Surgical Treatment Options for Benign Prostatic Obstruction

Abstract and Introduction

Abstract

Purpose of Review: Many surgical treatment options are available for patients who present with benign prostatic obstruction (BPO). This article reviews the current treatment options available and distinguishes them based on five clinical considerations: antithrombotic therapy, sexual function preservation, ambulatory procedures, anesthesia-related risks and duration of catheterization.

Recent Findings: A comprehensive review of the literature was performed on 10 BPO procedures. Laser enucleation of the prostate (LEP), bipolar plasma transurethral vaporization of the prostate and photoselective vaporization (PVP) of the prostate reduces the risk of bleeding, which is recommended for anticoagulated men. Ejaculatory function is more likely to be preserved following transurethral incision of the prostate, Rezūm, Aquablation, UroLift and iTind. Same-day discharge is possible for LEP, PVP and prostatic arterial embolization (PAE). For patients with high anesthesia-related risks, procedures compatible with local anesthesia (UroLift, Rezūm, iTind and PAE) should be favored. Catheterization duration is shorter with UroLift, PVP and LEP.

Summary: BPO treatment options are growing rapidly. The optimal procedure for a given patient is based on factors such as associated risks, recovery and expected outcomes. Besides prostate volume, the clinical considerations in the present article can help elucidate the best surgical BPO treatment option for each patient based on their values, preferences, and risk tolerance.

Introduction

As men age, it is common for them to experience benign prostatic obstruction (BPO), which may require surgery. The rapidly expanding surgical options available for patients requires shared decision-making to determine which procedure is the most appropriate. Prostate volume is a notable and objectifiable factor that guides the decision of which procedure the patient should undergo. However, there are other factors to consider in order to select the most appropriate technique for a given patient, such as those compatible with (1) antithrombotic therapy, (2) sexual (ejaculatory) function preservation, (3) same-day discharge, (4) local anesthesia (for high anesthesia-risk patients) and (5) duration of catheterization (Table 1).

The following review aims to categorize the numerous currently available treatment modalities according to the above clinical considerations and help the decision-making process for both patient and urologist. English articles were screened on PubMed for content on the 10 procedures reviewed and the 5 clinical considerations.

Table 1. Indications and drawbacks of surgical treatment options available for benign prostatic obstruction
Technique	Indications	Drawbacks
1. Transurethral Resection of the Prostate (TURP)	Historical 'gold standard'	- Sexual function impairment [13] - Longer catheterization time [54]
2. Transurethral incision of the prostate (TUIP)	+ Better preservation of ejaculation than TURP[17,18]	- Qmax inferior to TURP [17,18] - Only for small prostates (<30cc) [42,61]
3. Bipolar transurethral Vaporization of the Prostate (BiTUVP)	+ Lower rate of blood transfusions compared to TURP [11,12]	- Only recommended for prostates 30–80cc [61]
4. Photoselective Vaporization of the Prostate, GreenLight (PVP)	+ Lower rate of blood transfusions compared to TURP [8,9] + Short hospitalization/day surgery [40,41] + Short catheterization time [56] + May be offered to patients undergoing antithrombotic therapy [61]	- Elevated retreatment rates in larger glands [42]
5. Prostatic Urethral Lift, UroLift	+ Preservation of sexual function [26–28] + Local anesthesia [47] + Short hospitalization or day surgery [49] + Short catheterization time [26,55]	- Lower Qmax and IPSS in first 2 years compared to TURP [27] - High retreatment rate [27,28] - Only recommended for prostates < 80cc [26,27,42,61]
6. Water Vapor Thermal Therapy, Rezūm	+ Preservation of sexual function [19,20,42] + Local anesthesia [48,49]	- Only for prostates <80cc [42,48] - Long catheterization time [19]
7. Laser Enucleation	+ Significantly less blood transfusions [2,3,57] + Short hospitalisation/day surgery [36,37] + Size independent [42,57] + Short catheterization time [57] + Very low retreatment rate	- Similar retrograde ejaculation to TURP [42,57]
8. Aquablation	+ Less retrograde ejaculation compared to TURP [23–25]	- Requires general or regional anesthesia [49] - Currently only indicated for prostates <80cc [42,61] - Lack of data; still under investigation [61] - Risk of bleeding [61]
9. Temporary implantable nitinol device (iTIND)	+ Local anesthesia [52] + No catheterization [30] + Preservation of sexual function [33]	- Implantation period - Median lobes contraindicated [33] - Paucity of long-term data [42,61]
10. Prostatic artery embolization (PAE)	+ Day surgery possible [45,46] + Local anesthesia [44,50,51] + Short catheterization time [44] + Less bleeding [44]	- Paucity of long-term data [42,61]

Table 1. Indications and drawbacks of surgical treatment options available for benign prostatic obstruction

Technique

Indications

Drawbacks

1. Transurethral Resection of the Prostate (TURP)

Historical 'gold standard'

- Sexual function impairment [13]
- Longer catheterization time [54]

2. Transurethral incision of the prostate (TUIP)

+ Better preservation of ejaculation than TURP[17,18]

- Qmax inferior to TURP [17,18]
- Only for small prostates (<30cc) [42,61]

3. Bipolar transurethral Vaporization of the Prostate (BiTUVP)

+ Lower rate of blood transfusions compared to TURP [11,12]

- Only recommended for prostates 30–80cc [61]

4. Photoselective Vaporization of the Prostate, GreenLight (PVP)

+ Lower rate of blood transfusions compared to TURP [8,9]
+ Short hospitalization/day surgery [40,41]
+ Short catheterization time [56]
+ May be offered to patients undergoing antithrombotic therapy [61]

- Elevated retreatment rates in larger glands [42]

5. Prostatic Urethral Lift, UroLift

+ Preservation of sexual function [26–28]
+ Local anesthesia [47]
+ Short hospitalization or day surgery [49]
+ Short catheterization time [26,55]

- Lower Qmax and IPSS in first 2 years compared to TURP [27]
- High retreatment rate [27,28]
- Only recommended for prostates < 80cc [26,27,42,61]

6. Water Vapor Thermal Therapy, Rezūm

+ Preservation of sexual function [19,20,42]
+ Local anesthesia [48,49]

- Only for prostates <80cc [42,48]
- Long catheterization time [19]

7. Laser Enucleation

+ Significantly less blood transfusions [2,3,57]
+ Short hospitalisation/day surgery [36,37]
+ Size independent [42,57]
+ Short catheterization time [57]
+ Very low retreatment rate

- Similar retrograde ejaculation to TURP [42,57]

8. Aquablation

+ Less retrograde ejaculation compared to TURP [23–25]

- Requires general or regional anesthesia [49]
- Currently only indicated for prostates <80cc [42,61]
- Lack of data; still under investigation [61]
- Risk of bleeding [61]

9. Temporary implantable nitinol device (iTIND)

+ Local anesthesia [52]
+ No catheterization [30]
+ Preservation of sexual function [33]

- Implantation period
- Median lobes contraindicated [33]
- Paucity of long-term data [42,61]

10. Prostatic artery embolization (PAE)

+ Day surgery possible [45,46]
+ Local anesthesia [44,50,51]
+ Short catheterization time [44]
+ Less bleeding [44]

- Paucity of long-term data [42,61]

Surgical Treatment Options for Benign Prostatic Obstruction

Beyond Prostate Volume

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Surgical Treatment Options for Benign Prostatic Obstruction

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