Surgical treatment of BPH

This is the last article from a short series of 3 articles on benign prostatic hyperplasia or BPH. In the previous ones we have reviewed the definition and diagnose of HBPas well as the pharmacological treatment.

In this article we will explain which are the surgical treatments that are most frequently used in the treatment of BPH, as well as their advantages and disadvantages. We will organize surgical treatments into three categories:

  • Endoscopic Surgery
  • Laparoscopic Open Surgery
  • Minimally invasive procedures

Surgeries for BPH, with the exception of minimally invasive treatments and transurethral prostatic incision, aim to remove the prostatic adenoma and leave the prostatic capsule intact. To better understand this concept, we can imagine that the prostate is an orange. BPH surgery consists of removing the pulp of the orange, while keeping the peel as undamaged as possible.

This makes it possible to increase the caliber of the tube through which urine leaves the bladder (the prostatic urethra) without damaging important structures around the capsule of the prostate, such as the nerves that allow erections or the muscles that prevent urine from escaping.

Various different surgical techniques may be used to achieve this goal.


Endoscopic Surgery

Endoscopic surgery is one that is performed through natural orifices or through a small incision. In urology and in the case of prostate surgery, this term is used to refer to operating through the urethra with specially designed instruments. The most common endoscopic prostate surgery techniques are:

  • Transurethral resection of the prostate (TURP): It consists of resecting or cutting small fragments of the prostate from the prostatic urethra to the prostatic capsule. The cuts are made with an electrical loop that also serves to coagulate and control bleeding.
    • The main immediate complications are bleeding (which may require a blood transfusion), not being able to urinate after surgery (acute urinary retention) or having a urine infection; although these complications usually occur in less than 5% of cases.
    • Possible long-term complications include narrowing of the urethra that can make urination difficult and urinary incontinence, but they occur in about 3% of cases [1].
    • Clinical practice guidelines usually recommend performing this type of surgery when the prostate is between 30cc and 80cc in size, although this could be modified depending on the experience of the surgeon [2,3].
  • Transurethral prostatic incision: This technique consists of making an incision at the neck of the bladder and prostate. In this technique, prostate tissue is NOT removed. It is indicated especially for prostates of less than 30cc and that do not have a middle lobe [4].
  • Prostatic Vaporization: This technique uses electricity or a laser to vaporize the prostate. When comparing this technique with TURP, it has been observed that prostate vaporization presents less bleeding during surgery and shorter hospitalization time. On the other hand, it has been observed that prostate vaporization has a longer surgery time and has a higher risk of needing a new surgery in the future. Prostatic vaporization could be useful in cases where there is a high risk of bleeding since it produces better coagulation than TURP. It is indicated for prostates of <80cc.
  • Prostatic Endoscopic Enucleation: This technique consists of separating the prostatic capsule from the prostatic adenoma, that is, separating the pulp of the orange from the orange peel, in 1 or 2 complete pieces, to later leave them inside the bladder and extract them with a device called morcellator that suctions and cuts the prostate tissue [7]. It is in this technique that lasers are most used. Lasers are used to create this separation between the adenoma and the prostatic capsule. The most widely used laser for enucleation, and for which there exists more positive research, is the Holmium laser.

Endoscopic laser enucleation has some advantages over TURP. Less bleeding during surgery, less time wearing a tube after surgery, and shorter hospital stay have been observed. It also can be used for prostates larger than 80cc. No important differences have been observed in long-term complications compared to TURP, such as urethral strictures or urinary incontinence [8].

When comparing the results of endoscopic enucleation with open surgery (which we will see later) it is observed that they are similar in terms of results, with endoscopic surgery being less aggressive and therefore with faster recovery and less bleeding [9]. The main drawback of endoscopic enucleation is that it is a complex and difficult technique to learn.


Laparoscopic Open Surgery

  • Open Simple Prostatectomy or Adenomectomy: It is the oldest and most aggressive type of surgery, since it presents more bleeding, a larger wound and longer hospitalization time. However, it is an effective method with very good long-term results [10,11]. The technique consists of making an incision in the lower part of the abdomen to access the prostate, then, through an incision in the bladder or in the prostate capsule, the prostatic adenoma is removed. It is the treatment of choice for prostates >80cc if the equipment or experience to perform endoscopic enucleation is not available [12].
  • Simple Laparoscopic or Robotic Prostatectomy: These are relatively new techniques. The available studies show similar functional results to open prostatectomy, with the advantage of presenting less bleeding and less time in the hospital and less time wearing a bladder catheter.

Minimally invasive procedures

  • Rezüm:  Injecting steam into the prostate. The energy released by the water vapor produces a reduction in the size of the prostate. It has the advantage that it can be performed under local anesthesia, outside the operating room, and the patient goes home the same day. It has the drawback that after the procedure, it is necessary to wear a bladder catheter for 3 to 5 days. [16] 
  • Prostatic urethral lift: Applying a permanent suture implant that compresses the prostatic lateral lobes. The functional results are worse than those of TURP and it is more common for the patient to require a new surgery after 5 years, but it does not affect ejaculation, and recovery after the procedure is faster [17].
  • iTIND: Placing a device that expands inside the prostatic urethra and the neck of the bladder and applying pressure to these areas for 5 days, after which it is removed. It would seem that it is effective, but we are awaiting more robust studies to evaluate its effectiveness [18].
  • Aquablation: It consists of applying a jet of serum at high speed that manages to destroy prostate tissue. It has the advantage of reducing surgery time and presenting greater preservation of ejaculation than TURP [19,20]. However, it requires general anesthesia and presents some problems in controlling bleeding, with a greater need for transfusion than TURP in the available studies [21]. More data on its long-term effectiveness is needed.

These are the most used techniques in our environment, the ones that have the most scientific evidence, of course they are not all the techniques that exist.

Whenever we talk about surgical techniques, we must remember the importance of the experience of a surgical team or a surgeon in a particular technique. The subspecialization of medicine and the development of different technologies means that more and more surgeons subspecialize in a group of surgical techniques and dedicate their medical activity to this subtype of surgery. 


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