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Surgery for benign prostatic hyperplasia

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Surgery for benign prostatic hyperplasia
Transurethral resection of the prostate (TURP)

If medical treatment is not effective, surgery may need to be performed for benign prostatic hyperplasia.

Invasive therapies

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There are two invasive surgical procedures done for BPH:

  • Transurethral resection of the prostate (TURP): In general prior to emergence of laser technologies, TURP had been considered the gold standard of prostate interventions for people who require a procedure. This involves removing (part of) the prostate by inserting a resectoscope (cystoscope) through the urethra. However, after this endoscopic surgery the ejaculations are dry in about 65% of patients, unless a novel, ejaculation preserving, altered technique of TURP is applied.[1][2]
  • Simple prostatectomy can also be offered to men who have large prostates (>50 grams). This can be done by open technique, laparoscopically, or with robotic assistance.[3]

There are two types of transurethral resection of the prostate (TURP): the standard monopolar and the newer bipolar procedure. A 2019 Cochrane review of 59 studies that included 8924 men with urinary symptoms due to benign prostatic hyperplasia.[4] This review found that bipolar and monopolar TURP probably results in comparable improvements in urinary symptoms, as well as a similar erectile function, the incidence of urinary incontinence, and the need for retreatment. Bipolar surgery likely reduces the risk of TUR syndrome and the need for blood transfusion.[citation needed]

Efforts to find newer surgical methods have resulted in newer approaches and different types of energies being used to treat the enlarged gland. However some of the newer methods for reducing the size of an enlarged prostate, have not been around long enough to fully establish their safety or side-effects. These include various methods to destroy or remove part of the excess tissue while trying to avoid damaging what remains. Transurethral electrovaporization of the prostate (TVP), laser TURP, visual laser ablation (VLAP), ethanol injection, and others are studied as alternatives.[5]

Minimally invasive therapies

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Minimally invasive therapies can offer faster recovery compared with traditional prostate surgery.[6] They can further be divided into laser surgery (requiring spinal anesthesia) and other non-laser procedures.

Prostate laser surgery

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Prostate laser surgery is used to relieve moderate to severe urinary symptoms caused by prostate enlargement. The surgeon inserts a scope through the penis tip into the urethra. A laser passed through the scope delivers energy to shrink or remove excess tissue that is preventing urine flow.[7]

Different types of prostate laser surgery include:

  • Visual laser ablation of the prostate (VLAP) technique involving the Nd:YAG laser with contact on the prostatic tissue.
  • Photoselective Vaporisation of the Prostate (PVP). A laser is used to melt away (vaporize) excess prostate tissue and enlarge the urinary channel.[7] A high-power 180-watt 532 nm wavelength laser with a 650-micrometre laser fiber is used. This fiber has an internal reflection with a 70-degree deflecting angle. It is used to vaporize the tissue to the prostatic capsule. GreenLight 532 nm lasers target haemoglobin as the chromophore and typically have a penetration depth of 0.8 mm (twice as deep as holmium).
  • Holmium Laser Ablation of the Prostate (HoLAP) is similar to PVP but uses a different type of laser.[7] HoLAP uses a 550 um disposable side-firing fiber that directs the beam from a high-power 100-watt laser at a 70-degree angle from the fiber axis. The holmium wavelength is 2,140 nm, which falls within the infrared portion of the spectrum and is invisible to the naked eye. Whereas GreenLight relies on haemoglobin as a chromophore, water within the target tissue is the chromophore for Holmium lasers. The penetration depth of Holmium lasers is <0.4 mm, avoiding complications associated with tissue necrosis often found with the deeper penetration and lower peak powers of Nd:YAG lasers used in the 1990s.[5]
  • Holmium Laser Enucleation of the Prostate (HoLEP) is used to cut and remove the excess tissue that is blocking the urethra. Another instrument is then used to cut the prostate tissue into small pieces that are easily removed. HoLEP can be an option for men who have a severely enlarged prostate and is the only prostate size-independent treatment option approved by the American Urologic Association.[8] HoLEP is largely similar to the HoLAP procedure; the main difference is that instead of ablating the tissue, the laser cuts a portion of the prostate, which is then cut into smaller pieces and flushed with irrigation fluid. As with the HoLAP procedure, there is little bleeding during or after the procedure. Three 2015 reviews found that HoLEP is superior to TURP in some respects and for some patients.[5][9][10]

Both wavelengths, GreenLight and Holmium, ablate approximately one to two grams of tissue per minute.[citation needed]

Post-surgical care often involves placement of a Foley catheter or a temporary prostatic stent to permit healing and allow urine to drain from the bladder.

Non-laser treatments

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These procedures are typically performed with local anesthesia, and the patient returns home the same day. Some urologists have studied and published long-term data on the outcomes of these procedures, with data out to five years.

Transurethral microwave thermotherapy

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Transurethral microwave thermotherapy (TUMT) was originally approved by the United States Food and Drug Administration (FDA) in 1996, with the first generation system by EDAP Technomed. Since 1996, other companies have received FDA approval for TUMT devices, including Urologix, Dornier, Thermatrix, Celsion, and Prostalund. Multiple clinical studies have been published on TUMT. The general principle underlying all the devices is that a microwave antenna that resides in a urethral catheter is placed in the intraprostatic area of the urethra. The catheter is connected to a control box outside of the patient's body and is energized to emit microwave radiation into the prostate to heat the tissue and cause necrosis. It is a one-time treatment that takes approximately 30 minutes to 1 hour, depending on the system used. It takes approximately 4 to 6 weeks for the damaged tissue to be reabsorbed into the patient's body.

Transurethral needle ablation

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Transurethral needle ablation (TUNA) operates with a different type of energy, radio frequency (RF) energy, but is designed along the same premise as TUMT devices, that the heat the device generates will cause necrosis of the prostatic tissue and shrink the prostate. The TUNA device is inserted into the urethra using a rigid scope much like a cystoscope. The energy is delivered into the prostate using two needles that emerge from the sides of the device, through the urethral wall and into the prostate. The needle-based ablation devices are very effective at heating a localized area to a high enough temperature to cause necrosis. The treatment is typically performed in one session, but may require multiple sticks of the needles depending on the size of the prostate. The most recent American Urological Association (AUA) Guidelines for the Treatment of BPH from 2018 stated that "TUNA is not recommended for the treatment of LUTS/BPH".[11]

Water vapor thermal therapy

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Water vapour thermal therapy (marketed as Rezum) is a newer office procedure for removing prostate tissue using steam. Several studies including a four-year follow-up provided evidence for improvement of BPH symptoms, preserved sexual function, and low surgical retreatment rates.[12][13]

Prostatic urethral lift

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Prostatic urethral lift (marketed as Urolift) is a procedure for men with urinary symptoms caused by prostate enlargement. It consists of placing small hooks that compress the prostate tissue to open the urinary stream without cutting or removing tissue. This procedure likely improves quality of life without additional negative side effects when compared with a sham surgery.[14]

Compared with transurethral resection of the prostate, the standard surgery for treating benign prostatic hyperplasia, this procedure may be less effective in reducing urinary symptoms but may preserve ejaculation and have fewer unwanted effects on erections.[14]

Temporary implantable nitinol device

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Temporary implantable nitinol device (marketed as TIND and iTIND) is a device that is placed in the urethra that, when released, is expanded, reshaping the urethra and the bladder neck.

The American Urological Association (AUA) guidelines for the treatment of BPH from 2018 list minimally invasive therapies including TUMT - but not TUNA - as acceptable alternatives for certain patients with BPH.[11] However, the European Association of Urology (EAU) has - as of 2019 - removed both TUMT and TUNA from its guidelines.[15]

Complications of Prostate Surgery

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The two most feared complications of prostate surgery are erectile dysfunction and stress urinary incontinence.[16] The type of complications depend on the treatment modality used:

Other

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The National Institute for Health and Care Excellence (NICE) of the UK in 2018 classified some novel methods as follows.[22]

Recommended:

Not recommended:

General prospects of surgery success

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The success of surgery for benign prostatic hyperplasia (BPH) – as measured by a significant reduction of lower urinary tract symptoms (LUTS) – strongly depends on a reliable (unequivocal) pre-surgery diagnosis of bladder outlet obstruction (BOO). A pre-surgery diagnosis of other LUTS only, such as overactive bladder (OAB) with or without urinary incontinence predicts little or no success after surgery.[27]

If BOO is present or not can be determined by reliable non-invasive tests, such as the Penile cuff test (PCT). In this test, first published in 1997, a software-steered inflatable cuff (similar as in a blood pressure meter) is placed around the penis to measure the pressure of urinary flow.[28] By applying this methode, a study of 2013 showed that 94% of the patients with the pre-surgery test result "Obstruction" had a successful surgery outcome. In contrast, 70% of the patients with the pre-surgery test result "No Obstruction" had a non-successful surgery outcome.[29][27]

If BPH with obstruction additionally presents with overactive bladder (OAB), which is the case in about 50% of patients,[30] this latter symptom (OAB) persists even post-surgery in about 20% of patients. However, this rate only applies to a period of a few years. 10–15 years after surgery 48 of 55 patients (87%) with obstruction and OAB had kept their post-surgery reduction of obstruction, but their OAB symptoms had gone back to the pre-surgery status.[31]

Research

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The UNBLOCS trial compared using transurethral resection of the prostate (TURP) to the thulium laser transurethral vaporesection of the prostate (ThuVARP). Both methods led to similar improvements, number of complications and lengths of hospital stay. Both were effective as treatment but TURP resulted in a better urinary flow rate.[32][33]

References

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  1. ^ Lebdai S, Chevrot A, Doizi S, Pradere B, Delongchamps NB, Benchikh A, et al. (February 2019). "Do patients have to choose between ejaculation and miction? A systematic review about ejaculation preservation technics for benign prostatic obstruction surgical treatment". World Journal of Urology. 37 (2): 299–308. doi:10.1007/s00345-018-2368-6. PMID 29967947. S2CID 49556196.
  2. ^ Marien T, Kadihasanoglu M, Miller NL (2016). "Holmium laser enucleation of the prostate: patient selection and perspectives". Research and Reports in Urology. 8: 181–192. doi:10.2147/RRU.S100245. PMC 5085273. PMID 27800470.
  3. ^ Helfand B, Mouli S, Dedhia R, McVary KT (December 2006). "Management of lower urinary tract symptoms secondary to benign prostatic hyperplasia with open prostatectomy: results of a contemporary series". The Journal of Urology. 176 (6 Pt 1): 2557–61, discussion 2561. doi:10.1016/j.juro.2006.07.143. PMID 17085158.
  4. ^ Alexander CE, Scullion MM, Omar MI, Yuan Y, Mamoulakis C, N'Dow JM, et al. (Cochrane Urology Group) (December 2019). "Bipolar versus monopolar transurethral resection of the prostate for lower urinary tract symptoms secondary to benign prostatic obstruction". The Cochrane Database of Systematic Reviews. 12 (12): CD009629. doi:10.1002/14651858.CD009629.pub4. PMC 6953316. PMID 31792928.
  5. ^ a b c Cornu JN, Ahyai S, Bachmann A, de la Rosette J, Gilling P, Gratzke C, et al. (June 2015). "A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update". European Urology. 67 (6): 1066–1096. doi:10.1016/j.eururo.2014.06.017. PMID 24972732.
  6. ^ "Laser PVP surgery" mayocilic.org
  7. ^ a b c "Prostate laser surgery" mayoclinic.org
  8. ^ Parsons JK, Dahm P, Köhler TS, Lerner LB, Wilt TJ (October 2020). "Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline Amendment 2020". The Journal of Urology. 204 (4): 799–804. doi:10.1097/JU.0000000000001298. PMID 32698710.
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  11. ^ a b Foster HE, Barry MJ, Dahm P, Gandhi MC, Kaplan SA, Kohler TS, et al. (September 2018). "Surgical Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline". The Journal of Urology. 200 (3): 612–619. doi:10.1016/j.juro.2018.05.048. PMID 29775639.
  12. ^ Doppalapudi SK, Gupta N (January 2021). "What Is New with Rezūm Water Vapor Thermal Therapy for LUTS/BPH?". Current Urology Reports. 22 (1): 4. doi:10.1007/s11934-020-01018-6. PMID 33403529. S2CID 230783957.
  13. ^ Miller LE, Chughtai B, McVary K, Gonzalez RR, Rojanasarot S, DeRouen K, Bhattacharyya S (July 2020). "Water vapor thermal therapy for lower urinary tract symptoms secondary to benign prostatic hyperplasia: Systematic review and meta-analysis". Medicine. 99 (30): e21365. doi:10.1097/MD.0000000000021365. PMC 7387023. PMID 32791742.
  14. ^ a b Jung JH, Reddy B, McCutcheon KA, Borofsky M, Narayan V, Kim MH, Dahm P, et al. (Cochrane Urology Group) (May 2019). "Prostatic urethral lift for the treatment of lower urinary tract symptoms in men with benign prostatic hyperplasia". The Cochrane Database of Systematic Reviews. 2019 (5): CD012832. doi:10.1002/14651858.CD012832.pub2. PMC 6535104. PMID 31128077.
  15. ^ EAU: Management of Non-neurogenic Male LUTS - Summary of Changes 2019.
  16. ^ Michaelson MD, Cotter SE, Gargollo PC, Zietman AL, Dahl DM, Smith MR (2008). "Management of complications of prostate cancer treatment". CA. 58 (4): 196–213. doi:10.3322/CA.2008.0002. PMC 2900775. PMID 18502900.
  17. ^ "Urinary Incontinence After Prostate Surgery: Everything You Need To Know". Urinary Incontinence Education | Bladder Health | National Association for Continence. Retrieved 2020-04-16.
  18. ^ Anderson CA, Omar MI, Campbell SE, Hunter KF, Cody JD, Glazener CM (January 2015). "Conservative management for postprostatectomy urinary incontinence". The Cochrane Database of Systematic Reviews. 1 (1): CD001843. doi:10.1002/14651858.cd001843.pub5. PMC 7025637. PMID 25602133.
  19. ^ Anderson CA, Omar MI, Campbell SE, Hunter KF, Cody JD, Glazener CM (January 2015). "Conservative management for postprostatectomy urinary incontinence". The Cochrane Database of Systematic Reviews. 1 (1): CD001843. doi:10.1002/14651858.CD001843.pub5. PMC 7025637. PMID 25602133.
  20. ^ Moore KC, Lucas MG (April 2010). "Management of male urinary incontinence". Indian Journal of Urology. 26 (2): 236–244. doi:10.4103/0970-1591.65398. PMC 2938549. PMID 20877603.
  21. ^ "Erectile Dysfunction After Prostate Cancer". www.hopkinsmedicine.org. 19 November 2019. Retrieved 2020-04-16.
  22. ^ National Institute for Health and Care Excellence (NICE): Current care pathway (for BPH), August 2018.
  23. ^ Ray A, Morgan H, Wilkes A, Carter K, Carolan-Rees G (October 2016). "The Urolift System for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A NICE Medical Technology Guidance". Applied Health Economics and Health Policy. 14 (5): 515–526. doi:10.1007/s40258-015-0218-x. PMC 5025508. PMID 26832146.
  24. ^ National Institute for Health and Care Excellence (NICE): Transurethral water jet ablation for lower urinary tract symptoms caused by benign prostatic hyperplasia, Interventional procedures guidance, 19 September 2018.
  25. ^ National Institute for Health and Care Excellence (NICE): Rezum for treating benign prostatic hyperplasia, Medtech innovation briefing, 24 August 2018.
  26. ^ National Institute for Health and Care Excellence (NICE): Current care pathway (for BPH), issue "Minimally invasive treatments", August 2018.
  27. ^ a b Jiang YH, Kuo HC (2017). "Recent research on the role of urodynamic study in the diagnosis and treatment of male lower urinary tract symptoms and urinary incontinence". Ci Ji Yi Xue Za Zhi = Tzu-Chi Medical Journal. 29 (2): 72–78. doi:10.4103/tcmj.tcmj_19_17. PMC 5509199. PMID 28757770.
  28. ^ Malde S, Nambiar AK, Umbach R, Lam TB, Bach T, Bachmann A, et al. (March 2017). "Systematic Review of the Performance of Noninvasive Tests in Diagnosing Bladder Outlet Obstruction in Men with Lower Urinary Tract Symptoms". European Urology. 71 (3): 391–402. doi:10.1016/j.eururo.2016.09.026. hdl:10138/233866. PMID 27687821.
  29. ^ Losco G, Keedle L, King Q (November 2013). "Non-invasive urodynamics predicts outcome prior to surgery for prostatic obstruction". BJU International. 112 (Suppl 2): 61–64. doi:10.1111/bju.12382. PMID 24127677. S2CID 46245863.
  30. ^ Eapen RS, Radomski SB (2016). "Review of the epidemiology of overactive bladder". Research and Reports in Urology. 8: 71–76. doi:10.2147/RRU.S102441. PMC 4902138. PMID 27350947.
  31. ^ Thomas AW, Abrams P (May 2000). "Lower urinary tract symptoms, benign prostatic obstruction and the overactive bladder". BJU International. 85 (Suppl 3): 57–68, discussion 70–1. doi:10.1111/j.1464-410X.2000.tb16953.x. PMID 11954200. S2CID 42369935.
  32. ^ "Laser surgery for an enlarged prostate is no more effective than standard surgery". NIHR Evidence (Plain English summary). National Institute for Health and Care Research. 2021-02-17. doi:10.3310/alert_44637. S2CID 241164315.
  33. ^ Worthington J, Lane JA, Taylor H, Young G, Noble SM, Abrams P, et al. (September 2020). "Thulium laser transurethral vaporesection versus transurethral resection of the prostate for benign prostatic obstruction: the UNBLOCS RCT". Health Technology Assessment. 24 (41): 1–96. doi:10.3310/hta24410. PMC 7520718. PMID 32901611.
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