Benign prostatic hyperplasia: A new look at an old operation

Content provided by the Faculty of the Harvard Medical School

Benign prostatic hyperplasia: A new look at an old operation

Benign prostatic hyperplasia (BPH) is an important cause of distress in older men. It can produce urinary frequency and urgency as well as a slow urinary stream, dribbling, and incomplete emptying of the bladder. BPH is also an important cause of nocturia — nighttime urination. The symptoms begin to mount as men enter their 60s, and they continue to increase as the prostate continues to enlarge over time. By the age of 80, about 25% of all men have BPH that is bothersome enough to require treatment, and countless others have mild symptoms they can “live with.” In all, an estimated 5.5 million American men have clinically significant BPH, and about two million seek medical help for their symptoms every year.

Treatment options

Until recently, men who asked for help got it in the form of an operation devised more than 75 years ago, the transurethral resection of the prostate (TURP). As recently as 1995, about 400,000 TURPs were performed in the United States each year. Since then, however, the number has declined dramatically, even though doctors still view it as the “gold standard,” the surest way to relieve symptoms of BPH. The decline hasn’t been triggered by any problems with the operation itself — it’s actually gotten better and safer — but by three important developments:

1. A new understanding of the natural history of BPH. In the past, many men underwent TURPs principally to prevent serious complications, such as acute urinary retention. But doctors have learned that major complications are relatively infrequent, and that they can often be predicted in time to schedule surgery when it’s really needed. As a result, men are now encouraged to decide for themselves about treatment, moving ahead only if they are significantly bothered by their symptoms despite lifestyle adjustments.

2. New medical treatments. Until 1992, when a man asked to be treated for BPH, he was asking for a TURP. All that changed when the FDA approved medication for BPH. Most men experience improvement with prescription drugs such as alpha blockers and finasteride, or herbs such as saw palmetto (see box).

3. New surgical procedures. Although medications help about 70% of men with BPH, a TURP usually provides superior relief. When Harvard’s Health Professionals Follow-up Study compared the symptomatic benefits of alpha blockers, finasteride, and TURP, it found that surgery was the most effective. Unfortunately, surgery also had the most complications and side effects, which triggered an explosion of “less invasive” surgical techniques. Laser surgery is among the most promising, but there are others (see “Minimally invasive treatments,” below). The FDA approved laser treatments for BPH in 1998. Variations on the theme are being introduced at a staggering pace, and experience is still limited, particularly with regard to long-term results. Still, many men are attracted to laser surgery in the hope that it will be nearly as effective in reducing symptoms but will produce fewer side effects. Sexual dysfunction is a common concern for men facing surgery for BPH — but are sexual complications really less common after laser surgery than TURP?

What is a TURP?

Although a TURP does not require an incision, the 90-minute operation does require hospitalization and anesthesia, either general or spinal. The urologist inserts a resectoscope through the patient’s urethra. He then uses an electrical loop to cut away BPH tissue that is impeding the flow of urine. The doctor is able to recover fragments of that tissue so pathologists can be sure that BPH is the only abnormality. A Foley catheter is left in place to empty the bladder for a day or two, after which the patient should be able to void on his own. Most men go home 1–3 days after surgery.

Up to 90% of patients enjoy a significant reduction in their urinary tract symptoms after a TURP, although up to 20% require some form of additional treatment within 10 years. Potential early complications include bleeding and infection; late complications include urinary incontinence in just 1%–3%, but sexual dysfunction in many more.

What is laser prostatectomy?

A laser beam is a form of light energy. Urologists can focus that energy on the prostate to heat, vaporize, and cauterize the tissue; several techniques are available, including visual laser ablation of the prostate (VLAP) and contact laser ablation of the prostate (CLAP). In addition, several different sources of laser energy are in use. Because the prostate is cauterized, bleeding is uncommon. Since the tissue is vaporized, however, it’s not available for pathologic evaluation. Laser surgery takes about 10–90 minutes and can sometimes be performed on an outpatient basis. Some laser techniques require general or spinal anesthesia, but others can be performed with local anesthesia. A urinary catheter is left in place for 1–5 days or more, but some patients can return to work just days after the procedure.

Comparing old and new

TURP produces faster relief than laser surgery, which can take 6–8 weeks to yield maximum benefit. Although results vary, most studies suggest that lasers are a bit less effective than TURP in relieving symptoms. Since the operation is new, long-term results are not known. Still, many men are attracted to laser surgery to reduce the risk of postoperative sexual dysfunction.

To find out if laser surgery actually produces less sexual dysfunction than TURP, scientists in England compared the 2 in 340 men with BPH who volunteered to be randomly allocated to receive TURPs, laser treatments, or lifestyle therapy. All the men had moderate to severe BPH as judged by their symptoms and reduced urine flow rates. Each man answered detailed questions about his sexual function before the trial began and 7½ months later.

Because most of the patients were elderly, they had a high incidence of sexual dysfunction before the study. Surprisingly, perhaps, TURP reduced the prevalence of pain on ejaculation, which fell from 17% to 2%. As expected from other studies, however, TURP did produce an increase in retrograde (dry) ejaculation. A similar increase was seen in the men treated with lasers, but they failed to experience any change in their erectile function or pain on ejaculation. The nonsurgical group was also unchanged in these respects.

Although many of the patients reported some form of sexual dysfunction before the trial, some did not. Among those men, the risk of new erectile dysfunction was similar after TURP (5%) and laser surgery (8%).

Implications

The British trial does not tell men whether TURP is better than laser therapy. It did not compare their ability to reduce urinary symptoms, their overall complication rates, their cost, or their overall effect on quality of life. But the study does suggest that concern about sexual dysfunction should not enter the equation. In fact, TURP appeared to improve erectile dysfunction and to reduce pain on ejaculation, while the two procedures were equally likely to reduce the volume of semen in the ejaculate.

The choice of treatment for BPH is up to a man and his doctor. Many options are available, including lifestyle adjustments, herbal therapy, prescription medications, TURPs, and the newer, less invasive alternatives. But if the choice comes down to TURP or laser, concern about sexual dysfunction does not need to affect the decision.

E-mail This | Print This

Last updated:	August 21, 2006