Mayor Menino’s prostate surgery uncommon but necessary for those with very large glands

 Mayor Thomas M. Menino (left) endorsed Ed Markey for US Senate during a campaign event held last week. (Aram Boghosian for The Boston Globe)
Mayor Thomas M. Menino (left) endorsed Ed Markey for US Senate during a campaign event held last week. (Aram Boghosian for The Boston Globe)

Mayor Thomas Menino is heading to the hospital for surgery on Friday to fix a problem with his prostate that most men over age 60 experience. His enlarged prostate shows no signs of cancer, according to an interview his primary care physician had with the Globe, but it is likely impeding his ability to fully empty his bladder.

Doctors frequently prescribe medications such as finsasteride (Proscar) as an initial therapy to treat symptoms such as urgent, frequent urination—especially in the middle of the night—difficulty starting the flow, or a weak urine stream that leaves the bladder partially full. Urologists haven’t determined why the condition, called benign prostate hyperplasia, occurs with aging, but as the prostate gland swells, it puts pressure on the urethra tube that runs through it, like a clamp on a garden hose.

A number of minimally invasive procedures can heat and destroy excess prostate tissue using microwave or radiofrequency energy, by inserting a tiny device through a catheter. Another minimally invasive option uses a laser and heated water to vaporize prostate tissue. These outpatient procedures can usually be performed in about an hour, and have minimal side effects.

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About 1 percent of patients develop difficulty maintaining erections following the procedure. About 1 to 3 percent develop a condition called reverse ejaculation in which semen releases into the bladder; it causes a dry orgasm and infertility but no other health issues.

Minimally invasive procedures tend to have fewer side effects than surgery but they tend to be used most frequently in milder cases since they aren’t as effective, according to Dr. Michael Naslund, chief of urology at the University of Maryland Medical Center in Baltimore.

There is also a minimally invasive form of surgery in which the surgeon can remove prostate tissue via a scope inserted through the penis—called transurethral resection of the prostate, or TURP. It’s used 90 percent of the time for prostate surgeries and has a much shorter recuperation time than an open surgical procedure that requires an incision into the prostate gland.

“Men have about a 10 percent chance of losing their erections after this surgery and about an 80 to 90 percent chance of experiencing reverse ejaculation,” said Naslund. About 1 to 3 percent of patients experience urinary leakage following the surgery, which is sometimes chronic and may require the use of a catheter. This is due to bladder damage that resulted from the enlarged prostate.

Menino is having a more extreme and less commonly used open-surgical procedure called a suprapubic prostatectomy, according to his primary care physician, Dr. Charles Morris. His surgeon at Brigham and Women’s Hospital will cut directly into the mayor’s prostate gland and scoop out the tissue, leaving the gland’s capsule behind.

“It’s not an uncommon procedure to do for men who have a very very big prostate,” said Dr. James Ulchaker, a urologic surgeon at the Cleveland Clinic. “It can be a very good procedure with a very good functional outcome.” Side effects can include infections, bleeding, incontinence, and urine leakage.

The mayor will likely be in the hospital for a few days to heal from his incision, but if all goes well, he’ll likely have a better shot at a permanent improvement in his initial symptoms than he would have had with a minimally invasive procedure. “The open surgery has more risk but also offers greater benefits,” Ulchaker said.

“He should be able to return to his function as mayor very quickly,” he added, “but will he be swinging at Fenway during the next month or so? Probably not.”