surgical treatment related to voiding symptoms associated with benign prostatic enlargement

Last edited 12/2018 and last reviewed 03/2021

Surgical treatment related to voiding symptoms associated with benign prostatic enlargement

Modern surgical/minimally invasive options include:

• 1. removal of the hyperplastic prostate by:
  • transurethral resection (monopolar and bipolar TURP)
  • laser vaporisation (Green light laser prostatectomy) and enucleation (Holmium laser prostatectomy)
  • water stream (Aquablation)
• 2. Novel Day Case procedures
  • Urolift - retraction of obstructing BPH tissue by implants
  • Rezum - stream injection
• 3. Prostatic artery embolization (PAE) - radiological procedure to diminish flow through BPH

Generally, removal of BPH (TURP or laser) provides better symptom relief that novel minimally-invasive techniques at a trade-off of greater likelihood of complications, such as sexual dysfunction (retrograde ejaculation), stricture formation or urinary incontinence.

Indications for surgery

• Moderate/severe symptoms uncontrolled by medication
• Intolerance of medication or patient's preference (for minimally invasive techniques)
• Urinary retention (prostate removal by TURP or laser techniques recommended rather the novel minimally invasive techniques)

NICE have suggested that:

Surgery for voiding symptoms associated with benign prostatic enlargement (BPE):

• offer surgery only if voiding symptoms are severe or if drug treatment and conservative management options have been unsuccessful or are not appropriate. Discuss the alternatives to and outcomes from surgery
• if offering surgery for managing voiding LUTS presumed secondary to BPE, offer monopolar or bipolar transurethral resection of the prostate (TURP), monopolar transurethral vaporisation of the prostate (TUVP) or holmium laser enucleation of the prostate (HoLEP). Perform HoLEP at a centre specialising in the technique, or with mentorship arrangements in place
• offer transurethral incision of the prostate (TUIP) as an alternative to other types of surgery to men with a prostate estimated to be smaller than 30 g
• only offer open prostatectomy as an alternative to TURP, TUVP or HoLEP to men with prostates estimated to be larger than 80 g

Reference:

• 1) NICE (June 2015). Lower urinary tract symptoms The management of lower urinary tract symptoms in men