BPH (benign prostatic hyperplasia, a non-cancerous enlargement of the prostate) often causes LUTS (lower urinary tract symptoms, such as a weak stream and frequent urination). It can be managed by watchful waiting, by medicines, or by surgery. Surgery is either minimally invasive or invasive.
This talk was about the procedures. My aims were to set out the non-medical options, describe each one, compare them, and show how to apply them in practice.
What treatment should achieve, and when surgery is needed
The goals are to improve the patient's quality of life, measured by the IPSS (International Prostate Symptom Score, a standard questionnaire), to improve peak urine flow on uroflowmetry (a test that measures how fast urine flows), and to do this with the fewest side effects from medicines and the fewest complications from surgery.
A procedure is considered when medicines fail: the symptoms stay bothersome, urine flow stays low, the medicines cause side effects, or the patient prefers it. It is also considered when BPH causes complications: repeated bleeding in the urine, repeated retention of urine, bladder dysfunction, bladder stones, back pressure on the kidneys (hydronephrosis), or repeated infection.
To plan the operation I look at the size of the prostate, other illnesses, whether the patient takes blood thinners, and his own preference.
Minimally invasive methods and their limits
Angioembolisation blocks the prostate's arteries from inside, working through the blood vessels. It suits patients unfit for surgery, is done as an outpatient procedure by an interventional radiologist, and has had no major complications. It is available in selected centres and still needs more trials.
Intraprostatic stents are small tubes that hold the channel open. They are used in unfit patients as an alternative to a catheter, either short term or long term, and can be non-absorbable (6 to 36 months) or biodegradable. Complications include bleeding, migration of the stent, urinary infection and encrustation (crusting with mineral deposits). Permanent stents are no longer in use.
TUNA (transurethral needle ablation) passes needles through a telescope into the prostate and heats the tissue with radiofrequency energy to about 100 degrees Celsius, killing a zone of tissue about 20 by 10 mm in five minutes. It can be done as a day case under local anaesthesia or sedation. It does not suit prostates over 75 mL or a median lobe (a middle lobe that bulges into the bladder). It has less effect than TURP and a higher retreatment rate, and its long-term results are not sustained.
TUMT (transurethral microwave therapy) heats the prostate with microwaves from a probe in the urethra, above 45 degrees Celsius, while a cooling system protects the urethra. It is a true outpatient procedure and an option for elderly patients with other illnesses. But about 40% of patients need a catheter for about a week, urinary infection is more common, flow improves less than after TURP, retreatment rates are higher, and only 20% of patients were satisfied after four years.
Why TURP is the gold standard, and where it falls short
TURP (transurethral resection of the prostate, removing prostate tissue through a telescope with an electric loop) is the standard treatment for prostates under 80 g. For small prostates under 30 mL without a middle lobe, a simple incision at the bladder outlet (TUIP) can be enough.
TURP has shortcomings. Bleeding during surgery can need a blood transfusion, and patients on blood thinners are harder to treat. Bleeding after surgery and urethral stricture (scarring that narrows the urethra) are more common. It has a significant learning curve, and a prostate over 80 g may need two stages. The irrigation fluid can be absorbed into the bloodstream and cause TUR syndrome. Bladder stones or a stricture need a separate device.
Bipolar TURP removes the risk of TUR syndrome and lowers the rates of clot retention and transfusion. Irrigation and catheter time are shorter, and the hospital stay may be shorter too.
How the surgical lasers differ
Lasers work in three ways. In enucleation, the prostate lobes are lifted off the capsule and float in the bladder, then a morcellator cuts them up for removal. In vaporisation, solid tissue is turned into vapour. In vaporesection, a high-power laser cuts and mostly vaporises the tissue, with some pieces falling into the bladder.
No laser is perfect, and each has advantages and disadvantages. The Nd:YAG laser coagulated tissue that then sloughed away over weeks, with healing taking up to three months. High catheter and infection rates made it obsolete.
The holmium laser is pulsed. It enucleates well, but vaporisation and resection with it are very slow, and it stops bleeding less well than the continuous-wave lasers. It is the one surgical laser in my comparison that also treats stones.
The KTP or green light laser (used for PVP, photoselective vaporisation of the prostate) vaporises tissue well. It is specific to the prostate and cannot be used for stones or strictures. The diode laser combines good tissue removal with good control of bleeding, and its machines are small and portable.
Why the thulium laser stands out
The thulium laser has a wavelength similar to holmium but works as a continuous wave. That gives clean, fast cuts and good control of bleeding. It can ablate, resect or enucleate, and prostates larger than 80 g can be treated safely by ThuLEP (thulium laser enucleation of the prostate) with a manageable risk of complications.
It is also used for strictures of the urethra and ureter, narrowing at the kidney outlet, and bladder tumours, and it has a role in other specialties. In my comparison table, holmium and thulium leave tissue that can be examined under a microscope, while KTP and diode do not. The learning curve I listed was about 50 cases for holmium and about 5 for thulium, against about 30 for TURP.
Sexual function, cost and the overall picture
Erectile and ejaculatory problems become more common with age. Erectile function falls after TURP in nearly a quarter of patients. HoLEP, PVP and ThuLEP did not appear to affect erectile function, though loss of ejaculation was as frequent as after TURP.
Laser prostatectomy costs more than TURP, but for large glands laser treatment is more cost effective. Newer lasers such as holmium, PVP and thulium give results and quality-of-life improvement as good as TURP. Large prostates are no longer a barrier, prolonged catheterisation, infection and stricture have fallen considerably, and the growing number of patients on blood thinners can be treated safely. Cost-effectiveness is still a question for many urologists.