Surgical treatment of BPH
For those who fail or cannot tolerate the side effects of medical therapy, there are numerous surgical options for benign prostate hyperplasia (BPH). These treatments can be broken down into three categories, minimally invasive surgical therapies, also known as MISTs, transurethral surgeries, and removal of the entire prostate gland, known as a prostatectomy. New treatments are frequently introduced, and established surgical techniques are improved upon, so it is important for you physician to stay up to date with current developments.
Transurethral resection of the prostate (TURP)
TURP is a resection of the enlarged prostate gland from done from inside of the urethra. To accomplish this, a device called a resectoscope is inserted into the penis and advanced up to the prostate gland. A wire loop is heated with electricity and used to gradually cut out prostatic tissue that is obstructing the flow of urine out of the bladder. This can take about an hour or so, depending on the amount of tissue that needs to be resected. TURP is generally performed in a hospital. It does require the placement of a catheter for several days while inflammation from the surgery subsides. Recovery from the surgery takes several weeks, and any strenuous activity needs to be avoided. Depending on the occupation, taking leave from work for a few weeks is also often recommended while managing side effects. While a TURP is generally safe, most patients will develop retrograde ejaculation (dry ejaculation), and some will develop ED or urge incontinence.
Transurethral incision of the prostate (TUIP)
TUIP is performed using the same equipment and approach as a TURP, but instead of resecting the prostate, a few incisions are made at the junction of the prostate and the base of the bladder to widen the bladder outflow and allow urine to pass through the prostatic urethra easier. This procedure is useful to improve flow in men with mild BPH that is particularly affecting the junction of the prostate and bladder or men who wish to preserve their fertility. This does not carry the same risk of sexual side effects as a TURP. However, many patients with BPH are not candidates for this procedure.
Laser based transurethral prostate ablations or resections
There are a few other variations of transurethral prostate resection that are done from a similar approach as a TURP but can potentially be performed as an outpatient or cause less early postoperative morbidity, such as shorter hospital stays, less chance of bleeding requiring transfusion and shorter times having a urinary catheter.
Photoselective Vaporization of the Prostate (PVP): This uses focused light energy, or a laser, to ablate the enlarged prostate obstructing the flow of urine out of the bladder. It ablates the prostate gland in layers, which evaporate. This can be done in an office setting, and patients are discharged with a urinary catheter in place for several days.
Holmium Laser Enucleation of the Prostate (HoLEP): HoLEP uses a laser to cut away the prostate gland, which is then removed (enucleated). When this is performed, most of the prostate gland can be taken out, allowing HoLEP to be used to treat much larger glands than PVP or TURP. It is typically performed at a hospital because of the highly specialized equipment required to perform the surgery. It can be used on mildly enlarged prostates or on larger glands as an alternative to robotic-assisted laparoscopic simple prostatectomy. Studies have shown that it has a slightly more favorable postoperative course but sometimes lengthier postoperative incontinence.
Aquablation is one of the newest methods to perform a transurethral prostate resection. In this procedure, the prostate is mapped using a transrectal ultrasound probe. A small cystoscope is inserted through the penis and attached to a robotic arm. A high-pressure jet of water is generated by the robot and used to precisely resect the mapped portions of the enlarged prostate. This is performed in the hospital under moderate sedation. While this procedure is fairly new, the side effect profile does seem to be more favorable than TURP. Still, around ten to fifteen percent of patients have dry ejaculations, but the rate of ED is very low.
Prostate Artery Embolization (PAE)
Prostate artery embolization is a totally different way of treating an enlarged prostate gland compared to the rest of the options presented by urologists. Instead of cutting, heating, or removing portions of the prostate gland, PAE works by causing the prostate to shrink by greatly reducing its blood supply. An interventional radiologist will gain access into the arteries feeding the prostate gland using a small pinhole in the main artery of the groin and drip very small plastic particles to block off most of the blood supply to the prostate. This will result in the gland shrinking over the next 3 months. This is the only therapy that does not carry a significant risk of sexual side effects. Erectile dysfunction and ejaculation disorders are virtually unheard of following PAE. Because of the scarcity of interventional radiologists performing a significant number of these procedures and the steep learning curve, PAE is not offered in most urology practices.
Minimally invasive surgical therapies (MISTs)
MISTs are a group of treatments designed to reduce the size of the prostate without cutting away the gland, with the goal of achieving relief from BPH symptoms without causing undesirable side effects. In general, the better side effect profile of MISTs is counterbalanced by slightly less improvement in urinary flow than TURP, which is the gold standard for transurethral surgery, but they may be enough to provide patients with adequate relief.
Prostatic Urethral Lift (PUL): This therapy is performed by placing a delivery device through the penis into the prostatic urethra, which deploys thin metal implants that pull back the prostate gland, opening up the treated segment of the urethra. Because there is no cutting or heating of the prostate, patients have more rapid relief and recovery, with mild to moderate adverse effects only lasting a couple of weeks. Fewer patients need catheters following PUL, and it is the only other procedure besides PAE where sexual side effects are virtually unheard of. PUL cannot be performed on large prostates or prostates with certain shapes, and there are some concerns that this treatment may not last as long as other transurethral therapies.
Water Vapor Thermal Therapy: This treatment is performed by advancing a device through the penis into the prostatic urethra, which deploys a needle into the enlarged portion of the prostate gland. Next, these segments are heated using steam, which causes the surrounding prostate cells to die. This can be performed as an outpatient under moderate sedation. This technique is only approved for prostate glands that are under a certain size. It does have a more favorable sexual side effect profile than other prostate surgeries, but it still does have a low rate of retrograde ejaculation and can cause chronic lower urinary tract irritative symptoms.
Surgical Removal of the Prostate
Despite all of the technical advances and innovative techniques to treat BPH without surgery, a patient and their urologist may decide that removal of the prostate gland is the best course of action to manage their symptoms. Fortunately, advances in surgical techniques have made prostatectomy much less morbid than in the past.
Robotic-assisted Laparoscopic Simple Prostatectomy (RALP): This technique for removal of the prostate utilizes a specialized surgical robot and has significantly less post-operative morbidity compared to older surgical techniques. The urologist performing the procedure must be specially trained to operate with the robot. Briefly, the technique involves making an incision through the outer layer of the prostate and removing the inner portion of the gland that is enlarged. A commonly made analogy is that the surgery is like removing the pulp of a fruit but leaving the peel behind. Simple prostatectomy has the longest symptom improvement, with the need for subsequent surgery rare once the patient has recovered. There is often a prolonged period of some degree of urinary incontinence following a simple prostatectomy, which typically resolves.