benign%20prostatic%20hyperplasia
BENIGN PROSTATIC HYPERPLASIA
Benign prostatic hyperplasia (BPH) is a histopathological diagnosis characterized by epithelial cell & smooth muscle cell proliferation in the transition zone of the prostate leading to a non-malignant enlargement of the gland, which may result in lower urinary tract symptoms, including voiding and storage symptoms.
It is commonly called enlarged prostate.
The exact cause of BPH is still not well understood.

Surgical Intervention

  • Recommended when medications are not effective as well as when there are symptoms that are bothersome and severe, when complication arises (eg gross hematuria, renal insufficiency, refractory urinary retention, recurrent UTIs or bladder stones, urinary incontinence, chronic weakening of the bladder) and/or patient is unwilling to undergo or develops adverse effects from medical therapy
  • Choice of surgical technique is dependent on:
    • Prostate size
    • Presence of comorbidities
    • Ability of the patient to have anesthesia
    • Patient's preference and willingness to accept surgery-associated side effects
    • Availability of surgical equipment
    • Surgeon's experience and preference
  • Counsel patient regarding potential risks of treatment failure and need for additional therapies when surgical and minimally-invasive treatments are considered for LUTS secondary to BPH
    • Retreatment may be a medical therapy, a minimally-invasive intervention or a surgical procedure with the types of and thresholds for retreatment varying by patient, provider, initial treatment modality and type of treatment failure (ie objective, subjective or both)

Transurethral Resection of the Prostate (TURP)

  • Most common surgery for BPH
    • Standard procedure for patients with prostate volume >30 mL but <80 mL and bothersome symptoms secondary to benign prostatic obstruction (BPO)
  • Gold standard in treating the blockage of the urethra due to BPH
  • Resectoscope is inserted into the urethra to reach the prostate gland then pieces of tissue are scraped and removed using a heated wire loop

Open Prostatectomy

  • Done when the prostate is greatly enlarged, complication arises, bladder is damaged and repair is needed
  • Most invasive surgical procedure for the treatment of BPO
  • Incision is made and part or all of the prostate gland is removed
  • Procedure requires general anesthesia, longer hospital stay and rehabilitation period
  • Recovery period varies from 3-6 weeks

Laser Treatments

  • Cystoscope is used to pass a laser fiber into the urethra to the prostate and a high-energy laser is used to destroy prostate tissue

Diode Laser Vaporization of the Prostate

  • Option for patients on anticoagulants
  • Has been shown to have high intra-operative safety and with shorter catheterization and hospital times compared to TURP

Holmium Laser Enucleation of the Prostate (HoLEP)

  • Used to enucleate the prostate adenoma by using end firing pulsed solid state laser
  • Option for patients with varying prostate sizes and patients at higher risk of bleeding such as those on anticoagulants
  • Has the same result as TURP with fewer complications
  • Has shorter catheterization and hospital times, reduced blood loss but with longer operation time compared to TURP

Holmium Laser Resection of the Prostate (HoLRP)

  • Uses laser-generated heat to remove prostate tissue obstructing the urethra
  • Has shorter catheterization and hospitalization times compared to TURP

Photoselective Vaporization of the Prostate (PVP)

  • Using 120W or 180W platforms, it is an option for patients with small- and average-sized prostates
  • Option for patients at higher risk of bleeding such as those on anticoagulants or patients with a high cardiovascular risk
  • Utilizes 600-micron side firing laser with a wavelength of 532 nm in a noncontact mode
  • Prostate adenoma is vaporized sequentially outwards until the surgical capsule is exposed and a defect is created within the prostate parenchyma through which the patient will void
  • Has shorter catheterization and hospital times and with reduced clot retention but longer operating time compared to TURP

Thulium Laser Enucleation of the Prostate (ThuLEP)

  • Alternative to open prostatectomy or HoLEP in patients with moderate to severe LUTS and prostate volumes >80 mL
  • Option for patients with varying prostate sizes and patients at higher risk of bleeding such as those on anticoagulants
  • Lower rates of bleeding and complications compared to TURP and open simple prostatectomy

Transurethral Incision of the Prostate (TUIP)

  • Treatment option for patients with prostate volume ≤30 mL without a middle lobe 
  • Procedure that widens the urethra of patients with mildly enlarged prostate glands
  • Cystoscope is inserted and electric current or laser beam is used to reach the urethra going to the prostate
  • Foley catheter is inserted after the procedure to freely drain the urine out of the bladder

Complications of Invasive Procedures

  • Problems urinating
  • Urinary incontinence
  • Bleeding and blood clots
  • Urethral stricture
  • Bladder neck contracture
  • Infection
  • Scar tissue
  • Sexual/erectile dysfunction
  • Recurring problems such as urinary retention and UTIs
  • Retrograde ejaculation

Minimally Invasive Surgical Therapies (MISTs)

  • Transurethral methods that use a catheter or cystoscope to reach the prostate
  • May require local, regional or general anesthesia
  • Procedures are decided based on the patient’s symptoms and overall health

Aquablation

  • Option for patients with prostate volume >30 mL but <80 mL with or without middle lobe and desiring ejaculatory function preservation
  • Utilizes a transurethrally placed robotic handpiece, console and conformal planning unit (CPU) to resect the prostate using a water jet followed by hemostasis through electrocautery with cystoscope or resectoscope or traction from a 3-way catheter balloon
  • Requires general anesthesia

High-Intensity Focused Ultrasound

  • Also known as histotripsy 
  • Ultrasound probe is inserted onto the rectum near the prostate
  • Waves are used to heat and destroy the enlarged prostate tissue

Minimal Invasive Simple Prostatectomy

  • Includes laparoscopic simple prostatectomy (LSP) and robot-assisted simple prostatectomy (RASP)
  • May be an option for patients with prostate volume >80 mL but more randomized controlled trials are needed to evaluate long-term efficacy and safety

Prostate Artery Embolization (PAE)

  • Newer MIST endorsed by the Society of Interventional Radiology and the National Institute for Health and Care Excellence (NICE) for treatment of BPH in the UK but not recommended for treatment by the American Urological Association (AUA) and used only in clinical trials in the USA
  • May be an alternative for patients who are not good candidates for surgery due to comorbidities and those with prostate volume >80-100 mL

Prostatic Stent Insertion

  • Option for patients not suitable for surgery but with a functional detrusor muscle 
  • Prostatic stent is inserted to the narrowed area caused by the enlarged prostate
  • The stent expands like a spring in place and pushes back the prostate tissue to widen the urethra
  • May be used in men who are unable to tolerate other procedures

Prostatic Urethral Lift (PUL)

  • Option for patients with prostate volume <80 mL and without obstructive middle lobe and for eligible patients wanting to preserve erectile and ejaculatory function
  • Compresses encroaching lateral lobes by placing small, permanent, suture-based nitinol tabbed implants delivered through a cystoscope

Transurethral Microwave Therapy (TUMT)

  • Catheter with antenna is inserted to the urethra to reach the prostate and microwaves are sent to heat and destroy the selected portions of the gland
  • Cystoscopy is necessary prior to the procedure to determine the presence of a middle lobe or an insufficient length of prostatic urethra
  • Alternative for elderly patients with comorbidities or greater anesthesia risk

Transurethral Needle Ablation (TUNA)

  • Cystoscope with a needle at the end is inserted to send the radiofrequency to heat and destroy the selected prostate tissue
  • Treatment option in Europe but is not recommended in USA and Canada
  • Not recommended for prostate size >75 mL or isolated bladder neck obstruction and in the presence of a middle lobe

Transurethral Vaporization of the Prostate (TUVP)

  • May be an alternative for patients with prostate volume of 30-80 mL and moderate to severe LUTS 
  • Resectoscope with electrode is inserted to the urethra and moved across the prostate to transmit electric current to vaporize prostate tissue

Water Vapor Thermal Therapy

  • Also known as transurethral destruction of prostate tissue by radiofrequency-generated water thermotherapy
  • Option for patients with prostate volume <80 mL or with median lobe and for eligible patients wanting to preserve erectile and ejaculatory function
  • Catheter with a treatment balloon is used to heat and destroy the tissue
  • Can target specific region of the prostate while the tissues surrounding the urethra and bladder remain protected

Complications of Minimally Invasive Therapies

  • UTIs
  • Painful urination
  • Difficulty urinating
  • An urgent or a frequent need to urinate
  • Urinary incontinence
  • Blood in the urine for several days after the procedure
  • Sexual dysfunction
  • Chronic prostatitis
  • Recurring problems such as urinary retention and UTIs
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