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Surgical options for treating benign prostatic hyperplasia

One of the most common prostate conditions among older men, an enlarged prostate known as benign prostatic hyperplasia (BPH), affects 20 percent of men in their 50s, according to the Prostate Cancer Foundation (PCF). That rate quickly jumps to 60 percent for men in their 60s and continues to increase with age. When the resulting complications of BPH become severe, or if medical therapies have not worked, a surgical consultation is recommended.

There are a wide range of treatment options available for men with BPH that include everything from watchful waiting and medical therapies to surgical procedures, which can be minimally invasive or more involved.

Minimally invasive surgery

The best candidates for minimally invasive surgeries are men with moderate to severe BPH symptoms who have trouble urinating, according to the Urology Care Foundation (UCF). Those experiencing bladder stones, blood in the urine or urinary tract obstruction are also good candidates. Men with BPH who cannot empty their bladder completely, urinate very slowly and bleed from the prostate may also consider this option. Additionally, when medical therapies and medication treatments have not worked, many individuals will turn toward minimally invasive surgery options.

Minimally invasive surgical procedures to treat BPH are generally done on an out-patient basis. Choosing the right procedure will depend on overall health, the size of the prostate and personal preference, according to the UCF. An in-depth discussion with your physician will help you to chose an option that works best for you. Here are a number of top options:

Prostatic stent
A prostatic stent is a permanent, flexible spring-like device that is placed inside of the urethra to hold it open, according to the Department of Urology at Cornell. These devices are self-expanding and help to maintain patency of urethra.

  • Best candidates: Men with a number of medical problems who are at high-risk for surgery.
  • Benefits: No anesthesia is required and stents result in improved urine flow and decreased symptoms.
  • Side effects: Bothersome voiding symptoms are common after the procedure and blockage and frequent urination may occur. This treatment may also lead to incontinence, according to the UCF.

Laser prostatectomy
There are multiple forms of this treatment, which is performed with a laser and varying wavelengths. Until recently, this method was rarely used, but as technology continues to evolve, laser prostatectomy is becoming more common. Procedures can range from simple to challenging. Transurethral laser photoselective vaporation of the prostate (PVP) in particular is becoming very popular and there are few side effects, according to the UCF.

  • Best candidates: Men with larger prostates who hope to avoid invasive surgery.
  • Benefits: Shorter hospital stays and can often be done on out-patient basis. Decreased risk of complications including impotence, incontinence and intraoperative bleeding.
  • Side effects: Anesthesia is usually required and in some cases limited long-term benefits have been shown.

High intensity focused ultrasound (HIFU)
This procedure helps to reduce the damage done to surrounding tissue by placing an ultrasound probe into the rectum to transmit ultrasonic energy to heat the prostate to very high temperatures, causing the tissues in the prostate to reduce in size.

  • Best candidates: Men with large prostates who do not want surgery.
  • Benefits: Though recovery time is rather quick, there are several risks and side effects, according to the UCF.
  • Side effects: Blood in the urine, trouble urinating and the risk of needing a catheter after the procedure may result.

Transurethral needle ablation (TUNA)
Similar to HIFU, the TUNA procedure delivers thermal injury to the prostate – but by way of high-frequency radio waves. Inserting a cystoscope into the tip of the penis through the urethra, the surgeon will guide tiny needles to the tissue in the prostate to then deliver the radio waves.

  • Best candidates: Men who want to limit anesthesia and those who have too many medical problems for surgery.
  • Benefits: It is rare for serious complications to arise and it is a relatively short procedure.
  • Side effects: A burning feeling may result after the procedure and BPH symptoms may reoccur.

Additional options for minimally invasive surgery include UroLift, catheterization, transurethral microwave thermotherapy (TUMT) and transurethral electroevaporation of the prostate (TUVP).

Standard surgical procedures

According to the UCF, surgery can be used to remove obstructing prostate tissue if medical therapy fails or in severe cases such as BPH causing  kidney damage, frequent urinary tract infections, bladder stones, frequent bleeding or an inability to urinate.

A resectoscope is used in transurethral procedures.A resectoscope is used in transurethral procedures.

1. Transurethral resection of the prostate (TURP)
According to the Department of Urology at Cornell, the TURP procedure is the "gold standard of effective treatment for BPH." It is also the most common surgery among men with BPH, performed on about 150,000 men each year, reported the UCF. 

The TURP procedure does not require an incision. Instead, the surgeon will put a resectoscope through the end of the penis and through the urethra to remove tissue of the prostate gland, according to Johns Hopkins Medicine (JHM). The resectoscope has a lighted camera and electrical loop, as well as valves that maintain irrigating fluid. The tissue is cut and the blood vessels sealed with the loop. At the end of the TURP, the tissue pieces are removed through the irrigating fluid into the bladder and then flushed from the body.

"Less than 5% of TURP patients experience impotence after the procedure."

Outcomes are generally very positive with this procedure. Less than 5 percent of TURP patients experience impotence and only 1 to 2 percent develop incontinence after the procedure, reported the Department of Urology at Cornell. However, there are the usual risk factors associated with any surgery, reported JHM. This may include bleeding, infection, pain when urinating or retrograde ejaculation.

2.Transurethral incision of the prostate (TUIP)
For men that have a smaller prostate with a major blockage, TUIP is a good option. It is commonly used in men with smaller prostate glands and instead of cutting and removing tissue with a resectoscope, reported the UCF, small incisions are made in the prostate as well as where the urethra meets the bladder. This widens the urethra, making urination easier and removing some of the pressure of the prostate on the urethra, making it easier to urinate. 

Potential side effects may include incontinence, erectile dysfunction and dry orgasm. Some men experience urine retention temporarily or a urinary tract infection after the procedure.

3. Open prostatectomy
Some men with BPH have such large prostate glands that performing transurethral surgery would not be safe, reported the Department of Oncology at Cornell. For patients with prostate glands larger than 80 grams, an open prostatectomy is performed. After the surgeon makes an incision from the navel to the pubic bone, the bladder is opened and tissue of the prostate is removed. Following the surgery, a urethral catheter will remain in place for one week.

As this procedure is more invasive, it requires a longer hospital stay and complications may include infection and bleeding.