Surgery for Benign Prostatic Hyperplasia (BPH)
Review literature: (Burnett und Wein, 2006) (DGU-Guideline: diagnostic work-up, 2009) (DGU-Guideline: treatment, 2009) (EAU-Guideline: Oelke et al, 2010)
Transurethral Resection of the Prostate (TURP)
Transurethral resection of the prostate (TURP) is the gold standard of invasive therapy for benign prostatic hyperplasia (BPH), with a share of over 90 % of all invasive procedures for BPH.
Indications for TURP:
The most common indication for TURP is moderate to severe symptoms of BPH, which cannot be controlled with medication and lower the quality of life of the patients. Furthermore, surgical therapy is indicated:
Surgical Technique and Complications of TURP:
Please see section transurethral resection of the prostate (TURP) for details.
Results of TURP:
Obstructive symptoms are more successfully treated compared to irritative symptoms. Nocturia is not improved in 20-40% after TURP.
Transurethral microwave therapy (TUMT)
Transurethral microwave therapy (TUMT) uses microwaves (900–1300 MHz) to heat the prostate tissue up to 70 degrees Celsius, while the urethral mucosa is cooled by a special catheter. Newer generation devices are e.g. Prostatron, ProstaLund and Targis. TUMT leads to heat necrosis, apoptosis and destruction of adrenergic nerve fibers in the prostate with an improvement of symptoms. For TUMT with newer generation devices, sedation and analgesia is necessary.
Indications for TUMT:
TUMT shares the same indications like TURP, but is also applicable in patients with higher comorbidity.
Results of TUMT:
Randomized trials show a significant improvement in symptoms, which is, however, not always accompanied with an improvement in objective parameters like maximum urinary flow. There are only few side effects; the main complication is the necessity of postoperative long-term catheterization. There is a significant proportion of patients, which need different treatment due to treatment failure of TUMT.
Transurethral Laser Treatment for Benign Prostatic Hyperplasia (BPH)
Different Techniques of Prostate Laser Treatment:
Due to the availability of various laser types with different physical properties, a variety of clinical procedures have been developed:
Transurethral Ultrasound-Guided Laser-Induced Prostatectomy (TULIP):
TULIP is medical history, direct visualization of the laser effects were not possible.
Visual laser ablation of the prostate (VLAP):
Synonym: interstitial laser therapy of the prostate. VLAP is a side-fire laser application with tissue coagulation under vision. VLAP leads to necrosis of the adenoma and (later) in an improvement of symptoms.
Holmium laser enucleation of the prostate (HoLEP):
Direct cuts between prostate adenoma and prostate capsule enable mobilization of the prostatic hyperplasia like in transvesical prostatectomy. The prostatic adenoma is morcellated in the bladder and the fragments are removed transurethrally. HoLEP can be used for even very large adenomas (>100 g), the bleeding risk is minimized.
Transurethral evaporization of the prostate (TUEP):
Direct contact of the laser fiber with the prostate tissue leads to evaporation, deeper tissue planes are coagulated. Postoperative voiding is immediately improved.
Potassium titanyl phosphate (KTP) laser:
KTP-lasers are the latest generation of laser technology with high energy performance. The KTP laser (also greenlight laser) causes the vaporization of the prostatic tissue with good coagulation. The treatment can be carried out under continuous anticoagulation; the risk for a TUR syndrome is very low. The method is particularly ideal for cardiac risk patients. Draw backs are the high cost of the laser fiber. Technique and complications: see section Greenlight laser vaporization of the prostate.
Results from randomized trials with Laser techniques for BPH:
Of the numerous laser procedures, HoLEP and KTP laser vaporization have stood the test of time. For both procedures, randomized studies are available, which show comparable results and reduced complications in comparison to TURP or transvesical prostatectomy (Kuntz et al, 2004) (Kuntz et al, 2008) (Reich et al, 2011).
Transurethral Needle Ablation of the Prostate (TUNA)
Needle probes are inserted into the adenoma under direct vision (and TRUS control), a heat necrosis of the adenoma is induced with microwaves (500 kHz). The technique can be performed under local anesthesia or spinal anesthesia.
Results of TUNA:
The advantage is the treatment option without the need for general anesthesia or hospitalization. The initial postoperative course is characterized by recurrent urinary retention in 13–40% of patients, until the necrotic tissue is discharged.
Transurethral Vaporization of the Prostate (TUVP)
Monopolar or bipolar current is used to vaporize the prostatic tissue next to the electrode, while coagulation occurs in deeper tissue planes. The electrodes have the form of a rolling cylinder or a thick loop (thick loop resection).
Results of TUVP:
Randomized trials demonstrated similar results between TUVP and TURP, without dramatic clinical benefits for TUVP (a trend towards less blood loss).
Transurethral Incision of the Prostate (TUIP)
In TUIP, two incisions from the bladder neck to the verumontanum are done next to the midline at 5 and 7 o'clock with the resectoscope. TUIP is well suited for the treatment of small volume prostates and for young patients. Advantages: lower surgical risks (blood loss, TUR-syndrome), reduced rate of retrograde ejaculation (0–37%).
Transvesical and Retropubic Simple Prostatectomy (Adenomectomy)
Indication for adenomectomy:
Simple prostatectomy is indicated in large prostate adenomas with volumes over 80–100 ml. If huge bladder diverticula or bladder stones must be treated, simple prostatectomy is wise even with smaller prostate volumes. Other indications for simple prostatectomy are complex urethral diseases (e.g. after hypospadia correction) and existing contraindication to lithotomy position.
Technique and Complications of Simple Prostatectomy:
Suprapubic simple prostatectomy is suitable for significant middle lobe enlargement, treatment of bladder stones and correction of huge bladder diverticula. Retropubic simple prostatectomy offers the advantage of better hemostasis and better apical preparation, but it is not ideal with a large median lobe, bladder diseases or obesity. For a detailed description of the surgical techniques and complications, see section transvesical prostatectomy and retropubic simple prostatectomy.
Comparative Studies for the Treatment of Benign Prostatic Hyperplasia (BPH)
CLASP= Conservative management vs. laser therapy vs. transurethral resection of the prostate trial. Randomized, n = 117, 117 and 106 per group, follow-up 1 year: significantly better clinical success (defined by symptoms and improved urine flow) for invasive treatment 15% vs. 67% vs. 81%. TURP appears more effective than laser therapy at the expense of higher invasiveness. Advantages of the medication are the lack of complications (Donovan et al, 2000).
Influence of BPH Therapy on Erectile Function:
Prospective study, n=309, follow-up 6 months: simple prostatectomy and TURP (5–6% additional erectile dysfunction), TUVP (25% additional erectile dysfunction), doxazosin (3% additional erectile dysfunction), finasteride (22% additional erectile dysfunction) (Uygur et al, 1998).
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