Prostate surgery is “one of those areas of medicine where specialists have gone on faith that their own beliefs are correct,” says Dr. Alan Wein, chief of urology at the University of Pennsylvania School of Medicine. But now, for the first time, experts are systematically assessing the risks and benefits of surgery–a federal panel will issue new guidelines on the operation next month–and several alternative treatments are in the works.
In the most common prostate operation, known as TURP (for transurethral resection of the prostate), a surgeon inserts a catheter through the patient’s penis, then uses a tiny looped wire to shave prostatic tissue from the blocked portion of the urethra. No one questions the need for surgery when an enlarged prostate causes infection, bleeding or inability to urinate. But such symptoms account for only 25 percent of all prostate operations. Left untreated, less severe conditions often clear up spontaneously. And surgery poses hazards of its own. Up to 1 percent of all TURP patients lose control over their bladders; 6 percent (about 24,000 a year) experience what doctors call diminished erectile function, and 70 to 90 percent are left ejaculating backward into their bladders (an obstacle to fertility but not to sexual pleasure).
Spurred by such findings–and by evidence that a patient’s chances of undergoing surgery are affected by where he happens to live–the American Urological Association and federal health officials formed a panel two years ago to establish uniform guidelines. Due out in draft form next month, the new rules will help physicians make more informed recommendations. “We can now present risks of treatment and let the patient decide,” says Dr. Herbert Lepor, a professor of urology at the Medical College of Wisconsin.
Meanwhile, the range of options is slowly expanding. Some urologists are exploring the use of balloons or coiled implants to expand pinched urethras. Others are turning to drugs. “Alpha blockers,” normally used to control high blood pressure, can relieve symptoms by relaxing the prostatic muscles. Unfortunately, not all patients can tolerate their side effects. A still-unapproved drug called Proscar seems to shrink the prostate by blocking production of the hormone dihydrotestosterone. In June, scientists for the Merck company presented a study in which 71 percent of the men receiving the drug reported some relief, with few side effects. None of the new treatments is for everyone. But, as doctors are finally discovering, neither is surgery.
