Age is not the first thing to check before prostate surgery

“He is quite old — is it still all right for him to have prostate surgery?” It is a question I am asked constantly by elderly patients with benign prostatic enlargement and by the families who come with them. The stream has weakened and the nights are broken by repeated trips to the bathroom, but the moment an operation is mentioned, worry comes first. If there is hypertension or diabetes, and heart medication on top, more so. Sometimes the conclusion has already been reached before the consultation starts: uncomfortable as it is, at his age it is probably better to put up with it.

Deciding on surgery for benign prostatic enlargement is not a matter of sorting patients into possible and impossible by age. Among men in their eighties there are patients who are active and whose cardiopulmonary function is stable, and there are younger patients whose general condition is poor from several coexisting illnesses. What actually has to be examined is not the age on the identity card but the present state of the body, the coexisting conditions, the drugs being taken, the size and shape of the prostate, and how the bladder is working.

The drugs come first#

In older patients there are many variables to confirm before an operation. Beyond hypertension and diabetes, cardiac and cerebrovascular disease is common, and with it drugs that suppress clotting — antiplatelet agents and anticoagulants. These are related to bleeding during surgery, and yet they cannot simply be stopped at will. In some patients, stopping the drug raises the risk of a clot or a cardiovascular or cerebrovascular event instead.

So what has to be established in advance is which drug is being taken, whether it can be interrupted, and how much of a burden the patient can bear from the operation and the anaesthetic. That is a question for the cardiology team as much as for the urologist, and it is settled before a date is set rather than on the morning of the operation.

The size of the gland changes the operation#

The state of the prostate itself governs the difficulty. If it has grown very large, the volume of tissue that must be removed to secure the urinary passage is correspondingly greater. In the past a prostate that was too big required an operation opening the abdomen to remove the enlarged tissue. Now holmium laser enucleation of the prostate and similar techniques allow large volumes of prostate tissue to be removed with an endoscope passed through the urethra.

That does not make every operation equally straightforward simply because nothing is cut open. The larger the prostate, the more tissue there is to remove, and the more there is to consider in controlling bleeding and in recovery afterwards.

When it is not the first operation#

For a patient who has already had prostate surgery or a procedure, the situation is different again. Urinary difficulty returning after treatment does not necessarily mean the prostate has grown back. Remaining tissue may have enlarged, but scarring at the operated site may equally have narrowed the bladder outlet or the urethra. If a procedure such as a prostatic urethral lift was performed, the implants still in place and the state of the surrounding tissue also have to be assessed.

Treating a different cause the same way is unlikely to produce the result the patient wants, so the more this is a repeat operation, the more the process of establishing the present state accurately matters.

The organ nobody asks about#

There is one more thing to examine here, and it is the bladder. Benign prostatic enlargement does not end as a problem of the prostate alone. Pushing urine out through a narrowed passage, with effort, over a long period, accumulates a burden on the bladder muscle. When its contractile strength falls away with time, voiding function may not recover as much as expected even after enough prostate tissue is removed to widen the passage. In severe cases repeated retention and urinary infection follow, and the upper urinary tract and kidney function can be affected.

That is why continuing to postpone treatment purely because of age is not necessarily the safe choice.

What the question should be#

In treating an elderly patient, or one with existing illness, what matters is not only whether an operation can be done. If surgery is needed, what is required is to find first what risk factors this particular patient carries, and then to plan how those risks will be reduced. The same method cannot be applied to a patient whose bleeding risk has to be accounted for, a patient with a very large prostate, and a patient whose symptoms have returned after previous surgery. The operation, the anaesthetic and the management before and after all have to change with the patient's condition.

There is no single operation for benign prostatic enlargement that is best for every patient. What matters is finding, among several treatments, the one suited to the state of this prostate and this man's general health. Rather than abandoning treatment on the grounds of age or existing illness alone, it is worth assessing the present voiding state, bladder function and general condition accurately, and weighing the benefit that treatment can bring against its risk. The first thing to establish before prostate surgery in an older patient is not his age. It is how the treatment he needs can be given while reducing what it costs him.