BPH – surgical management

Indications for BPH surgery:

• Urinary retention
• Renal impairment or upper tract dilation
• Recurrent UTI
• (Recurrent) bladder stones
• Haematuria due to BPH
• Bothersome LUTS which are refractory or unsuited to medical treatment

 

 

TURP

Mechanism

• Use of either monopolar or bipolar electrosurgery to resect and remove tissue from the transition zone of the prostate

 

Efficacy

• Reduction in IPSS and PVR by 70 %
• Improvement in QoL score by 70 %
• Increase in Qmax by 160 %
• < 10 % need for further treatment at 5 years

 

Pros ·       Proven long term benefit (years) ·       Widespread availability ·       Suitable for almost all prostates ·       Tissue available for histology ·       Relatively cheap

Cons ·       1-3 night hospital stay ·       Retrograde ejaculation expected ·       10 % change in ED (some improve) ·       Complications relatively common cf. those reported with MIST

 

 

Complications:

 

Early:

• Retention and recatheterisation
• Bleeding, clot retention, transfusion
• UTI / sepsis
• TURP syndrome
• Bladder perforation

Late:

• Urethral stricture or bladder neck contracture
• Retrograde ejaculation

 

Bladder neck incision

Mechanism

• Incision of the bladder outlet and prostate without removal of tissue – generally using a Collins knife and electrosurgery.

 

Efficacy

• Meta-analyses show similar efficacy rates cf. TURP for small prostates < 30 cc
• AUA/EAU guidelines recommend for prostate < 30 cc

 

Pros ·       Less ejaculatory dysfunction cf. TURP ·       Less bleeding ·       Quicker procedure ·       Overnight case

Cons ·       Higher re-operation rate, up to 18 %

 

 

Complications

• Bleeding, retrograde ejaculation, infection, recurrent/recalcitrant symptoms

 

 

Greenlight laser photovaporisation

 

Mechanism

• Uses lasers which work at wavelength of 532 nm (green light) e.g. KTP – this laser energy is absorbed by haemoglobin and causes tissue vaporisation and concurrent coagulation, but is not absorbed by water.
• Uses a side-firing laser.
• Current systems in use are 180 W – majority of evidence was for 80 W and 120 W systems.

 

Efficacy

• Initial meta-analyses with 80 W and 120 W lasers:
  • No difference in Qmax or IPSS cf. TURP; at 12 months only
  • RR for re-operation 3.6 cf. TURP
  • Less bleeding, less catheter time and LOS, longer OT time
• GOLIATH RCT looked at 180 W
  • Durable results at 2 years, non-inferior to TURP
  • No difference in sexual side effects cf. TURP
  • Re-operation rate 9 vs 7.6 % (not significant)
  • Less bleeding, less catheter time and LOS, longer OT time

 

Pros ·       Less bleeding cf. TURP ·       May be done on anticoagulated patients ·       Shorter LOS and catheter duration ·       Saline irrigation ·       Smaller sheath

Cons ·       Longer OT time ·       Post-operative dysuria ·       Unclear long term outcomes cf. TURP (i.e., 5 years +) ·       No histology

 

 

Complications

• Bleeding, infection
• Post-operative dysuria and irritative symptoms can be troubling ++
• 532 nm wavelength laser can cause retinal injury to staff/patients – requires strict laser safety protocols
• Retrograde ejaculation

 

Transurethral needle ablation (TUNA)

• Uses radiofrequency ablation – high frequency electrical currents flow into prostate and interact with water molecules, exciting ions and creating heat and coagulative necrosis
• Scar replaces prostate tissue
• Less symptom improvement cf. TURP but less sexual side effects also. Largely replaced by other MISTs.

 

Transurethral microwave therapy (TUMT)

• Specialised catheter emits electromagnetic waves – aiming to thermally ablate prostate adenoma.
• Poor outcomes with high re-treatment rates. Not used in modern practice.

 

Holmium laser enucleation (HoLEP)

Mechanism

• Holmium laser (2140 nm wavelength) is a pulsed solid-state laser which is absorbed by water and water-containing tissues – with minimal tissue penetration. It quickly vaporises tissue but also has good coagulation from heat generated.
• HoLEP aims to recreate open enucleation techniques.

 

Efficacy

• Comparable outcomes cf. TURP over long term for IPSS and Qmax (perhaps favouring HoLEP for large glands).
• Less bleeding, shorter LOS and catheter time cf. TURP; but longer OT time.

 

Pros ·       Suitable for very large glands and may obviate need for open procedure ·       Shorter IDC time ·       Shorter LOS ·       Less bleeding/transfusion (?anticoagulated patients)

Cons ·       Steep learning curve ·       Risk of morcellator injury ·       Transient SUI rates may be higher ·       Not widely available or taught

 

Complications

• Usual bleeding and infection with comparative rates of ejaculatory dysfunction.
• Morcellator and bladder injury is rare but can be significant.

 

 

Prostatic urethral lift (UroLift)

Mechanism

• Permanent transprostatic sutures are delivered cystoscopically to mechanically open the prostatic urethra

 

Efficacy

• LIFT study vs sham:
  • IPSS 22 to 11 at 12 months, back to 14 at 5 years
  • Qmax improved by 4 mL/sec
  • Retreatment 10 % at year 3, 13 % at year 5
  • “Failure” including removal or medical therapy – 33 %
• BPH6 – RCT vs TURP
  • Re-treatment at 2 years 13 % for UroLift vs 5 % for TURP
  • IPSS and Qmax favour TURP (although QoL scores similar)

 

Guidelines restrict recommendations to prostates < 70 – 80 cc and with no middle lobe.

 

Pros ·       Day case ·       Minimal sexual side effects – preserves ejaculation and doesn’t appear to affect erections ·       Minimises storage symptoms and stricture risk

Cons ·       Long term efficacy unknown but likely poorer cf. TURP ·       Short term objective outcomes worse than TURP ·       Higher re-treatment rates ·       Limited by size and middle lobe ·       Expensive in Aust.

 

 

Complications

• Post-operative symptoms tend to be mild and self-limiting – haematuria, dysuria, pelvic pain and urgency.
• Appears to have no significant change in ejaculatory or erectile function.

 

 

Convective water vapour energy ablation (Rezum)

Mechanism

• Uses radiofrequency power to generate thermal energy in the form of water vapour.
• Water vapour is injected at 39.4° for 9 seconds, at a pressure above interstitial pressure, facilitating dispersion of water vapour through cells – as the vapour contacts tissue it condenses to liquid which releases energy causing cell membrane breach and cell death and tissue necrosis.

 

Efficacy

• Sham RCT (Roehrborn)
  • 51 % reduction in IPSS and 4 mL/sec improvement in Qmax at 2 year (results seemed durable at 4 year follow up)
  • 4 % re-treatment rate at 4 years.

 

Pros ·       Day case (but requires IDC) ·       No erection changes ·       Low rates of ejaculatory dysfunction (not zero) ·       Effective for middle lobes

Cons ·       IDC for 5-7 days ·       Significant symptoms after catheter removal ·       Not proven in retention ·       Expensive

 

 

Complications

• Significant voiding symptoms and dysuria after catheter removal
• Ejaculatory dysfunction / retrograde ejaculation not zero, around 5 %

 

 

Aquablation

Mechanism

• TRUS guided technology which uses high velocity non thermal saline water jet stream to ablate tissue.
• A real time TRUS probe is used to define the target tissue, then a robotically guided transurethral system quick hydrodissects the planned area
• Post treatment haemostasis with catheter and balloon or fulguration.

 

Efficacy

• WATER RCT vs TURP (30 – 80 cc prostates) – followed for three years – mean IPSS improvements of 14 both groups, 8 – 11 mL/sec improvement in Qmax, non-inferior to TURP re-operation rates
• WATER II – cohort study 80 – 150 cc prostates – significant improvements in all parameters – IPSS mean dropped from 23 to 5

 

Pros ·       Appears as effective as TURP ·       Short resection time (overall OT time comparable to TURP) ·       Better sexual side effect profile cf. TURP ·       Seems effective in glands up to 150 cc

Cons ·       Still relatively early data ·       Costly equipment ·       Bleeding rates comparable to TURP – 6 – 8 % transfusion rate (esp larger glands)

 

 

Complications

• 10 % retrograde ejaculation in smaller prostates, 20 % in larger prostates
• 14 % bleeding ‘event’ with 8 % transfusion and 3 % return to OT in larger glands

 

Prostatic artery embolisation

Mechanism

• Superselective catheterisation and embolisation of the prostatic arteries, aiming to devascularise the central gland causing hypoxia, necrosis and volume loss.
• Different embolising agents in use – alcohol, microspheres.
• Can be technically challenging due to tortuous vessels, atherosclerosis, variable anatomy.

 

Efficacy

• RCT vs sham – IPSS reduction of 17 at 6 months vs 5 in sham group.
• Meta-analyses of RCTs vs TURP – favours TURP for objective outcomes (Qmax, PVR, prostate volume reduction) with IPSS slightly favouring TURP or not significant
• One cohort study reported > 80 % success in non index patients with haematuria or retention.

 

USANZ statement – “PAE must be done in the correct context with proper patient selection and adequate informed consent, especially with regards to longer term clinical and safety data. It should be acknowledged that there are other minimally invasive BPE therapies that may offer better safety and efficacy profile”

 

Pros ·       Local anaesthetic ·       Day case ·       No retrograde ejaculation ·       No significant bleeding and could continue anticoagulation

Cons ·       Not as efficacious at TURP ·       Radiation exposure significant ·       Post-embolisation syndrome ·       Technically challenging with steep learning curve ·       Significant contrast load, requires adequate renal function ·       Potential for non target embolisation

 

 

Complications

• AUR up to 5 %
• Non target embolisation rare but may be devastating
• High radiation exposure
• Potential haematoma at access site

 

 

Temporary implantable nitinol device (TIND)

Mechanism

• 50 x 33 mm device with elongated struts and an anchoring leaflet – once in place the struts expand and exert longitudinal pressure which is intended to cause pressure ischaemic and necrosis, with subsequent scarring changing the shape of prostatic urethra.
• Device is removed day 5.

RCT vs sham shows benefit, no comparison to TURP or other treatments. Preservation of sexual and ejaculatory function.

 

 

Simple prostatectomy

Mechanism

• Enucleation of the adenoma either via the bladder or anterior prostatic capsule.
• Traditionally open although now often performed with robot.

 

Indications include the same indications for TURP in large glands, plus those with the inability to go into lithotomy position, significant urethral disease or concomitant very large bladder stones.

Contraindications are small fibrotic glands (no plane), prostate cancer and previous surgery which may limit access to retropubic space (lap herniae).

 

Efficacy

• Reduction in IPSS 60 – 80 %, Qmax improvement by 375 % (16 – 20 mL/sec)
• Reduces PVR by 86 – 95 %
• Similar efficacy to TURP or HoLEP

 

Pros ·       Very large prostates amenable ·       Low retreatment rate ·       Complete removal of adenoma ·       Avoids risk of TURP syndrome

Cons ·       Most invasive of all options ·       Higher bleeding and transfusion risk ·       Incision(s) ·       Longer hospitalisation and recovery

 

Complications

• Estimated transfusion rate 5 – 10 %
• Similar risks of bladder neck contracture and urethral stricture cf. TURP
• Leak – settles with catheter usually

 

Millin prostatectomy:

• Start in lithotomy and perform cystoscopy – is it actually resectable, are there stones or tumours
• Supine with break at pelvis
• IDC, ABx, headlight
• Lower midline incision, through rectus sheath, development of Retzius and de-fatting of prostate, fixed table retraction
• Haemostatic sutures – either routine control of DVC a la RRP or two rows of transversely placed capsular sutures
• Anterior transverse incision of capsule at level of bladder neck (can use stays at either end to prevent tearing extension
• Finger enucleation of adenoma – crack the anterior commissure and dissect in plane of the capsule, with care to not perforate capsule – may need sharp dissection with scissors for stuck areas
• Haemostasis – pack and remove, oversew bleeders with monocryl J needle or cauterise
• If needed, sutures at 5 and 7 o’clock of bladder neck to control urethral vessels
• Trigonisation of bladder mucosa – stitching bladder mucosa to posterior prostatic capsule
• Close capsular incision over 3-way IDC with irrigation
• Blakes drain and close wound
• TOV day 3 – 5 pending progress and drain outputs

 

Transvesical prostatectomy

• Similar setup – lower midline incision and development of Retzius, fixed table retraction
• Transverse cystotomy between stay sutures 2 – 3 cm superior to bladder neck
• Inspect bladder, identify UOs, remove bladder stones with Rampley’s
• Identify adenoma/middle lobe – incise and encircle bladder mucosa with cutting current and dissect plane with Metz
• Finger enucleation of adenoma, cracking anterior commissure and bluntly dissecting plane
• Haemostasis as per Millin prostatectomy (more difficult from transvesical approach)
• Oversew 5 and 7 o’clock at bladder neck if needed