On 19.09.18 NICE recommended the use of Aquablation for BPH in NHS treatment. Aquablation is a minimally invasive waterjet therapy.
How is BPH Managed and Treated?
Before a doctor decides on the best treatment for your situation, he or she will consider:
- What your symptoms are and how serious they are.
- How much the symptoms affect your quality of life.
- The extent of urine flow reduction and if there is any urine remaining in the bladder after you have been to the toilet.
Medical treatment of BPH
Medical treatment is suitable for patients with moderate to severe symptoms of BPH. If you have urinary retention or complications of BPH, such as bladder stones or damage to the kidneys, doctors may suggest surgical options.
Medical management of BPH involves α1-blockers and/or 5α-reductase inhibitors.
- α1-blockers, such as doxazosin, tamsulosin and alfuzosin:
- Produce a rapid and sustainable improvement in lower urinary tract symptoms and urine flow - but only in around 60% of patients.
- Do not stop BPH; neither do they prevent the eventual need for surgery.
- Symptoms usually improve within 2-3 weeks and these drugs can be used as a long-term option.
- Main side-effects, which affect 10-15% of patients, include tiredness, headaches and dizziness.
- 5α-reductase inhibitors, including finasteride and dutasteride:
- Improve symptom scores and urine flow rates.
- Capable of reversing the course of BPH.
- Works best in patients with large prostates and elevated PSA levels.
- The main clinical effects of 5α-reductase inhibitors take 3-6 months to become apparent and PSA levels are reduced by approximately 50% after 6-12 months.
- Side-effects include reduced libido and weak erections in 3-5% of men, which return to normal after treatment is stopped. About 1% of men develop breast tenderness.
- Women who are or who might be pregnant should avoid touching crushed or broken tablets.
- Combination treatment
A study published in the New England Journal of Medicine suggests that the use of both an α1-blocker and a 5α1-reductase inhibitor may be significantly more effective than the use of either agent alone.
Surgical treatment of BPH
Surgery is normally recommended for patients with complications from BPH, who do not respond to medical therapy or who choose to have surgery as part of a definitive treatment.
A number of new developments are being researched, but at the time of writing there are three main options:
- Transurethral resection of the prostate (TURP)
- Requires general or epidural anaesthetic.
- Surgeons insert a resectoscope (a slim telescope) into the urethra to see the prostate.
- The prostate is scraped away using an electrified wire loop. Afterwards a catheter (a thin flexible tube) is inserted and is left in place for up to 48-hours.
- TURP reduces the symptoms of BPH in 70-90% of patients, and peak urine flow rates of 15-20ml/second can be achieved reliably.
- However, in many men the prostate grows back and may necessitate a further TURP to reduce symptoms.
- Men cannot have children after this procedure.
- Possible complications include retrograde ejaculation (when semen enters the bladder instead of being expelled from the body through the urethra), which affects most men after the procedure, erectile dysfunction, which affects 2-4% of patients, and occasionally incontinence or bleeding.
- Transurethral incision of the bladder neck
- Works best for patients without much prostate enlargement who still experience urine flow obstruction.
- Requires general or epidural anaesthetic.
- Surgeons view the bladder through a cystoscope inserted into the urethra.
- Surgeons make incisions from inside the bladder to a point just above where the prostatic ducts enter the urethra, relieving the obstruction and allowing the bladder neck to open.
- A catheter will be inserted and left for 24 to 48 hours.
- Almost as effective as TURP in relieving symptoms, and may produce similar increases in urine flow rates.
- Overall the incidence of side effects is lower than for TURP. Retrograde ejaculation is seen in only about 10% of patients. However, further treatment will eventually be necessary and will probably involve TURP.
- Open prostatectomy
- Usually considered for very large prostates (i.e. over 100ml).
- Under general anaesthetic, surgeons remove the growth in the prostate via an incision made into the lower abdomen. This will leave a scar.
- A catheter will be inserted that will remain for 3-4 days.
- Requires a hospital stay of 5-7 days.
- The results of this surgery are comparable to those achieved with TURP: peak urine flow rate normally increases to over 20ml/second.
- Patients are less likely to need further surgery after this procedure has been carried out.
- Owing to the more invasive nature of this operation, there is scope for blood loss that may need replacing in the form of a transfusion. Retrograde ejaculation occurs in about 70% of patients. The risk of incontinence is comparable to that of TURP but the risk of impotence or erectile dysfunction is higher (about 20%).
- Prostatic Urethral Lift (PUL) procedure
- Tiny permanent implants are placed to lift and hold the enlarged prostate tissue so it no longer blocks the urethra. It is the only BPH procedure that does not involve any cutting, heating or removal of prostate tissue.
- Is a quick day case procedure.
- Is generally performed under true local anaesthesia.
- As a minimally-invasive surgical option, the PUL procedure is associated with fewer side effects and post-operative complications. It is the only BPH procedure shown not to cause sexual dysfunction
- Patients generally do not require a catheter post operatively.
- Patients generally experience rapid recovery and symptom relief.
- Prostatic Urethral Lift is recommended by NICE as an alternative to current surgical procedures in men with LUTS due to benign prostatic hyperplasia..
Robotic Prostatectomy is the #1 choice in the USA for the treatment of prostate cancer that is confined to the prostate and is rapidly being chosen by more men in the UK, as well as their doctors, and the rest of the world. A Robotic Prostatectomy is a minimally invasive, robotic-assisted surgical procedure that removes the cancerous prostate gland and related structures.
The potential benefits of robotic prostate surgery include:
- Effective Cancer Control: Studies have shown that experienced surgeons have achieved excellent results in removing prostate cancer without leaving cancer cells behind.
- Improved and Early Return of Sexual Function: Studies have shown that most patients have a rapid return of sexual function.
- Improved and Early Return of Continence: Studies have shown that most patients have a rapid return of urinary continence.
Other therapies for BPH
A number of new techniques are being developed for the treatment of BPH. Currently, as they are not widely used, there is little experience with these techniques and little is known about their long-term efficacy.
- Laser therapy
In a procedure similar to TURP, a green-light laser is used to remove prostatic tissue. The laser effectively vaporizes the tissue and as a result there is very little blood loss. Most patients report little pain afterwards and the catheter is normally removed less than 12 hours after the procedure, so it can be done as a day case operation. The risks of incontinence and impotence are very low, and the risk of retrograde ejaculation is less than that in TURP.
- Transurethral needle ablation
This technique uses radiation to apply high temperatures to the prostate; this destroys the prostatic growth without damaging the urethra. Unlike other techniques it can be carried out under local anaesthesia. Peak urine flow rates are comparable with a TURP, but although bleeding is minimal, the catheterisation period is usually longer than after TURP.
Watchful waiting
In patients with very mild BPH symptoms, or those whose quality of life is not unduly affected, a strategy of 'watchful waiting' may be used. This involves:
- Annual evaluation of symptoms and signs, and blood and urine analyses.
- PSA test to assess the risk of prostate cancer.
- Recommendation for appropriate lifestyle changes, such as avoiding drinking large volumes in the evening.
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