A nonsurgical approach to patients with obstruction due to prostate carcinoma involves hormonal manipulation. This modality should be especially considered for those patients not previously treated in this fashion. Up to 72% of patients with advanced prostate cancer may have symptoms of bladder outlet obstruction (8). Surya and Provet (9) suggest that androgen deprivation may be preferable to surgery as the initial mode of therapy in this group of patients. Androgen deprivation may be accomplished by means of surgical bilateral orchiectomy or “medical orchiectomy” with luteinizing hormone releasing hormone (LHRH) analogs (leuprolide or goserelin) or diethylstilbestrol. In those patients with advanced disease who are to be initiated on LHRH analogs, a recent bone scan should be available to rule out significant occult bony disease in the vertebral column. After initiation of treatment with LHRH agonists, a luteinizing hormone and consequent testosterone surge may occur within the first 2 weeks of therapy; therefore patients with significant vertebral metastases, whether occult or overt, are at significant risk for spinal cord compression. For similar reasons, patients with bone pain may have increased analgesic needs shortly after beginning treatment with LHRH analogs. To reduce the potential for these adverse events, the authors recommend that all patients be started on antiandrogen therapy (flutamide, bicalutamide, nilutamide) before initiation of LHRH agonist therapy to avoid this testosterone flare phenomenon. At a minimum, patients with documented bony disease in the cervical, thoracic, or lumbar axial skeleton should be started on an antiandrogen 7 days before commencing therapy with LHRH analogs. Patients who fail to void 2 to 3 weeks after reduction of serum testosterone to castrate levels usually require surgical intervention or prolonged catheter drainage. It is notable that, in patients with advanced prostate cancer receiving androgen deprivation therapy, the development of obstructive uropathy has been shown to result in significantly reduced survival (10).

For the medically ill patient who does not wish to undergo a surgical procedure or who is deemed medically unfit to tolerate surgery, clean intermittent catheterization (CIC) and chronic indwelling catheterization represent common options for adequate bladder decompression. These options are best suited for those with urinary retention secondary to detrusor failure as opposed to outlet obstruction. CIC has been the nonsurgical treatment of choice to empty the bladder ever since Lapides introduced the concept in the late 1960s (11). CIC enables a motivated patient to avoid a chronic indwelling urethral catheter, thereby decreasing the attendant risks of infection, stricture, epididymitis, and symptoms associated with a defunctionalized bladder. Once a patient is placed on an adequate CIC schedule, bladder residuals must be monitored so that upper tract deterioration due to storing urine at high pressures is avoided. Common findings on routine urinalysis in those patients on CIC include pyuria and bacteriuria. Those patients with systemic evidence of infection (i.e., fever, flank pain, and leukocytosis) should receive appropriate antimicrobial treatment. However, in the absence of these symptoms, the use of broad-spectrum antibiotic therapy in an attempt to sterilize the urine should be avoided because of the potential to develop resistant bacterial species. In patients with recurrent urosepsis, however, chronic antibiotic prophylaxis using low-dose antibiotics or urinary antiseptic drug regimens may be considered. Sterile intermittent catheterization may also alleviate problems of recurrent infections in those patients with clinical symptoms. Other issues that must be addressed before initiating CIC, especially in chronically ill patients, are sufficient manual dexterity and an adequate urethral channel to perform catheterization.

Although the use of indwelling catheters is usually limited to acute urinary retention, the benefits and risks of chronic catheterization in the medically ill patient must be carefully weighed. Frequently, a permanent urethral catheter is the most appropriate method of management in the patient with a very short life expectancy. Because these catheters can be changed at relatively long intervals, they may also be the modality of choice for patients who are technically difficult to catheterize or who are unable to catheterize themselves because of functional impairments. Urethral catheters are relatively simple devices, but may cause significant discomfort in patients who experience bladder spasms. These patients may leak urine around the catheter and experience intense suprapubic discomfort. Treatment for this predicament may include oral anticholinergic medications or suppositories containing belladonna and opium. Other problems with long-term catheterization include obstruction of urine drainage secondary to calcification of the catheter itself, calcification of the catheter balloon, urethral stricture, urethritis, epididymitis, urosepsis, and urethral erosion. Although placement of a suprapubic catheter avoids urethral trauma and irritation and decreases the risk of urosepsis, significant complications may still occur.

During a transurethral resection of the prostate (TURP), benign or malignant prostatic tissue is resected using an electrocautery loop. Although the procedure itself is usually limited to 1 hour, potential exists for the development of significant complications, especially in patients with underlying cardiac disease. TURP has the potential to create large fluid shifts by the absorption of irrigation fluid through prostatic venous channels during resection. In a patient with underlying cardiac disease, this may cause congestive heart failure in an otherwise compensated patient. Other inherent risks associated with this procedure include bleeding, which has the potential to be significant during resection of a large gland; urinary tract infection; urethral stricture; dilutional hyponatremia; bladder perforation; erectile dysfunction; postoperative hydronephrosis; and urinary incontinence. Newer potassium-titanyl-phosphate (KPT) and holmium lasers are now available for vaporization of the prostate due to BPH. These devices offer decreased surgical morbidity and decreased postoperative catheter times when compared to standard TURP.

In patients who fail other treatments, TURP remains the gold standard for removal of obstructing prostatic tissue. Several newer techniques, however, have been developed for resecting, evaporating, or coagulating the obstructing prostate. These newer techniques include electrosurgical vaporization of the prostate, transurethral needle ablation, microwave
therapy, and high-frequency radio wave ablation. Several of these “minimally invasive” devices are now approved by U.S. Food and Drug Administration (FDA) for treatment of benign disease but no major studies have examined their use in patients with malignant disease of the prostate. Overall, these alternative methods seem to promise a rapid relief of symptoms with relatively low morbidity. However, long-term data to support sustained results for these techniques is still being collected. The role of these treatments for palliation has yet to be defined.

Bladder outlet obstruction may occur because of prostate cancer, and it has been estimated that 25–35% of patients on a watchful waiting treatment plan for prostate cancer may ultimately require TURP (12). An alternative to a standard TURP, in which all of the prostatic tissue is removed out to the surgical capsule, is the “channel” TURP performed for palliation. Channel TURP is defined as a TURP performed to alleviate obstructive voiding symptoms in the patient with advanced or previously treated cancer. It may also refer to a TURP performed to remove obstructing prostatic tissue without necessarily resecting all of the tissue to the surgical capsule. Advantages of channel TURP as against traditional TURP arise from performing a more limited operation with less associated operative morbidity. The risk of urinary incontinence is of particular concern during resection of malignant prostatic tissue, which may cause alteration of normal anatomic landmarks and may directly invade the external urethral sphincter.