimally invasive procedure performed in the office under local anesthesia shows such as UroLift procedure or Rezum procedure. The other alternative is a hospital-based surgery performed under general anesthesia such as laser enucleation of the prostate (HOLEP) or bipolar TURP.
The advantages of local anesthesia include no need for preparation, excellent pain control, and no risks of general anesthesia. By having the procedure under local anesthesia he is also saving a significant amount of money by avoiding the cost of co-insurance for a surgical center facility fee as well as anesthesiologist fee.
Follow-up – Urolift Procedure
The patient presents for the Urolift procedure under local anesthesia.
A prostate block with bupivacaine was given to induce local anesthesia and numbness of the penis and prostate. Urethral lidocaine was administered to numb the bladder and the urethra. The Urolift procedure was performed, which took less than 15 minutes to perform. At the end of the procedure, the patient reported minimal discomfort during the procedure with a pain score of 4 out of 10 (1 being no pain; 10 being the worst pain if his life).
The patient was able to urinate after the procedure and did not require a urethral catheter.
Follow-up Appointment – 4 weeks after Urolift procedure
The patient came back 4 weeks after the procedure.
He reported frequent urination and blood in the urine for the first few days after the procedure which subsided. He still feels that his urine stream is slow. He still experiences urge incontinence. He was advised that sometimes it takes longer for the irritation and inflammation from the Urolift procedure to subside.
Follow-up Appointment – 3 months
The patient returned 3 months after the Urolift procedure. He reported significant improvement in urinary symptoms. Most notably he feels that he empties his bladder completely, does not need to push or wait to start urinating. He reports that urine dripping after urination has stopped. He also does not wake up at night as much as he did before. He no longer experiences episodes of urgency. He is able to make it to the toilet when he needs to void and has much better control of his bladder. He reports a significant improvement in symptoms. He is very satisfied with the outcome of the Urolift procedure.
His AUA symptom score at 3 months is 8, compared to 25 prior to the Urolift procedure. This demonstrates objective improvement in urinary symptoms by >70%.