The highly conservative numbers in the second row derived from treatment studies of men with BPH, encompass every health problem the men reported—including problems that were not actually due to the BPH treatments. So, with that in mind, look at the figures: In most cases, complications do not occur. And even when they do, most complications are not serious. Some of them are—particularly bleeding that requires transfusion, a risk of surgery. Among the most common complications is retrograde ejaculation. This may occur in as many as 70 percent of men after TUB-, and in a few—about 7 out of 100—men on alpha blocker drugs. Some men taking alpha blockers report dizziness, tiredness and headaches. About 5 percent of men taking finasteride report some kind of sexual problem, such as a diminished sexual drive, a decrease in the amount of semen they make, or trouble achieving or maintaining an erection. Note: Although watchful waiting doesn’t carry any immediate complications, over time, symptoms may get worse or new symptoms may develop as the disease progresses and the urethral obstruction becomes more severe. Only TUR clearly reduces the risk of future problems with obstruction.

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Bleeding. Bleeding after surgery can be caused by too much activity, including straining to go to the bathroom. Your doctor will probably give you a stool softener or mild laxative to make that crucial first bowel movement after surgery easier. Also, you’ll probably be advised to steer clear of aspirin and strenuous activity for the first four weeks after surgery to avoid a delayed episode ofbteeding. With the TUR procedures, there’s a lower risk than with open prostatectomy of bleeding during and after surgery that requires a transfusion. (In one study, 7 to 14 percent of men who underwent TUR needed transfusions.) Bleeding seems to be associated with the size of the prostate and duration of surgery; a larger prostate generally means more tissue to remove, and thus a longer time spent in the operating room.

The “Rollerball” Variation. In a brand new approach to TUR, surgeons use an electrocautery “rollerball” instead of the cutting loop. Overgrown tissue is vaporized, not chiseled away, so there are no leftover chips. The technique is highly promising: It appears to have minimal complications, litde bleeding, and shorter catheterization and hospital stays. And, while it offers many advantages of laser prostatectomy and other high-tech procedures, it’s far less expensive. There are many good reasons to believe the rollerball may soon become the technology of choice.

TUR Syndrome. This, too, occurs very rarely—in about 2 percent of patients. It’s caused when the body absorbs excessive amounts of the irrigating fluid used during the TUR procedure. Its symptoms are nausea, confusion, vomiting, high blood pressure, a falling heart rate, and visual problems. TUR syndrome is temporary and is quickly reversible with diuretics or a saline solution, which help restore the body’s normal fluid and mineral balance.

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To recap: The keys to a normal erection are for the arteries to open and fill the penis with blood, and for the veins to close, so the blood can’t escape the penis; the smooth muscle tissue also needs to relax. Several drugs can produce erections by making these events happen. They are vasodilators; they open up blood vessels, making a wider channel for blood to go through. They also cause the smooth muscle tissue to relax and the veins to close. The main advantage here is that these drugs produce an absolutely normal erection. Some of these erection-producing drugs include papaverine, phentolamine, and prostaglandin E-1.

It usually takes less than five minutes for one of these drugs to work, and the erection can last as long as a couple of hours. It will be important for your doctor to determine the lowest possible doseyoxi need to achieve an erection; this will help reduce the risk of side effects. Other ways to help lessen side effects include limiting injections to no more than once a day, and using an insulin syringe (which has a smaller needle than many syringes) to minimize pain and bleeding from the injection. Also, men should compress the site where the needle went in for three minutes after the injection; this also helps reduce bleeding and tissue damage.

Penile injection is not for everybody. These erection-producing agents won’t help men with vascular problems. However, they do work in most patients. Because of the nature of this therapy—giving the penis a shot—it obviously is not ideal for men who can’t see well, men with poor hand-eye coordination, or men who are very overweight. Also, because many erection-producing drugs reduce blood pressure, this can cause problems for some men with heart disease.

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Antiandrogens

These drugs don’t care how much LHRH, LH, FSH, testosterone, or DHT you make; it doesn’t matter to them. (Actually, antiandrogens cause testosterone levels to go up because of an increase in LH.) All they do is make sure testosterone and DHT don’t reach their targets—the receptors. In other words, antiandrogens act as dummy keys in the “locks,” or receptors. When testosterone and DHT reach the receptors, there’s already a key sitting in the lock—so they can’t enter the lock and activate the receptors. Therefore, the tumor doesn’t get the hormones it needs to nourish its androgen-dependent cells.

Flutamide is the most widely used anti-androgen. Casodex, a new, not-yet-approved drug, is another; so is cyproterone acetate, an antiandrogen that’s used in Europe but is not yet approved in this country.

Their potential advantage is that, because testosterone is not suppressed, they preserve potency. In men taking flutamide, for example, 87 percent remain potent. (This is not true, however, for cyproterone acetate. This drug, like estrogen, also suppresses the hypothalamus-pituitary connection—so it lowers LH, which affects testosterone production. Thus, it does produce impotence.)

But do antiandrogens work? The answer, for now, is probably not enough when they’re used by themselves. They also produce breast enlargement in 74 percent of the men who take them.

In total androgen blockade (see below), flutamide is given along with an LHRH agonist. In new research, scientists are looking into combining flutamide with something else—perhaps finasteride (discussed later in this chapter) to increase its effectiveness.

Side effects: Flutamide’s major side effect is diarrhea. Also, it can cause significant liver damage in some men; therefore, it’s a good idea for men taking flutamide to have their liver function checked after the first few months of treatment.

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This is basically hand-to-hand combat, instead of missiles launched from far away. The idea here is that the farther away energy gets from its source—the more tissue a radiation beam has to pass through to reach its target—the less effective it will be in killing cancer. And that implanting tiny sources of radiation directly in the cancerous tissue (brachy comes from the Greek word meaning “short,” as in “a short distance away from the malignancy”) will really blast the tumor—and, as an added bonus, minimize the risk of harming innocent civilians, the cancer-free cells nearby.

The concept is not new. Pierre Curie thought of it nearly a century ago— even before external-beam radiation treatment came on the scene—and doctors in New York tried it several years later; they inserted thin glass tubes with a radioactive substance called radon directly into tumors. The treatment killed tissue, all right, but the results were uneven; some of the targeted tissue was devastated while other tissue remained unscathed. In the next decades, scientists improved the technique, but its popularity waned as hormonal treatment developed and as external-beam radiation therapy got better (see above). In the 1950s and 1960s, however, improvements in dosages and radioactive materials helped foster a comeback for interstitial therapy: Doctors implanted radioactive gold “seeds,” or tiny chunks of radioactive material, in men with prostate cancer; this was combined with external-beam radiation therapy. A few years later, doctors began using radioactive iodine seeds to fight prostate cancer.

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