What is BPH ?

Benign Prostatic Hyperplasia (BPH) refers to an enlarged prostate that is not cancerous. It can cause bothersome urinary problems due to the obstruction of urine flow. BPH is common in men, usually starting in middle age. About 50% of men between 51 and 60 years old experience symptoms, which can increase to 90% in men over 80. Typical symptoms include difficulty urinating, frequent or urgent trips to the toilet, nighttime awakenings to urinate, dribbling at the end of urination, and sometimes incontinence. These symptoms can affect quality of life, causing embarrassment, fatigue, and limitations in daily activities. BPH can also lead to sudden and painful inability to urinate (acute urinary retention), requiring emergency medical attention and the use of a catheter. It's important to note that symptoms like frequent urination and nighttime awakenings can be caused by other conditions aside from BPH. Therefore, it's essential to discuss these symptoms with your doctor. Additionally, it's worth mentioning that BPH is more common than prostate cancer, which often shows no symptoms in its early stages.

Patients experiencing urinary symptoms should be provided with a comprehensive selection of available treatment options, including innovative minimally invasive approaches that are more likely to preserve sexual function. This empowers patients to choose between tablets, minimally invasive procedures, or more traditional surgery. In the majority of cases, medication is the initial treatment approach.

In the past, a commonly used surgical treatment for moderate to severe BPH (prostate size up to 100ml) was transurethral resection of the prostate (TURP). This procedure involved removing a portion of the prostate using an electric current. Saline was then used to flush away any loose prostate tissue and prevent blood clots in the bladder. Although TURP is effective, it typically requires a hospital stay of 2 to 3 days and can lead to side effects such as bleeding, retrograde ejaculation (in over 75% of cases), erectile dysfunction, and other potential complications like incontinence (affecting 1-2% of patients) or the need for a blood transfusion (1% of patients). A variation of TURP called Bipolar TURP (B-TURP) utilizes isotonic saline during the procedure, reducing blood loss.

Because of the emergence in the last few years of several new, relatively non-invasive techniques and technologies which have fewer side effects, we would no longer recommend TURP in most circumstances, although it remains an effective treatment if these other options are not available.

For massive prostate glands, 200ml, open or robot assisted prostatectomy may be the only option if there are coexisting problems such as bladder stones or diverticulum (small bulges or pockets that can develop in the lining of the intestine as you get older). However there are higher rates of complications and issues of erectile dysfunction and incontinence, but for a small minority of men these may be the only options.

BPH Treatment Summaries

Minimally Invasive BPH Therapy

Steam ablation of prostate cells is a minimally invasive procedure where a small probe is inserted through the urethra to deliver a few drops of steam in the narrowed area. Radio frequency energy heats the water in the device, generating the steam that kills the prostate cells causing urethral compression. The body naturally absorbs the dead cells. Usually, a catheter remains in place for 3-5 days after the procedure.

There is strong evidence supporting the effectiveness of this non-invasive treatment. It offers men an alternative to surgery and helps avoid potential sexual side effects like impotence and ejaculation problems.

The temporary implantable nitinol device, made of a material called nitinol, is placed in the prostate for 3-5 days before being removed. Currently, there is limited data available to fully endorse its widespread use. However, further studies are needed to evaluate its effectiveness and determine how it fits into the range of treatment options for BPH.

This non-invasive approach is highly recommended for moderate disease. It offers a major advantage: instead of cutting or removing prostate tissue, the procedure involves lifting the obstructing prostate to prevent it from blocking the urethra. As a result, recovery time is typically much quicker compared to traditional methods. In many cases, it can be performed under local anesthesia, eliminating the need for a urethral catheter.

Minimally invasive - recurrent urethral stricture

The Optilume Drug Coated Balloon (DCB) procedure is a new and innovative treatment for urethral stricture in adult men who are over 18 years old. It’s different from the usual treatment because it combines two things: widening the narrow area in the urethra using a balloon and using a drug called Paclitaxel to prevent the stricture from coming back. This procedure follows standard practices for treating urethral stricture and can be done in an outpatient setting using local anesthesia while the patient is awake.

Minimally Invasive BPH Therapy

HoLEP

Holmium laser enucleation of the prostate (HoLEP) is a laser-based treatment for prostate problems. Instead of vaporizing the prostate tissue, the laser is used to remove the prostate tissue like peeling an orange from the inside.

HoLEP has a lower chance of needing another operation compared to both TURP and PVP. It also has a short catheterization time and a low risk of bleeding. The results of HoLEP are similar to traditional open prostate surgery, and it can be used for prostates of any size. A research study in 2016 found that HoLEP and Greenlight had similar short-term outcomes and postoperative symptoms. However, for patients with Chronic Urinary Retention (CUR), HoLEP had better results in completely emptying the bladder.

HoLEP can also be used for very large prostates (150ml or more) when other methods are not suitable. However, it requires more expertise compared to Greenlight to avoid complications. It is widely available in the UK.

GreenLight Laser Prostatectomy (or Photo-Selective Vaporisation of the Prostate – PVP) is a relatively new procedure for the treatment of urinary blockage caused by non-cancerous enlargement of the prostate (otherwise known as Benign Prostatic Hyperplasia).

GreenLight Laser Prostatectomy is a minimally invasive procedure that involves the insertion of a cystoscope (a telescopic camera) and a thin, flexible fiber through the penis, up the urethra (the water pipe), and into the prostate. Once the surgeon positions the instruments correctly within the prostatic portion of the urethra, they utilize the cystoscope to visualize the area and deliver high-power GreenLight laser energy. This laser energy instantly vaporizes the prostatic tissue, and the process continues until all obstructing prostate tissue has been eliminated.

Aquablation is a new treatment method that was approved by NICE in September 2018. However, there is limited evidence available for this procedure, so it is recommended to be used in conjunction with special arrangements for audit or research. Aquablation, also known as transurethral water ablation, uses ultrasound image guidance and robotics to target a jet of saline water to destroy prostate tissue. The procedure is usually performed while the patient is under general or spinal anesthesia.

Typically, the actual removal of tissue using the water jet takes about 3 to 5 minutes. After the procedure, a catheter is inserted and removed the following day when the patient is usually discharged from the hospital.

Some potential benefits of this procedure are that it takes less time compared to other methods involving a camera inserted through the urethra, and it may help preserve sexual function. Since the procedure is heat-free, there is no risk of complications from thermal injury. It is suitable for prostates up to a theoretical maximum volume of 100ml, but realistically around 80ml. Since the tissue is not cauterized with heat, there will be some bleeding, and an overnight hospital stay is required. Further studies are needed to determine the long-term effectiveness of this treatment.