Benign Prostate Hyperplasia – surgical treatment

The indications for surgical treatment for the treatment of BPH include:

– symptoms of the lower urinary tract which are not depressed after medication;
– acute urinary retention;
– recurrence or persistence of urinary tract infections;
– persistent hematuria due to prostate, which is not treated or after administration of inhibitors of 5a-reductase.
– renal failure.
– gritty bladder (i.e. multiple stones or large stones existing that may not be reached intraurethral).

1. Open prostatectomy

Open prostatectomy may be applied either via transvesical or retropubic access. Method’s advantages include the direct control of the bladder neck,  medium high vision prostate lobe intravesical removal; conducting prostatectomy in obese patients and concomitant surgical treatment of bladder disorders such as diverticular stones. Open prostatectomy’s disadvantages include preparation of the blind near the outside gland clamp and the greater proportion intraoperative bleeding compared to TURP.

Complications that have been reported after open prostatectomy include urinary incontinence and urinary urgency, which can last from weeks to months; urgent incontinence and total incontinence due to injury of the external sphincter; erectile dysfunction (in percentage 3 to 5%), retrograde ejaculation (80-90%); bladder neck constriction; intraoperative and postoperative bleeding, which will result in a decision for blood transfusion (27%); fistula creation (0,4 – 4%), while very rarely mentioned acute cystitis and acute epididymitis. Complications may also include venous thrombosis, pulmonary embolism, myocardial infarction and stroke and presented to less than 1%.

In conclusion, transvesical or open retropubic prostatectomy is the treatment of choice in men with symptoms of prostatic obstruction aetiology due to large size (> 75 cm3) prostate adenoma in patients with concomitant diseases of the urinary bladder, such as diverticulum, and in patients who can not be placed in the lithotomy position carrying TURP.

2. Transurethral prostatectomy (TURP)

Indications are the same as those of open prostatectomy and is recommended for the treatment of prostatic hyperplasia in glands up to the size of 70 – 80 cm3. The time of surgery does not exceed 60 minutes and the technique involves removing the adenoma from the 6th until the 12th hour for a first lobe and then for the other.
Method complications include intraoperative or postoperative bleeding, rupture of the prostatic capsule (2%);  syndrome of transurethral resection – TUR syndrome – (2%), urinary incontinence due to sphincter injury; urethral stricture; bladder neck stenosis; priapism due to surgery and non urological complications such as venous thrombosis, pulmonary embolism, pneumonia, and myocardial infarction.

In conclusion we can say that transurethral resection of the prostate is the surgical treatment of choice of BPH in men with gland volume to 80 cm3. The improvement of symptoms and urodynamic parameters are adequate to open prostatectomy, but the advantages of the method includes less surgical trauma and lowest percentage of after surgery complications.

3. Robotics prostatectomy

4. Transurethral fission neck (TUIP)

The transurethral fission of the neck is a short and simple to perform surgery. The technique of the method comprises a deep section of tissue at the 5th and 7th hour of the bladder neck, which begins a little before the ureteral orifices and ends in seminal lofidio. This method is recommended in young sexually active men with prostate volume <30 cm3=”” br=””>5. Laser

6. HIFU

HIFU is a piezoelectric extractor, which can change in density according to the applied voltage. Although theoretically the prostate may be destroyed by HIFU via transabdominal and / or rectal tract, it is used in practice.

The HIFU treatment should not apply in the following cases:

– the size of the prostate gland is> 75 ml;
– in cases of multiple small stones of the gland;
– when the distance between the neck of the bladder and rectum are> 4 cm and
– in the cases that there are no absolute indications for surgical removal of the gland.

All the above combined with the fact that the technique requires general anesthesia and / or intravenous sedation and shows that failure rates of about 10% per year is the main disadvantage of the method.

7. Transurethral Needle Ablation of the prostate (TUNA)

The method is a simple and secure technique which can be applied under local anesthetic in a large number of patients. The apparatus for transmitting low frequency TUNA energy to the prostate by needle is inserted through the urethra.

Probe needles’ top are two covered by Teflon and exiting the catheter with an angle between the 40th. The TUNA method is not be applied in patients with prostate volume> 75 ml, to obstruction of the bladder neck and in patients fitted metal inserts.

8. Thermotherapy (Transurethral Microwave Therapy – TUMT)

Cytoscopy of the urethra is necessary before applying TUMT since the presence of medium prostatic lobe or short urethra are considered contradictive indications of the method. The probe, which will be applied depends on the treatment extend, once connected to the device, is inserted into prostatic urethra and thereby transfers microwaves in prostate tissue.
This method has complications such as perineal pain, dysuria, urinary frequency, hematuria and urinary retention have been reported and rarely observed retrograde ejaculation and erectile dysfunction.

9. Stents

The concept for using stents in urology born after the beneficial results obtained by the use in vascular surgery, to prevent restenosis after angioplasty. Stents are classified into two major categories: temporary and permanent.

Temporary stents remain in the urethra for a limited period and serve as an alternative instead of permanent catheterization or suprapubic catheter – in patients with BPH, who are high operative risk and considered unsuitable for surgery. They are placed very easily. However, the great disadvantage is that both stents remain in the urethra while it is not possible to place the catheter nor the carrying cystoscopy.

The permanent or epithelial-like stents are characterized, as their name may betray, from the fact that they get absorbed from the tissue in which they apply. Thus, you may realize that stents are placed in patients with BPH, because they can provide better quality of life in men who due to serious concomitant health problems can not undergo surgery.

In conclusion, the guidelines of the European Urological Association regarding treatment of benign prostatic hyperplasia include:

– inhibitors of 5a-reductase are administered in men with large prostates (> 40 ml);

– alpha-blockers may be administered to patients with pronounced symptoms and who have no absolute indication for surgical treatment;

– surgical treatment is proposed as a treatment of choice for the treatment of complications of BPH

– lasers are an alternative treatment of patients at high risk with LUTS.

– HIFU is not recommended as a treatment option in patients with BPH;

– TUNA method is regarded as a promising alternative.