BPH: Updated Guidance on Surgery and Minimally Invasive Treatments
Some men with an enlarged prostate (also known as benign prostatic hyperplasia, or BPH) experience lower urinary tract symptoms (LUTS). Common urinary symptoms include:
- Difficulty starting to urinate
- A weak urinary stream
- A sudden, strong desire to urinate (urinary urgency)
- Increased frequency of urination
- Frequent nighttime urination (nocturia)
- A sensation that the bladder is not empty after urinating
In general, no treatment is needed for men who have only a few symptoms, they are not bothered by them, and they have no evidence of kidney or bladder function compromise. When symptoms are bothersome, lifestyle changes and medications effectively relieve LUTS in many men. More invasive treatment is recommended when a man has:
- Kidney damage due to inadequate bladder emptying
- A complete inability to urinate after treatment of acute urinary retention
- Recurrent bladder stones or blood in the urine due to BPH
- Recurrent urinary tract infections
- A continuation of symptoms that are troublesome enough to diminish quality of life, despite treatment with medication or a desire to avoid taking a daily medication
The American Urological Association (AUA) recently updated its guidelines on commonly used surgical procedures and minimally invasive surgical treatments for men with BPH-related LUTS. Following is the group's latest advice on which to consider—and which to avoid.
Transurethral resection of the prostate (TURP). This is the most common surgical treatment for BPH, and it remains the gold standard against which other procedures are measured. Unlike simple prostatectomy (see below), TURP is performed transurethrally (through the urethra); as such TURP does not require an incision to reach the organ. For the procedure, a long thin instrument (resectoscope) is inserted through the urethra. An electrical wire loop at the end of the instrument is used to cut away excess prostate tissue blocking the urethra. About 90 to 95 percent of men with severe symptoms—and 80 percent with moderate symptoms—experience significant improvement, which is a better outcome than treatment with medication or self-help measures.
Simple prostatectomy. A simple prostatectomy is the surgery most often performed when a man's prostate is too large for a transurethral procedure to safely be performed. During surgery, the core of the prostate is removed. (By comparison, during a prostatectomy for prostate cancer, the entire prostate and the seminal vesicles are removed). The operation can be performed during open surgery, which requires a single abdominal incision, or a laparoscopic approach (with or without a robotic-assisted procedure), which requires several small incisions to accommodate the tiny instruments used during the procedure. The guideline advises basing the choice—open vs laparoscopic vs robot-assisted—on the surgeon's expertise.
Minimally Invasive Surgical Treatments
Transurethral incision of the prostate (TUIP). Using an electrical knife or laser through the resectoscope, the surgeon makes one or two small incisions where the prostate meets the bladder. This relieves the pressure caused by excess prostate tissue and alleviates the man's symptoms. TUIP takes less time to perform than TURP and can often be done on an outpatient basis under general or spinal anesthesia. The guideline recommends TUIP only for men with a small (30g or less) prostate.
Transurethral vaporization of the prostate (TUVP). For this procedure, which is a modification of TURP, the resectoscope is fitted with a small grooved roller at the end instead of the wire cutting loop. An electric current delivered through the roller and vaporizes the excess prostate tissue.
Photoselective vaporization of the prostate (PVP). For PVP, a long thin tube (cystoscope) is inserted through the urethra until it reaches the prostate. A green light laser threaded through the tube is used to vaporize excess process tissue; this creates a channel through which urine can freely flow. Blood loss during the procedure is minimal and therefore, unlike TURP, it can usually be performed as an outpatient procedure. PVP and TURP outcomes are generally similar in terms of improvement in symptoms, urinary flow, and complication rates. According to the guideline, men should be aware that PVP may be more effective for smaller prostates, and they should "adjust their expectations accordingly."
Prostatic urethral lift (PUL). In 2013, the U.S. Food and Drug Administration (FDA) approved the UroLift system, a permanent implant inserted during a minimally invasive procedure known as a prostatic urethral lift (PUL). No prostate tissue is destroyed during the procedure. Instead, the surgeon inserts a special device containing a tiny implant through the urethra and uses it to move the overgrown prostate tissue that is blocking the flow of urine. The tiny implants are deployed and are sutured to the prostate to hold the widened channel in place.
According to the AUA guideline, PUL can be considered as an option for men with prostates less than 80g with no sign of median lobe prostate obstruction. In its review of the research, the panel charged with updating the guideline found only one published study comparing PUL and TURP. It showed that at 12 and 24 months, TURP provided greater symptom relief than PUL. However, the need for reoperation due to symptom recurrence did not differ between groups over the 2-year study. In the study, there were no adverse events related to sexual function in the PUL group. By comparison, ED occurred in 9 percent and retrograde ejaculation in 20 percent of men in the TURP group. Consequently, the guideline states, PUL is an option to consider for eligible men concerned about erectile and ejaculatory function.
Transurethral microwave thermotherapy (TUMT). In TUMT, a special catheter inserted through the urethra delivers microwave energy that heats the prostate tissue to high temperatures. This destroys the excess tissue. At the same time, a cooling system protects the urethra from heat, preventing damage to the surrounding tissue. The guideline states that when compared with TURP, surgical retreatment rates are higher for TUMT.
Water vapor thermal therapy. This procedure, called Rezum Therapy, uses small amounts of steam injected into the prostate to damage and eventually destroy the excess tissue causing the obstruction. Approved by the FDA in 2015, it is an option for men whose prostates are less than 80g. Two-year results from one double-blind study comparing water vapor thermal therapy to a sham procedure showed sustained improvements from baseline in symptoms, quality of life, and urine flow rate. However, the guideline cautions that "evidence of efficacy, including longer-term retreatment rates, remains limited."
Laser enucleation. During this procedure, the surgeon uses a laser to remove the prostate gland tissue from its surrounding capsule, leaving only the prostatic capsule behind. The guideline recommends either Holmium laser enucleation of the prostate (HoLEP) or Thullium laser enucleation of the prostate (ThuLEP), depending on the surgeon's expertise with the technique. The guideline advises that laser enucleation can be considered regardless of prostate size. As with PVP, HoLEP and ThuLEP are options for men who are at higher risk of bleeding, such as those taking anticoagulation medications.
Prostatic artery embolization (PAE). During PAE, tiny particles are injected into the prostatic arteries to block the blood supply to the prostate, which eventually causes it to shrink. The guideline recommends that "PAE should only be performed in the context of a clinical trial until sufficient evidence from rigorously performed studies is available to indicate benefit over other more well established therapies." A limited number of high-quality studies available for review, safety concerns regarding radiation exposure, difficulty performing the procedure, and adverse events were cited as reasons for the recommendation.
Transurethral needle ablation (TUNA). For this procedure, radio waves delivered through needles positioned in the prostate gland heat and destroy the enlarged prostate tissue. Although TUNA has been available for more than a decade, the guideline no longer recommends it. According to the guideline, published research, albeit limited, demonstrated that prostate size following TUNA is reduced less than initially anticipated. Additional reasons for the recommendation include inconsistent findings on short- and long-term response to treatment and lack of clarity regarding which men were suitable candidates for the procedure.