Health and Prostate

Treatment for benign prostatic hyperplasia (BPH) must be patient specific and includes watchful waiting and monitoring, pharmacotherapy, minimally invasive therapy and surgery. Certain patients may benefit more from surgery than pharmacotherapy based upon results of the clinician’s evaluation and the patient’s subjective assessment of their disease state. When contemplating therapeutic options, it is important for the clinician to realize that 30%–50% of men will experience spontaneous improvement of symptoms. This is also evident when assessing efficacy in clinical trials since there is a significant placebo effect. Additionally, one must be wary of clinical trials evaluating nonsurgical and minimally invasive therapies for BPH since they often have numerous limitations — they may not be properly randomized, double-blinded or placebo controlled. These inconsistencies might explain why a clear consensus in the literature regarding the effectiveness of different treatment options for benign prostatic hyperplasia (BPH) is lacking.

For many years transurethral resection of the prostate (TURP) was the standard of care for patients with BPH and is still considered the most effective treatment by many experts. Unfortunately, many patients have complications related to this surgical procedure and are dissatisfied with the results. Therefore, there is an increased interest in finding effective nonsurgical therapies for patients with benign prostatic hyperplasia (BPH). One option for patients with mild prostatism is simply watchful waiting. Watchful waiting may be appropriate when symptoms are not affecting the patient’s activities of daily living and there is no evidence of bladder or upper urinary tract deterioration. With this approach, patients are continually reevaluated and are assessed for complications or worsening of symptoms. Although this may be viewed as a nonaggressive approach, it is important to remain cognizant that a significant number of patients not receiving treatment will either improve or have no change in their symptomatology. For those patients who experience bothersome symptoms, medical intervention is indicated since watchful waiting may result in unnecessary complications.

Surgical Treatment of Benign Prostatic Hyperplasia (BPH)

Surgical intervention is considered the gold standard for the treatment of benign prostatic hyperplasia (BPH) and offers the best chance for symptom improvement. Surgical management is recommended for patients who have failed either pharmacological or minimally invasive therapy (e.g., balloon dilatation, transurethral microwave hyperthermia) for obstructive symptoms, and in patients with more advanced disease (e.g., serious urinary retention).

Surgical prostatectomy refers to the surgical removal of the enlarged portion of the prostate. This can be performed either through the urethra (TURP) or an open prostatectomy. Twenty-five percent of appropriately aged men undergo TURP, and it is second only to cataract removal as the most common surgery reimbursed by Medicare. Transurethral resection of the prostate costs approximately $10,000 including hospitalization per procedure; total expenditures to the health care system are approximately $5 billion annually.

The probability of symptomatic improvement is greatest with surgical options; however, there are a plethora of significant adverse effects. Approximately 20% of patients will experience procedure complications, and mortality is estimated at 0.2%. Typical perioperative complications include urinary retention, thrombus formation, hemorrhage requiring transfusion, urethral stricture and bladder neck contracture. Retrograde ejaculation (failure of the bladder neck to close during ejaculation) occurs in over 70% of patients after TURP or open prostatectomy. Another 5%–10% of patients will suffer from impotence postoperatively. Urinary incontinence is common and may be subclassified as stress urinary incontinence (involuntary urine loss during physical activity), urge urinary incontinence (involuntary urine loss associated with an uncontrollable urge to void), or total urinary incontinence (complete loss of the voluntary control of voiding). In addition, patients frequently will complain of bladder irritability.

Post-TURP syndrome occurs perioperatively in 2% of patients undergoing TURP. Post-TURP syndrome is a dilutional hyponatremia that occurs secondary to absorption of large quantities of hypotonic fluid used for irrigation during the procedure. It is manifested by mental confusion, nausea, vomiting, hypertension, bradycardia and visual disturbances. Despite the success associated with TURP, many patients will need a repeat procedure in the following years and 20%–25% of patients do not have satisfactory long-term outcomes. Some investigators have also suggested that men who undergo TURP have a shorter lifespan than those who do not; however, this data has been refuted. Due to the associated morbidity of TURP and patient discontent, interest in other treatment modalities has emerged.

Transurethral incision of the prostate (TUIP) is a minimally invasive procedure ideal for men with small prostates. TUIP’s indications are analogous with those of TURP and prostatectomy. Deep incisions are made through the prostate gland to the level of the capsule, relieving bladder outlet obstruction. Studies have demonstrated that TUIP can significantly improve patients’ symptom scores and objective parameters. Comparative studies reveal lower complication rates with TUIP than TURP. Duration of surgery, hospitalization and onset of convalescence are all shorter. Notably, there is a lower incidence of impotence, retrograde ejaculation and incontinence. Transurethral incision of the prostate (TUIP) is ideal for many surgical candidates; however, it is markedly underutilized.

In addition to transurethral incision of the prostate (TUIP), other minimally invasive procedures include the use of prostatic stents, microwave therapy delivered to the prostate trans-rectally or transurethrally,laser ablation of the prostate or laser prostatectomy, and prostatic balloon dilation. These are promising procedures that will need to be investigated further.