New surgical techniques for benign prostatic hyperplasia – an overview

This review outlined recent advances in surgical techniques for benign prostatic hyperplasia (BPH).

The authors concluded that new technologies for treating BPH are promising. However, further randomized trials are needed.

BPH can lead to bothersome urinary symptoms that often require surgery targeting the enlarged prostate tissue. Transurethral resection of the prostate (TURP) is the most common surgery used for removing enlarged prostate tissue. Recent advances in surgical techniques have led to procedures being less invasive and easier to tolerate. The aim of this review is to provide an overview of recently developed surgical techniques for treating BPH-related urinary symptoms. 

Prostatic urethral lift is a short, minimally invasive procedure to secure enlarged prostate tissue away from the urethra (the urine tract) without removing prostate tissue. Prostatic urethral lift is believed to relieve pressure on the urethra and thereby ease urination. Results from one large trial showed that general urinary symptoms, bladder emptying, urine flow, as well as quality of life, were all significantly improved 3 years after the prostatic urethral lift procedure. A recent meta-analysis (an analysis of pooled data from several trials) noted similar findings in symptom improvement with preservation of sexual function. While the prostatic urethral lift procedure does not achieve the same effectiveness seen with conventional TURP, it is believed to be a suitable alternative for men with high surgical risk.

The convective water vapor procedure allows for a destruction of prostate cells with water vapor delivered via a small needle. One trial noted significant improvements in urinary symptoms following this procedure, when compared to a sham control procedure (no active treatment given). Improvements were maintained after 1 year. A further study supported these findings and also showed a 28.9% reduction in prostate volume 6 months after the procedure. The convective water vapor procedure is very short (average 5 minutes) and can be carried out under local anesthesia. However, previous reports have noted that up to 75% of men required a urinary catheter for several days due to urinary retention (an inability to pass urine).

During prostate artery embolization, particles are injected into the groin by means of a catheter, which decrease blood supply to the prostate and therefore reduces prostate size. In a recent trial, improvements in urinary symptoms and quality of life following prostate artery embolization were comparable to those of TURP. However, TURP was associated with better bladder emptying and prostate size reduction, but also more complications. Side-effects associated with prostate artery embolization included a burning sensation, bruising, urinary retention, local pain, diarrhea, and rectal bleeding. The average procedure time ranges from 75 to 150 minutes.

Waterjet hydrodissection uses a high-velocity saline stream that selectively destroys enlarged prostate tissues, while sparing healthy surrounding cells. This novel technique was tested in 15 men in a recent study. Significant improvements in general urinary symptoms and urine flow were noted 6 months after the procedure with a preservation of sexual function in all cases. Five men (33%) required a urinary catheter for several days due to urinary retention. The average procedure time was 40 minutes.

Histotripsy uses high-intensity ultrasound pulses to break down targeted prostate tissue. A recent study that included 25 men showed significant improvements in urinary symptoms and quality of life. Histotripsy was associated with few complications, with only one case of urinary retention reported. However, no marked changes in urine flow, bladder emptying, and prostate volume were noted.

PRX302 involves an injection of an engineered protein directly into the prostate, which leads to prostate-specific cell death. One trial noted that a single administration of PRX302 was associated with small, but significant improvements in urinary symptoms and quality of life. However, an additional late-phase trial noted small improvements that were comparable to those of placebo treatment (a procedure with no active effect, used as a control).

While many of the new surgical approaches for treating BPH are in early stages of development, the authors concluded that they provide a promising alternative to current standard-of-care surgical procedures.