I'm Dr. Gaurav Bandi. I am a urologist at MedStar Georgetown University Hospital. My patients are
mostly men with urologic conditions commonly related to their prostate. I also do a fair amount
of sexual dysfunction amongst men. The most common problems include prostate enlargement, prostate
cancer, and conditions where we are concerned about prostate cancer like an elevated PSA. Most
men who present with concern about prostate cancer present to us either with an elevated PSA or an
abnormal prostate examination. Our process usually starts with taking a history and doing a physical
examination. There are times where we have to do some additional tests to evaluate the elevated PSA.
A lot of things which I do are related to quality of life. And once the patients come in, they're
bothered with their quality of life. And we help them out, and the patients are always happy with
how we have helped them out to their bothersome symptoms including urinary and sexual dysfunction.
It's really nice to see how the patient's came in with a medical problem, and then you treated
them, and then you keep following up the medical problem all their lives. I think it's important
to make the patient comfortable, reassure them that not all medical problems are life-threatening, and
then we go in a stepwise process going over what the evaluation would consist of and how we would
go ahead and treat them. At MedStar Georgetown, we have the best doctors, and we have one of the
best technologies to treat conditions related to men's urologic health including prostate
enlargement and prostate cancer. There has been multiple advancement over the last few years that
started with robotic surgery for prostate cancer which started about 10 years ago. And then now, we
have novel biomarkers. We have the MRI which we use to evaluate patients with elevated PSA.
And, we always have new technologies come in to treat BPH or enlarged prostate as well. A lot
of patients who come in are not aware of the different possibilities available to them. My
goal as a physician is to educate them, let them know what the medical problem is, and how we can
treat them. And then, me and the patient decide what's the best treatment option for them.
BPH stands for benign prostatic hyperplasia. It's a condition characterized by enlargement
of the prostate and common terms it's also called enlarged prostate.
BPH is a very common medical condition. About 50% of men between 50 and 60 years
old have symptoms related to BPH, and about 90% of men 80 and above will have symptoms from BPH.
BPH is a benign condition. In other words, it is not a cancer, and it usually does
not lead to any life threat. Now in some rare cases when the patient's
not emptying the bladder, it can lead to kidney problems like kidney failure.
BPH, it's important to address BPH because it is a very common problem, and a lot of
men about 50 will have symptoms related to BPH which will affect their quality of life.
Prostate is a part of the male reproductive health system. It is a walnut-sized organ
located below the bladder and in front of the rectum .The urinary tube from the bladder
out through the penis goes through the center of the prostate. And the main function of
the prostate is to produce secretions which are responsible for the health of the sperms.
The enlargement of the prostate compresses the urinary tube going through the prostate.
As a result, it makes it harder for the bladder to empty and irritates the bladder. The result
of the bladder emptying leads to the urinary symptoms related to the prostate enlargement.
Prostate enlargement is the process of aging. As men get older, there are
hormonal imbalances related to age which leads to enlargement
of the prostate tissue. As men grow older, their prostates will continue to enlarge.
The most common symptoms of BPH are the need to urinate more frequently
and urgently especially at nighttime. Men could also have other symptoms like weak
urinary stream, straining with urination, dribbling of urine, and urinary incontinence.
The typical diagnosis of BPH is done based on performing a urologic history and doing a
physical examination of the prostate. In some patients, other tests may be necessary. These
include a PSA to rule out prostate cancer, a urinalysis to rule out a urinary tract
infection, a urine flow measurement, and a post void ultrasound measurement to evaluate for bladder
empty. In some rare cases of cystoscopy, a prostate ultrasound, or a urodynamic study may be necessary.
There are multiple treatment options available for BPH. These include observation, medical therapies,
minimally invasive procedures, and surgical therapies. The best treatment option depends on
the size of the prostate, the associated urinary symptoms, and the medical problems in a patient.
There are many minimally invasive procedures for BPH. These include
microwave therapy, prostatic urethra lifts, and transurethral nuclear ablation.
So at MedStar Georgetown, we for the Urolift procedure and the holmium laser enucleation
of the prostate. The Urolift procedure is a minimally invasive, office-based procedure
done under local anesthesia. The procedure takes about five minutes. The main advantage
of the Urolift is it works immediately and has minimal or no sexual side-effects.
Urolift is a minimally invasive procedure wherein the urologist places tiny implants in the prostate
to stretch the prostate lobes open. This allows the urinary tube to open up, thereby
making it easier for the bladder to empty. The procedure is done in the office under
local anesthesia and takes about five minutes to perform the procedure. Most patients do not
require a catheter and have immediate outcomes. And the results are durable. The
procedure has no sexual side effects which are commonly associated with the medical therapies.
Majority of patients love it. The patients do not have to take daily medications for the
rest of their lives, and they have no sexual side effects. The results are immediate, and
patients are happy as soon as they come back to see me for a post-operative visit.
To be a candidate for Urolift, your urologist needs to evaluate your prostate anatomy. Not every
patient is a candidate for Urolift, and patients should have a prostate size of less than 80 grams
and should not have a median lobe. The typical evaluation includes performing a cystoscopy to
look inside your bladder and performing a transrectal ultrasound to measure the size of the prostate.
TURP stands for transurethral resection of the prostate, and it's considered the gold standard surgery for
prostate enlargement. The procedure is done under general anesthesia, wherein the urologist goes in
with the telescope through the penis and using an electric current, shaves off the inner part
of the prostate and seals the blood vessels. The patients require overnight hospitalization and
catheterization. The most common complications are bleeding and retrograde ejaculation.
With the TURP, the surgeon uses electric current to cut pieces of the prostate. And
with the HOLEP, we go through a surgical plane between the inner and the outer prostate and peel off all the
inner prostate from the outer prostate. So, it's more durable because more tissue is
removed, and it's less bloody because the surgeon works in a surgical plane.
The most common complications are still bleeding with blood in the urine for a few
weeks after the procedure, occasional urinary incontinence, and retrograde ejaculation.
That's more complete and less invasive and less bloody than a TURP. And the other advantage of the
HOLEP is it does not have a size limitation. With a TURP, you can only go as far as 100 grams
of the prostate. With the HOLEP, there is no size limitation. You can remove any size
and also you can do it on patients on blood thinners because the bleeding risk is lower.
Urolift is a relatively new procedure which has been out for about 10 years.
Most of the initial studies were done in Europe. However, there were recent randomized
control trials done within the United States with up to 1000 patients and 5-year follow-up
showing great efficacy of Urolift compared to other surgical procedures.
Medical research suggests that 80% of patients will have continued
symptom improvement for up to five years after the procedure.
So if a patient has a Urolift procedure and fails it after a few years, the procedure does
not exclude the patient from needing other prostate surgeries like a TURP or a HOLEP.
So not all patients with prostate enlargement need a treatment. Some patients have
mild or minimal symptoms. These patients could usually be managed with active
surveillance where they see a urologist on a yearly basis for a prostate exam
and measurement of post-void residual to make sure they're emptying their bladder completely.
So there are many medications available for treatment of BPH. These include alpha
blockers, 5 alpha reductase and emitters, pde5 inhibitors, and anticholinergic medications.
These medications work on the muscles in the prostate or in the bladder to relax
them or by shrinking the prostate. Most medications will have some side effects,
and patients need to take these medications all their lives to have continued benefit.
Some patients may even need a combination of medications to have the desired effect.
The decision to choose the procedure depends on the discussion between the patient and the
physician. Some patients prefer to take a daily medication or a combination of daily
medications for the rest of the lives. Some patients prefer doing a minimally invasive
procedure or a surgical procedure to avoid side effects of the medications.
The Urolift procedure has two main advantages over the medical therapy. Number one, the patient's do
not have to take a daily medication for the rest of their lives. A lot of patients are
not compliant with daily medications, or it may be a significant cost barrier to take
daily medications. The other advantage of Urolift is that it does not lead to any
sexual side effects. Some of the medications used for prostate enlargement can lead to
sexual side effects like decreased sex drive, decreased ejaculation, and decreased erection.
The most common neurologic problems for which men seek a urologic consultation is either
trouble with urination or trouble with sexual function. Both of them
are very common in men over 50. I usually recommend men over 50 to either go see a
primary care physician or a urologist to discuss their men's health issues.
Erectile dysfunction is the medical condition characterized
by difficulty obtaining or sustaining an erection for adequate sexual intercourse.
Erectile dysfunction is a very common medical problem.
The incidence of erectile dysfunction is about 50% in men between 50 and 60
years old. The incidence is as high as 90% as men get beyond their 80s.
Erectile dysfunction is most commonly from a vascular disease. As men get older, there
is less blood flow into the blood vessels from hardening of the blood
vessels and deposition of cholesterol in the blood vessels. The other rare causes
include decreased testosterone, and in some cases, it could be from psychological causes.
There are many therapies available for treatment of erectile dysfunction. In
most men with mild erectile dysfunction, medical therapy is utilized. These include
medications like Viagra or Cialis to improve sexual function. Some patients do not respond
to medical therapies in which case second or third line therapies may be needed. The
most common second line therapies include intracavernosal injection and vacuum erection device.
For patients with more severe erectile dysfunction, a penile prosthesis implantation
is usually necessary. This procedure is done under anesthesia and requires overnight hospitalization.
The procedure involves placing an implant inside the penis to help achieve an erection. More than
90% of patients and their partners will be satisfied after placing a penile implant.
Majority of the patients and partners are satisfied with the treatment options available.
For patients with severe disease, usually second and third line therapies are needed.
Urologists specialize in management of men's health issues including erectile dysfunction.
Many times, urologist can offer second and third line therapies for management of ED which are
not available through a primary care physician. Urologists also understand the physical and
psychological impact of erectile dysfunction on other mental and physical issues which is why
it's important for men with problems with erections to go seek a urologic opinion.
Erectile dysfunction is mostly a vascular disease. Anything which can
affect the blood vessels have the potential to cause erectile dysfunction. These include
things like aging, diabetes, high blood pressure, smoking, and metabolic syndrome.