BPH Treatment
Surgery
Standard surgical options include: transurethral resection of the prostate (TURP), transurethral incision of the prostate (TUIP), and open prostatectomy.
TURP, the gold standard of effective treatment for BPH, involves removal of the core of the prostate using an instrument passed through the urethra. High frequency current flowing through a wire loop allows removal of "chips" of prostatic tissue and coagulation of blood vessels. The prostate tissue is removed through the cystoscope used to visually guide and monitor this process. Patients require a urethral catheter for 2 days and usually stay in the hospital for 2 days. Most patients (80% to 90%) experience dramatic improvement in their symptoms and urinary flow rates after TURP. Possible side effects include bleeding requiring transfusion, salt imbalances from fluid absorption, impotence (less than 5%) and incontinence (1% to 2%).
TUIP similar to TURP. Instead of removing prostatic tissue, an electrical knife is used to make small cuts in the prostate. This relieves pressure on the urethra and generally results in decreased symptoms and increased flow rates. TUIP is generally used in smaller prostates.
Open prostatectomy is performed for those patients with very large prostates (greater than 80 grams) in whom transurethral surgery would be difficult to perform safely. In this procedure, an incision is made from the navel to the pubic bone. The bladder is opened; and prostatic tissue is removed through the bladder. A urethral catheter remains for approximately 7 days and patients stay in the hospital 5-7 days. It is a more invasive procedure and complications include bleeding and infection.
back to top
Minimally Invasive Procedures:
Laser prostatectomy: performed with the use of a laser with various types and wavelengths have the advantages of lack or decreased risk of complications such as intraoperative bleeding and fluid absorption, retrograde ejaculation, impotence, and incontinence. Patients undergoing this procedure tend to require shorter hospital stays and can be admitted on an outpatient basis. Four general techniques include:
- Non-contact visual laser ablation of the prostate (VLAP)
- Interstitial laser coagulation of the prostate(ILC)
- Transurethral laser enucleation prostatectomy
- Transurethral laser vaporation of the prostate
- Transurethral laser photoselective vaporation of the prostate (PVP)
The advantages and disadvantages of these procedures vary with each technique and can include lengthy operative times, higher incidence of postoperative urinary retention, prolonged catheterization, and increased irritative voiding symptoms and urge incontinence. Efficacy is generally less than that seen in TURP and can be technically simple to challenging. Until recently, most laser techniques were rarely used. However, the technology is constantly evolving.ILC is a minimally invasive thermotherapy is currently utilized in an outpatient to office setting. PVP is a new laser technology that promises to be as effective as TURP with less complications.
Transurethral thermotherapy (microwave hyperthermia) uses microwave energy with frequencies between 915 and 2450 MHz to heat tissues through radiant heat transfer. Using a probe transurethrally (also transrectally), microwave heat delivery is maximized to the prostatic tissue (to a temperature of 42 ? to 45 ? C) while the surrounding tissue is cooled by a special catheter in certain devices. This procedure can be performed as an outpatient procedure with local anesthesia. Although it is safer than TURP, it is not as effective. Reported results involve a 67% reduction of symptoms with a 42% increase in urinary flow rate at 1 year. Retreatment is necessary in 1 % to 13 % and recatheterization rates are as high as 40%. Side effects include bleeding, bladder spasms, and blood in the ejaculate.
High intensity focused ultrasound uses ultrasonic energy (transrectally) to heat the prostate without causing damage to tissue lying in the path of the ultrasonic beam. In one study: following treatment, symptom scores decreased from 31 to 16 and flow rates increased by a mean of 5 ml/sec. However, these are only short-term results (90 days). Most common complications include transient urinary retention (73%) and blood in the ejaculate (47%). This therapy is still investigational in the United States.
Transurethral needle ablation (TUNA) uses high-frequency radio waves to cause thermal injury to the prostate (above 100 ? C). Needles deliver the energy to a localized area of the prostate. In one study, one year following treatment, symptom score decreased from 21 to 10 and flow rates increased from 8 ml/sec to 15 ml/sec. It is fast, usually requires only local anesthesia, and can be done on an outpatient basis (sometimes without the need for a catheter). Complications include urinary retention, blood in the urine, and irritative voiding symptoms. The long-term efficacy of this procedure has not been determined.
Prostatic stents are permanent, flexible, self-expanding devices placed in the urethra to maintain patency of the lumen. Improvement in symptoms and flow rate approach those of TURP, although randomized trials need to be performed. One study showed an decrease in symptom score from 14 to 5 and increase in flow rates from 1 ml/sec to 13 ml/sec with a follow-up of 24 months. Other advantages include: short operative time under regional anesthesia, minimal bleeding, no need for indwelling catheter postoperatively, and performed on an outpatient basis. Many patients experience irritative voiding symptoms following the procedure.
Transurethral electrovaporization simultaneously vaporizes and coagulates prostatic tissue so no bleeding or fluid absorption occurs. First introduced into the urologic community in 1995, there have been many studies demonstrating similar efficacy, increased safety, and decreased side effects compared to the standard TURP. Studies with long-term follow-up over 7 years have demonstrated this to be a durable procedure. It is now utilized by about 40% of the urologic community. Catheters remain for 1 day and patients spend 1 day in the hospital. Though complications similar to TURP can occur, the risk of significant complications such bleeding, salt imbalances from fluid absorption, impotence and incontinence are low.
|
