Benign Prostatic Hyperplasia: Review of Modern Minimally Invasive Surgical Treatments

Benign prostatic hyperplasia (BPH) is a common problem among older men and can have a significant impact on quality of life. BPH is a histologically diagnosed disease and is present in 8% of men aged 41 to 50, 40 to 50% of men aged 51 to 60, 70% of men aged 61 to 70, and more than 80% of men older than 80 years. The pathogenesis of BPH remains incompletely understood, but there are many known risk factors for developing this disease. These include race, family history of cancer, higher serum levels of testosterone and estradiol, alcohol consumption, prostatitis, and nonsteroidal anti-inflammatory drug use.[1] [2] [3] [4] [5] The classic clinical presentation of BPH is the experience of lower urinary tract symptoms (LUTS). These symptoms include frequency, nocturia, urgency, incontinence, slow or intermittent stream, straining, and terminal dribbling ([Table 1]). These symptoms are experienced moderately to severely in 25% of men in their 50s, 33% of men in their 60s, and approximately 50% of men in their 80s. Like any other disease, the clinical evaluation for a man with suspected BPH begins with a thorough history and physical exam. The International Prostate Symptom Score (IPSS) index can be used to classify the severity of LUTS in patients. This consists of seven questions that assess the severity and frequency of different symptoms of BPH as well as a question asking the patient to rate how their quality of life is affected by these symptoms.[6]

Table 1 BPH Symptoms[7]

Storage symptoms	Voiding symptoms
Increased frequency Nocturia Urgency	Feeling of incomplete emptying Intermittency Straining Weak stream

Abbreviation: BPH, benign prostatic hyperplasia.

• References

• 1 Negri E, Pelucchi C, Talamini R , et al. Family history of cancer and the risk of prostate cancer and benign prostatic hyperplasia. Int J Cancer 2005; 114 (4) 648-652
• 2 Kristal AR, Schenk JM, Song Y , et al. Serum steroid and sex hormone-binding globulin concentrations and the risk of incident benign prostatic hyperplasia: results from the prostate cancer prevention trial. Am J Epidemiol 2008; 168 (12) 1416-1424
• 3 Crispo A, Talamini R, Gallus S , et al. Alcohol and the risk of prostate cancer and benign prostatic hyperplasia. Urology 2004; 64 (4) 717-722
• 4 St Sauver JL, Jacobson DJ, McGree ME, Girman CJ, Lieber MM, Jacobsen SJ. Longitudinal association between prostatitis and development of benign prostatic hyperplasia. Urology 2008; 71 (3) 475-479 , discussion 479
• 5 St Sauver JL, Jacobson DJ, McGree ME, Lieber MM, Jacobsen SJ. Protective association between nonsteroidal antiinflammatory drug use and measures of benign prostatic hyperplasia. Am J Epidemiol 2006; 164 (8) 760-768
• 6 McVary KT. BPH: epidemiology and comorbidities. Am J Manag Care 2006; 12 (5, Suppl): S122-S128
• 7 American Urological Association Guideline Management of Benign Prostatic Hyperplasia (BPH): American Urological Association Education and Research, Inc., 2010
• 8 Mamoulakis C, Ubbink DT, de la Rosette JJ. Bipolar versus monopolar transurethral resection of the prostate: a systematic review and meta-analysis of randomized controlled trials. Eur Urol 2009; 56 (5) 798-809
• 9 Lee SW, Choi JB, Lee KS , et al. Transurethral procedures for lower urinary tract symptoms resulting from benign prostatic enlargement: a quality and meta-analysis. Int Neurourol J 2013; 17 (2) 59-66
• 10 Te AE. The next generation in laser treatments and the role of the green light high-performance system laser. Rev Urol 2006; 8 (Suppl. 03) S24-S30
• 11 Te AE, Malloy TR, Stein BS , et al. Photoselective vaporization of the prostate for the treatment of benign prostatic hyperplasia: 12-month results from the first United States multicenter prospective trial. J Urol 2004; 172 (4, Pt 1) 1404-1408
• 12 Ruszat R, Wyler S, Forster T , et al. Safety and effectiveness of photoselective vaporization of the prostate (PVP) in patients on ongoing oral anticoagulation. Eur Urol 2007; 51 (4) 1031-1038 , discussion 1038–1041
• 13 Thangasamy IA, Chalasani V, Bachmann A, Woo HH. Photoselective vaporisation of the prostate using 80-W and 120-W laser versus transurethral resection of the prostate for benign prostatic hyperplasia: a systematic review with meta-analysis from 2002 to 2012. Eur Urol 2012; 62 (2) 315-323
• 14 Suardi N, Gallina A, Salonia A , et al. Holmium laser enucleation of the prostate and holmium laser ablation of the prostate: indications and outcome. Curr Opin Urol 2009; 19 (1) 38-43
• 15 Elterman DS, Chughtai B, Lee R , et al. Comparison of techniques for transurethral laser prostatectomy: standard photoselective vaporization of the prostate versus transurethral laser enucleation of the prostate. J Endourol 2013; 27 (6) 751-755
• 16 Kumar SM. Rapid communication: holmium laser ablation of large prostate glands: an endourologic alternative to open prostatectomy. J Endourol 2007; 21 (6) 659-662
• 17 Mottet N, Anidjar M, Bourdon O , et al. Randomized comparison of transurethral electroresection and holmium: YAG laser vaporization for symptomatic benign prostatic hyperplasia. J Endourol 1999; 13 (2) 127-130
• 18 Seki N, Naito S. Holmium laser for benign prostatic hyperplasia. Curr Opin Urol 2008; 18 (1) 41-45
• 19 Elzayat EA, Al-Mandil MS, Khalaf I, Elhilali MM. Holmium laser ablation of the prostate versus photoselective vaporization of prostate 60 cc or less: short-term results of a prospective randomized trial. J Urol 2009; 182 (1) 133-138
• 20 Elmansy HM, Elzayat E, Elhilali MM. Holmium laser ablation versus photoselective vaporization of prostate less than 60 cc: long-term results of a randomized trial. J Urol 2010; 184 (5) 2023-2028
• 21 Tan A, Liao C, Mo Z, Cao Y. Meta-analysis of holmium laser enucleation versus transurethral resection of the prostate for symptomatic prostatic obstruction. Br J Surg 2007; 94 (10) 1201-1208
• 22 Ahyai SA, Gilling P, Kaplan SA , et al. Meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic enlargement. Eur Urol 2010; 58 (3) 384-397
• 23 Lourenco T, Pickard R, Vale L , et al; Benign Prostatic Enlargement team. Alternative approaches to endoscopic ablation for benign enlargement of the prostate: systematic review of randomised controlled trials. BMJ 2008; 337: a449
• 24 Geavlete B, Multescu R, Dragutescu M, Jecu M, Georgescu D, Geavlete P. Transurethral resection (TUR) in saline plasma vaporization of the prostate vs standard TUR of the prostate: ‘the better choice’ in benign prostatic hyperplasia?. BJU Int 2010; 106 (11) 1695-1699
• 25 Geavlete B, Georgescu D, Multescu R, Stanescu F, Jecu M, Geavlete P. Bipolar plasma vaporization vs monopolar and bipolar TURP-A prospective, randomized, long-term comparison. Urology 2011; 78 (4) 930-935
• 26 Karaman MI, Kaya C, Ozturk M, Gurdal M, Kirecci S, Pirincci N. Comparison of transurethral vaporization using PlasmaKinetic energy and transurethral resection of prostate: 1-year follow-up. J Endourol 2005; 19 (6) 734-737
• 27 Hoffman RM, Monga M, Elliott SP , et al. Microwave thermotherapy for benign prostatic hyperplasia. Cochrane Database Syst Rev 2012; 9: CD004135
• 28 Djavan B, Kazzazi A, Bostanci Y. Revival of thermotherapy for benign prostatic hyperplasia. Curr Opin Urol 2012; 22 (1) 16-21
• 29 Mynderse LA, Roehrborn CG, Partin AW, Preminger GM, Coté EP. Results of a 5-year multicenter trial of a new generation cooled high energy transurethral microwave thermal therapy catheter for benign prostatic hyperplasia. J Urol 2011; 185 (5) 1804-1810
• 30 Tan AH, Nott L, Hardie WR, Chin JL, Denstedt JD, Razvi H. Long-term results of microwave thermotherapy for symptomatic benign prostatic hyperplasia. J Endourol 2005; 19 (10) 1191-1195
• 31 Vesely S, Knutson T, Damber JE, Dicuio M, Dahlstrand C. TURP and low-energy TUMT treatment in men with LUTS suggestive of bladder outlet obstruction selected by means of pressure-flow studies: 8-year follow-up. Neurourol Urodyn 2006; 25 (7) 770-775
• 32 Hill B, Belville W, Bruskewitz R , et al. Transurethral needle ablation versus transurethral resection of the prostate for the treatment of symptomatic benign prostatic hyperplasia: 5-year results of a prospective, randomized, multicenter clinical trial. J Urol 2004; 171 (6, Pt 1) 2336-2340
• 33 Boyle P, Robertson C, Vaughan ED, Fitzpatrick JM. A meta-analysis of trials of transurethral needle ablation for treating symptomatic benign prostatic hyperplasia. BJU Int 2004; 94 (1) 83-88
• 34 Chin PT, Bolton DM, Jack G , et al. Prostatic urethral lift: two-year results after treatment for lower urinary tract symptoms secondary to benign prostatic hyperplasia. Urology 2012; 79 (1) 5-11
• 35 Armitage JN, Cathcart PJ, Rashidian A, De Nigris E, Emberton M, van der Meulen JH. Epithelializing stent for benign prostatic hyperplasia: a systematic review of the literature. J Urol 2007; 177 (5) 1619-1624
• 36 Bilhim T, Pisco J, Campos Pinheiro L , et al. Does polyvinyl alcohol particle size change the outcome of prostatic arterial embolization for benign prostatic hyperplasia? Results from a single-center randomized prospective study. J Vasc Interv Radiol 2013; 24 (11) 1595-602.e1
• 37 A Pereira J, Bilhim T, Duarte M, Rio Tinto H, Fernandes L, Martins Pisco J. Patient selection and counseling before prostatic arterial embolization. Tech Vasc Interv Radiol 2012; 15 (4) 270-275
• 38 Carnevale FC, Antunes AA. Prostatic artery embolization for enlarged prostates due to benign prostatic hyperplasia. How I do it. Cardiovasc Intervent Radiol 2013; 36 (6) 1452-1463
• 39 Antunes AA, Carnevale FC, da Motta Leal Filho JM , et al. Clinical, laboratorial, and urodynamic findings of prostatic artery embolization for the treatment of urinary retention related to benign prostatic hyperplasia. A prospective single-center pilot study. Cardiovasc Intervent Radiol 2013; 36 (4) 978-986
• 40 Ditrolio J, Patel P, Watson RA, Irwin RJ. Chemo-ablation of the prostate with dehydrated alcohol for the treatment of prostatic obstruction. J Urol 2002; 167 (5) 2100-2103 , discussion 2103–2104
• 41 Plante MK, Bunnell ML, Trotter SJ, Jackson TL, Esenler AC, Zvara P. Transurethral prostatic tissue ablation via a single needle delivery system: initial experience with radio-frequency energy and ethanol. Prostate Cancer Prostatic Dis 2002; 5 (3) 183-188
• 42 Bschleipfer T, Bach T, Gratzke C, Madersbacher S, Oelke M. [Intraprostatic injection therapy in patients with benign prostatic syndrome]. Urologe A 2013; 52 (3) 354-358
• 43 Sacco E, Bientinesi R, Marangi F , et al. Patient-reported outcomes in men with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) treated with intraprostatic OnabotulinumtoxinA: 3-month results of a prospective single-armed cohort study. BJU Int 2012; 110 (11, Pt C): E837-E844