VERY often, as urologists, we are called upon to perform surgery in men with symptomatic benign prostatic hyperplasia (BPH). We will discuss the indications for surgery in these men and the various surgical options.

Surgery for an enlarged prostate is not indicated in all men, however, several situations may warrant surgery. These include: the presence of an associated bladder stone/s; recurrent bladder infections; associated kidney failure as a result of bladder outflow obstruction; recurrent bleeding from the prostate; failure of medications to relieve urinary symptoms; and chronic urinary retention.

Urinary retention is the inability of a man to pass urine. Chronic urinary retention is distinguished by the retention of a very large volume of urine in the bladder, and this may be complicated by kidney failure.

It is important to note that the surgeries performed for men with BPH are different from that performed in men with prostate cancer. The procedures to treat BPH range from open surgery to minimally invasive options. The main aim of surgery is to improve urinary flow rate and relieve lower urinary tract symptoms.

Prostatectomy

A simple prostatectomy is an operation that dates back to the late 1800s — when an incision was made in the lower abdomen, entering the bladder — and only the inner portion of the prostate which causes obstruction is removed. The procedure may also be performed laparoscopically and robotic-assisted laparoscopically.

Traditionally, this operation may be performed in a man with BPH where the prostate is too large to resect via minimally invasive techniques.

Transurethral resection of the prostate

The gold standard and perhaps the most common surgical treatment of BPH is the transurethral resection of the prostate (TURP). The procedure is done under general or regional anaesthesia in the main operating theatre. The procedure involves inserting a rigid instrument in the urethra and resecting or “shaving” chips or portions of the obstructing prostate away. One advantage of this procedure is that it does not involve making external incisions.

A transurethral incision may be done under similar conditions as the TURP, but instead of resecting the prostate an incision is made to relax the bladder opening and allow for improved urine flow. This procedure is usually reserved for men with smaller prostates than those recommended for a TURP.

Newer techniques

Recent advances in surgical techniques for the treatment of BPH have welcomed new technology which aims to improve urinary flow rate by using minimally invasive techniques but limiting the side effects of the treatment. Several of these newer techniques may be performed in the office setting under local anaesthesia and are suitable for patients who are poor candidates for major surgery.

Some of the newer options include:

• Urolift — a mechanical procedure in which implanted pins are placed in the prostate to lift and compress the obstructing lobes away;

• Greenlight laser — a technique in which there is photo-selective vaporisation of the prostate;

• Plasma button electro-vaporisation;

•Water vapour therapy (Rezum) — this is where water vapour is delivered directly to the prostate, leading to destruction and absorption of the tissue over time;

• Aqua-ablation — a procedure in which the prostate is resected using a water jet;

• Transurethral microwave therapy — a procedure in which microwaves are used to destroy the obstructing prostate tissue;

• Holmium laser enucleation of the prostate (HoLEP) — a procedure in which a laser inserted through the urethra can resect the prostate.

The choice of surgical procedure will depend on the size of the prostate, associated urinary complications, medical fitness of the patient, resources available, and long-term treatment goals. Surgery of the prostate for BPH is highly successful with significant improvement in urinary flow rates. As many of these surgical options are relatively new, data is emerging over time on treatment tolerability, durability and affordability.

Side effects of the procedures vary but are usually temporary. These may include bloody urine, urinary tract infections, increased urinary frequency, retrograde ejaculation (semen enters the bladder rather than through the urethra down the penis), and urinary incontinence.

Men who are candidates for surgical treatment of BPH should have a discussion with their urologist about the best treatment options.

Dr Belinda Morrison-Blidgen is a consultant urologist and senior lecturer at The University of the West Indies. E-mail her at: Belinda.morrison02@uwimona.edu.jm