Recent developments in the surgical management of benign prostatic hyperplasia

Abstract

A new era in the surgical management of benign prostatic hyperplasia (BPH) has emerged in the past decade. A variety of less invasive treatment modalities have been introduced and well-established surgical treatments are being reassessed. Although progress has been made in the management of BPH, the substantial economic burden to the healthcare system caused by BPH emphasizes the importance of cost-effective treatment. Open prostatectomy is the most efficient BPH treatment for relieving symptoms and improving uroflow, but it is also the most invasive and morbid. Transurethral resection of the prostate (TURP) is still the "gold standard" for treatment of BPH, but open prostatectomy has been reported to have a lower perioperative mortality than TURP, and low retreatment rates reduce the long-term cost. The morbidity associated with TURP, such as impotence or urinary incontinence, has been reduced in recent years while new features, such as performing TURP under local anesthesia and bipolar electrosurgical techniques, have been introduced. Transurethral electrovaporization of the prostate (TVP) is a recent modification of TURP that has rapidly gained popularity. TVP greatly reduces TURP syndrome, provides good hemostasis, and may reduce catheterization and hospitalization times. Transurethral incision of the prostate (TUIP) is another safe and inexpensive procedure that is well-documented and comparable to TURP in long-term efficacy. TUIP is an underused procedure with which the newer, less invasive treatments should be compared. Whereas the well-established surgical treatments primarily relieve obstruction by tissue ablation, some of the newer treatment modalities may ameliorate lower urinary tract symptoms (LUTS) with minimal urodynamic change. In some of the newer nonresection treatments, no major significant postoperative reduction in prostate volume can be demonstrated. Laser treatments are based on a broad variety of techniques, generators, and fibers, of which most have initially demonstrated promising results. Well-known techniques include visually laser-assisted prostatectomy (VLAP) and interstitial laser coagulation (ILC). The laser techniques are generally not as effective as TURP, but are safe under local anesthesia on an outpatient basis with low complication rates. Transurethral microwave thermotherapy of the prostate (TUMT) and radiofrequency transurethral needle ablation (TUNA) are minimally invasive, safe new therapies. There is some evidence that the procedures create long-term, alpha-adrenoceptor-like blockade. Complications, except for transient catheterization in up to 40% of patients, may be practically nonexistent. The cost is difficult to estimate and the long-term outcome is still to be assessed. If the newer, less invasive treatment modalities provide stable long-term results and competitive costs, they will be tempting alternatives to prostate resections and may also challenge medical therapy.