More Options Than Ever

Remedying benign prostatic hyperplasia is not a one-size-fits-all proposition. Fortunately, multiple treatments abound.

Benign prostatic hyperplasia (BPH) is a common condition for men older than 45. Its prevalence increases as men age. As the median age of Americans rises, we need effective BPH treatments more than ever. Fortunately, we’re well on our way.

Evolving treatment landscape

There really are more treatment options than ever. The procedures continue to evolve and we’re getting more data from outcomes research that allows us to compare the procedures to one another in terms of success rates and durability. The wide array of minimally invasive options can ease problems associated with an enlarged prostate, which include frequent urination, urinary urgency, difficulty starting urination and a weak stream.

Here are several of the most popular surgical interventions for BPH.

Transurethral Resection of the Prostate (TURP)

This procedure, which uses bipolar electrical energy, was the gold standard for a really long time. It is typically an outpatient procedure, although patients with larger prostates are sometimes kept overnight for observation. Many seasoned urologists use it in part because they are comfortable with it and may not have the time or interest in learning newer procedures. I still use it for select patients and I believe it definitely still has its place in our armamentarium.

“I want the procedure my patients undergo to be the result of a shared decision-making process.”

Specifically, I use the TURP in radiate patients and patients with neurological conditions such as Parkinson’s or MS that put them at substantial risk for leakage of urine postoperatively. The TURP allows you a little bit more control of how much tissue you take, particularly at the apex of the prostate. With these patients, I’m very conservative in making sure that I don’t open them up too much because they have a much higher risk of having postoperative incontinence. I like to do what I call a channel or “conservative TURP” on those types of patients to get them open but also have more control on how much tissue I’m taking.

Robotic-assisted waterjet technology

This relatively new technology is image-guided to allow for greater precision of surgical planning. We use a transrectal ultrasound in the patient’s rectum at the same time that we have a scope in the urethra. The platform allows us to plan out the contours and shape of each person’s prostate, which really helps make a precise treatment plan, since no prostate is the exact same size or shape.

Once we have the surgical plan mapped out, the actual treatment is delivered through the scope, which I equate to a high-pressure power washer that you would use on your back deck. It delivers the water stream in a windshield-wiper motion to ablate the tissue with a high-pressure water jet without any heat. This allows the tissue to be ablated, and the lack of heat helps to decrease the risk of retrograde ejaculation as well as leakage of urine. The risks of those two side effects with this procedure are about 10%, whereas it can be upwards of 30% to 50% with some other procedures.

The waterjet technology fits the niche of younger patients with larger prostates >80g who want to preserve ejaculation. An ideal size range for this procedure is 50g to 150g.

After ablation with the waterjet is complete, I go in with the resectoscope, which is what we use in TURPs, remove the treated tissue and then fulgurate the mucosa to get good hemostasis before we put the catheter in. This helps expedite the sloughing process during recovery as well as obtain control of any bleeding within the prostate. The catheter is usually kept in for about two days postoperatively, or five to seven days for those who are already catheter-dependent. Some patients go home the same day, while some are kept overnight.

Additional options

Prostatic urethral lift. This procedure does not involve any tissue removal. Rather, it uses clips to “lift” the prostatic tissue out of the way of the channel. As mentioned earlier, there are some populations you don’t want to be overly aggressive with, such as radiated patients, who can be appropriate for this kind of procedure. The best candidates for this technology are younger patients who want to preserve ejaculation and have prostates weighing less than 80g, without a median lobe. The retrograde ejaculation rate is extremely low with this procedure. The issue with this technology is suboptimal outcomes, often due to poor patient selection.

Steam therapy. Another relatively recent technology, this is quite minimally invasive and often used in populations who want to preserve ejaculation. Similar to the prostatic urethral lift, the ideal prostate size for this therapy is 30-80g. It’s a very quick outpatient procedure that takes only about 15 minutes to perform. You inject the lobes of the prostate with steam, and then over a six- to eight-week timeframe that tissue gets slowly reabsorbed. A potential downside is that the procedure can trigger quite an inflammatory response within the prostate. Typically, these patients have a catheter for about a week to let that inflammation subside and give them the best chance to pass their void trial. Additionally, after the catheter comes out, these patients can have some significant burning with urination and bothersome urinary urgency and frequency as the tissue gets reabsorbed. It takes six to eight weeks for that tissue to reabsorb, so patients may not notice a change right away.

Photovaporization of the prostate (PVP). This is very similar to the TURP but uses a green light laser instead of bipolar energy. It can have a slightly lower bleeding risk than some of the other procedures, so physicians will often use it in patients who are on blood thinners. It doesn’t, however, have quite the precision of a TURP because the motion of the laser to ablate is much broader and it can be harder to guage the change in tissue planes as accurately to know if you have removed enough tissue. While some patients have a little more burning with urination in the days after the procedure, they get good immediate results overall because it effectively removes the intended tissue.

GROWING PROBLEM Many middle-aged men are seeking new minimally invasive treatments for enlarged prostates.

Prosthetic artery embolization (PAE). This is a good alternative for patients who may not be the ideal surgical candidates or have a high bleeding risk. Interventional radiology performs this procedure by using access through the femoral vessels and inserting coils into the smaller feeding vessels of the prostate to essentially cut off the blood supply and allow the prosthetic tissue to atrophy over time.

It can take six to 12 months to see the full effects of this therapy, which can be a downside for patients who are looking for more immediate results. However, the procedure can work well on very large prostates as an initial treatment and patients can then undergo future cytoreductive BPH treatments if they do not get resolution of their symptoms from PAE alone.

Holmium laser enucleation of the prostate (HoLEP). This is a very effective BPH procedure that removes the greatest amount of prostate tissue. Physicians use a holmium laser or the bipolar loop to core out all of the prostate tissue. The durability of it is really good, with a less than 1% chance that patients will need another procedure in their lives. It’s an incision-free intervention that is performed endoscopically through the penis.

The biggest limiting factor to this surgery is the steep learning curve for physicians. Additionally, the incontinence rate can be much higher, around 30% postoperatively, and retrograde ejaculation is pretty much expected after this procedure.

Robotic simple prostatectomy. This can also be done as an open procedure but nowadays most surgeons perform it robotically and core out the prostate from inside the bladder rather than going in from the urethra. This minimally invasive option, like enucleation, is more aggressive and removes large amounts of prostate tissue. This is particularly appropriate for patients with prostates >100g or if they also have large stones in their bladder, which can be removed simultaneously.

The fact that there are so many surgical options for BPH can be overwhelming to patients. Doctors who are competent in multiple procedures can offer patients individualized treatment plans based on their goals, priorities and anatomy.

I tailor my recommendations based on my patient’s overall clinical picture so we are both on the same page and understand the goals and expectations of the surgery. I want the procedures my patients undergo to be the result of a shared decision-making process and not a one-size-fits-all approach. OSM