A Better Way to Treat BPH

Urology

By: Douglas Grier

Published: 3/19/2020

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Men with enlarged prostates are seeking out surgeons who offer a minimally invasive solution to their symptoms.


Benign prostatic hyperplasia (BPH) is a chronic age-related condition associated with symptoms of having to urinate frequently, urgently and many times throughout the night. The condition affects half of men between 50 and 60 years of age and more than 90% of men aged 80 years and older. More than 13 million men in the United States have symptomatic BPH, and there are many thousands of transurethral resections of the prostate (TURP) performed each year.

Now men have a better treatment option. The prostatic urethral lift is a minimally invasive cystoscopic procedure that can be performed in about 10 minutes in surgery centers or office spaces with the patient under oral or conscious sedation. Instead of removing tissue, surgeons apply a mechanical fix to a mechanical problem: Pulling collapsed walls of the prostate apart with small implants. By offering the procedure, you'll increase case volume because the indication threshold is lower than for the traditional TURP surgery and patient demand has increased. Surgery centers are ideal for the procedure with throughput times of 45 minutes to one hour from admission to discharge.

When meds fail
FLOW RATE Surgeons place a series of small implants to open the prostatic urethra.

Management of BPH with prostate-relaxing medications is the first treatment option and is effective in improving symptoms for four to possibly 10 years. However, more than 25% of medically managed patients are noncompliant or discontinue their therapy due to associated side effects such as nasal congestion, dizziness and ejaculatory dysfunction. Plus, the prostate continues to grow, and suffering men will eventually need to undergo surgery when the symptoms become intolerable.

TURP, long considered the gold standard surgical intervention, involves removing segments of the prostate gland with a resectoscope placed through the urethra. TURP procedures are invasive, lead to longer recoveries with increased risk of bleeding and result in longer catheterization. Many men avoid undergoing this procedure due to concerns about long recoveries, complications and side effects, including losing the ability to ejaculate. The procedures are performed in 45 minutes to an hour with the patient under general anesthesia and typically require a minimum 48-hour catheterization after surgery. For that reason, a significant percentage of these procedures can't be done in the outpatient setting.

The prostatic urethral lift procedure offers a middle ground between medication therapy and the more invasive TURP. Men who are on medications, but tiring of the associated side effects, can opt to undergo the lift procedure to get off the therapy.

Although the lift isn't quite as effective as TURP in terms of increasing urinary flow rates, patients recover quickly and return to normal life activities within three to five days. Two-thirds of patients don't need to be catheterized after the procedure. Half of my patients with enlarged prostates undergo the TURP procedure and half undergo the lift (I perform about 10 per month). Men with large prostates might require the more invasive TURP procedure, but those with moderate sized or a smaller symptomatic prostate are candidates for the lift procedure. Patients who undergo the lift are not precluded from later TURP if indicated.

The lift is also an appropriate option for patients who aren't candidates for TURP, including older, sicker men in whom anesthesia would be risky or patients for whom holding blood thinners are contraindicated. Unlike the TURP procedure, patients don't have to stop blood thinners before having a lift performed.

Clear benefit

Patients undergoing a lift receive oral sedation with valium or hydrocodone and a local anesthetic after being prepped and draped in the lithotomy position. Nurses place viscous lidocaine in the urethra or 4% liquid lidocaine in the bladder for 10 minutes prior to the procedure.

Surgeons then pass a rigid cystoscope through the urethra to push the obstructing prostate lateral lobes to the side. They then place a series of polypropylene implants — a minimum of two, a maximum of seven or eight — in order to open the prostatic urethra. Each implant can be fired and deployed in a matter of seconds. The procedure can be completed in 20 minutes or less. Patients are in the facility for about an hour in total.

Patients recover quickly and return to normal life activities in three to five days.

Data show 86% of patients don't need retreatment, reoperation or alternative treatment at five years post-op. Measurement of voiding function, based on flow rate and pressure, before and after surgery shows lift is about 75% effective as TURP in improving urinary flow rates, enough to achieve significant improvement and reduction in voiding symptoms. Patient satisfaction after the lift procedure is very high because the approach is not as invasive as TURP and doesn't negatively impact the ability to achieve erections or ejaculate.

The lift has two assigned APC codes: 5375 and 5376. The unadjusted facility reimbursement amount for the first 3 implants placed is approximately $3,117; reimbursement climbs to $6,505 for up to six implants. The implants cost about $950 each. Placing four therefore eats into about half of the reimbursement, but overall the lift is a reasonably profitable procedure based on the number of implants used.

I can complete three lifts in the amount of time it takes to do two TURPs. Realistically, I can perform 60 to 100 lifts per year. Being able to perform more cases adds to the procedure's profit potential. There's also no global follow-up period on the lift procedure, compared with a 90-day global period for TURP.

Some younger men who have been avoiding TURP due to interest in preserving their sexual function are more likely to schedule a lift procedure. Patients seek me out because they're looking for an alternative to TURP, and many of my satisfied patients refer friends and family to me. OSM

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