Benign prostatic hyperplasia: Treat or wait?

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Applied Evidence

Benign prostatic hyperplasia: Treat or wait?

J Fam Pract. 2008 July;57(7):454-463

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References

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TURP is indicated for patients with refractory urinary retention due to severe bladder outlet obstruction, recurrent urinary tract infections, progressive renal insufficiency, hematuria unresponsive to 5-a reductase inhibitors, bladder stones, and BPH-related hydronephrosis. Lower urinary tract symptom improvement is expected in 80% to 90% of cases, with a retained efficacy of 75% for at least 7 years and a risk of repeating surgery of only 1% annually.^4,14,15 IPSS scores may decrease 15 to 20 points, but quality of life is enhanced only with severe lower urinary tract symptoms, and postoperative ejaculatory dysfunction (65%-70%) is expected, along with 1% to 2% perioperative mortality.¹⁵

FAST TRACK

TUMT is well-suited to high-risk patients or those who oppose surgery

It's important to note that TURP is a procedure that requires a hospital stay and is associated with a variety of potential side effects, including sexual dysfunction, bladder neck contracture, urinary tract infection, hematuria, and irritative voiding symptoms, while patients may also require blood transfusions.^4,52

Other surgical therapies include open prostatectomies for patients with glands =80 mL and transurethral incision of the prostate (TUIP) for glands <30 mL.^1,4,15 TUIP is a simpler outpatient operation than TURP. It offers equivalent symptomatic relief and less associated ejaculatory dysfunction or bleeding, but has a higher rate of reoperation.^1,4,15 High-risk surgical candidates with severe urinary retention may also receive prostatic stents, but significant complications of pain, infection, and encrustation are common.⁴

Holmium laser enucleation of the prostate (HOLEP) is another alternative to TURP that has demonstrated equivalent efficacy in terms of AUA-SI scores, peak flow rates, and quality-of-life scores in studies of up to 3 years in length. Longer-term studies are required to determine its efficacy beyond that time frame.^53-56

Minimally invasive route for high-risk patients

Transurethral needle ablation (TUNA) and transurethral microwave thermotherapy (TUMT) offer AUA-approved alternative treatment choices based on the severity of symptoms and the presence of complications.⁴ TUNA uses radiofrequency waves administered through 2 18-gauge needles to heat prostatic tissue. An outpatient procedure, TUNA is effective over the long term, demonstrating a low failure rate (25% after 5 years); however, temporary side effects such as irritative urinary symptoms and urinary retention can occur.^4,57

With >100,000 procedures performed, TUMT is the most frequent minimally invasive treatment utilized worldwide. Heat destroys targeted prostatic tissue, while a cooling system protects the prostatic urethra. Its efficacy has been demonstrated by randomized trials, and its failure rate documented at 10% to 16% annually.⁴ Morbidity is related mainly to required indwelling catheterization for 4 to 6 weeks following intervention. However, it is an outpatient, low-risk procedure well-suited to high-risk patients or those who oppose surgery.

Correspondence
Darryl Chutka, MD, Division of Preventive and Occupational Medicine and Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905; chutka.darryl@mayo.edu.