Innovations in Treatment of BPH

By: Ivan Grunberger, MD | Posted on: 27 Feb 2018

Innovations in Treatment of BPH

New procedures are less invasive than many older choices, with good results and comfortable recovery.

Although there is no cure for benign prostatic hyperplasia (BPH), also known as enlarged prostate, there are many useful options for treating the problem. Treatments focus on prostate growth, which is the cause of BPH symptoms. Once prostate growth starts, it often continues unless medical therapy is started. The prostate grows in two different ways. In one type of growth, cells multiply around the urethra and squeeze it, much like you squeeze a straw. The second type of growth is middle-lobe prostate growth in which cells grow into the urethra and the bladder outlet area. This type of prostate growth typically requires surgery.

The first line of care for treating BPH is often medication. Doctors may prescribe an alpha blocker to relax the prostate, a 5-alpha reductase inhibitor to reduce the prostate's size, or both. While medications are helpful for many patients, some may impact a man's sexual function or only reduce, not eliminate symptoms if the patient has a moderate to severe case of BPH.

In cases where patients have moderate to severe BPH or have a middle-lobe growth and need further treatment, there are a range of BPH-related surgical procedures, including ones that are less invasive than older surgeries. A patient and his doctor will choose the best option based on the size and shape of the prostate, as well as the patient's preference and overall medical condition.

Transurethral resection of the prostate (TURP) was considered the gold standard surgical treatment for many years. It involved "shaving" the enlarged prostate tissues with an electric current delivered through a wire loop. While this technique worked well, its' side effects could include bleeding, urinary incontinence and erectile dysfunction.

Today, two newer procedures are performed in the urologist's office. For patients with mild to moderate BPH with no middle lobe, there is a stapling procedure known as UroLift where the physician places the patient under local anesthesia or conscious sedation and lifts and staples the prostate to open up the urethra. Because it pulls the prostate out of the way, this approach offers rapid relief, but it cannot be done if the prostate has a middle lobe. The procedure takes about 15-30 minutes, and patients return to normal activities in about 3 days. Results are not always permanent; symptoms could eventually return.

The second procedure, known as Rezum, is also performed with local anesthesia or conscious sedation and is available for patients, regardless of the presence of a middle lobe. The physician uses a radiofrequency device to deliver drops of water vapor to the prostate. Condensation of the water vapor releases energy that causes the surrounding cells to die and results in retraction of the prostate and opening of the urethra. The procedure takes about 10 minutes, and patients return to normal activities in 3 days. It takes about 1 month for patients to get the full effect.

For patients with moderate to large prostates or who have a large median lobe, laser surgery is often the preferred choice. This type of procedure is useful for men who may also have had other procedures in the past, and now prostate re-growth is causing obstruction again. During this procedure, usually performed in a hospital, the laser vaporizes the tissue obstructing the urethra, opening it up almost immediately.

There are several laser wavelengths available to treat BPH. The most popular of these wavelengths are holmium and Photoselective Vaporization of the Prostate (PVP), also known as "greenlight laser." Although each of these wavelengths can be used to vaporize prostatic tissue, there are important differences.

The greenlight laser is a minimally invasive technique with good results. The procedure uses high-powered laser light, combined with fiber optics, to quickly vaporize the overgrowth of prostate cells. This procedure takes about 1 hour and provides patients quick symptom relief, ease and comfort of urinary flow, and minimal short-term side effects.

Holmium lasers have been used for more than 20 years to treat many urologic conditions. These lasers have the ability to interact with soft tissues while keeping known safety margins and controlling bleeding. Usage of this versatile tool for BPH treatment relies specifically on the high-power systems with relatively high energies and, more importantly, high repetition rates, which are important for efficient tissue effect.

A procedure called Holmium Laser Vaporization of the Prostate (HoLVP), which uses high-powered holmium lasers, has some advantages over PVP for patients with BPH including, in my experience, less bleeding and the ability for urologists to treat men with larger prostates. HoLVP is a solid option for small to moderate-sized prostates and those with a large median lobe. It also can be used to treat concurrent bladder stones during the same procedure.

One of the most effective holmium laser treatments for BPH is a procedure called Holmium Laser Enucleation of the Prostate (HoLEP). It is an effective option for patients who have large prostates and/or other health problems that can make surgery more complicated. People taking blood thinners are candidates for this procedure because it minimizes bleeding. The clinical outcomes of HoLEP, including a very low reoccurrence rate, are well established.1,2

Bipolar Vaporization Electrode (BiVAP) Saline Vaporization, also called Transurethral Vaporization (TUVP), has been available for several years. Like holmium laser surgery, it is a good option for people with recurrent disease, but it is not generally used for patients with very large prostates. BiVAP is typically used when a patient's obstruction recurs and a small amount of tissue needs to be removed, but the patient is not a candidate for one of any of the in-office procedures. It can also be utilized as a primary treatment for mild to moderate BPH.

Whether patients have mild, moderate or advanced BPH, are getting treatment for the first time or seeking retreatment, highly effective options are available. Patients should discuss the treatment options for BPH with their urologist and find out which ones are right for them.

About the Author: Ivan Grunberger, MD, is Chief of Urology at New York-Presbyterian Brooklyn Methodist Hospital and a Professor of Clinical Urology at Cornell Weill Medical College.

1. Holmium Laser Enucleation of the Prostate; Results at 6 Years, Gilling PJ, Aho, TF, Frampton CM, et al. Eur Urol 2008 Apr:53(4):744-9
2. Holmium Laser Enucleation of the Prostate Versus Open Prostatectomy for Prostates Greater Than 100 Grams; 5-Year Follow-up Results of a Randomized ClinicalTrial, Kuntz RM, Lehrich K, Ahvai S. Eur Urol 2008 Apr:53:160-168

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