What is the new UroLift for benign prostatic hyperplasia?

Mr Alan Doherty

Earlier this year, a new approach to benign prostatic hyperplasia (BPH) received approval for use in the NHS. The new approach is called UroLift and is designed to alleviate the symptoms of BPH without cutting or vaporising the surplus prostate tissue.

To understand this new treatment, we need to start by looking at what happens when the prostate becomes enlarged. A prostate is normally about the size of a walnut, located just beneath the bladder and surrounding the urethra, the tube through which urine passes out of the body. An enlarged prostate can expand to three times the normal size and this has an effect like a kink in a hosepipe; urine cannot flow freely and therefore the bladder does not fully empty. Sufferers are troubled by a constant need to go to the toilet.

First line of treatment has been to prescribe medication which relaxes the muscles of the bladder, allowing urine to pass through more easily or drugs which help to shrink the bladder. Some men find the medication causes troublesome side-effects, such as headaches, dizziness, loss of libido and constipation.

If the side-effects of medication are difficult to tolerate and symptoms persist, the next step is to remove the excess prostate tissue. Up until fairly recently, the only means of removing tissue was by cutting it away, using a surgical wire heated by an electrical current. Called a TURP (trans-urethral resection of the prostate), the procedure can cause significant blood loss and post-operative pain, with risks of nerve damage leading to impotence and incontinence.

Around a decade ago, an alternative was introduced in the UK, called GreenLight laser. It is based on the same principle of removing surplus tissue, but does so using a laser, which means blood vessels are vaporised and sealed. There is far less blood loss than a TURP and patients make a much quicker recovery. BPC has now carried out more than 600 individual GreenLight laser procedures. We carefully evaluate results, assessing patients at three and 12 months post-op, audit and evaluate these results. Our first study showed 189 patients had a positive outcome, stating they were either “delighted” or “satisfied” with the results of the procedure. A total 18 reported a negative outcome and 17 a neutral verdict.

The key difference in the new UroLift approach is it is not based on removing any prostate tissue. Instead, small implants are used to push the surplus prostate glands to the side, creating more space around the urethra in order for urine to flow normally. Two to four implants are used and these remain in place permanently. The procedure can be carried out under a local anesthetic and patients can return home on the same day. There is no need for a catheter.
It is clearly a well-thought out new approach, taking the principle of minimally invasive treatment one step further. How effective is it? The NICE guidance published in January 2014 has a large section on efficacy, citing several examples. A case series of 64 patients reported a significant improvement in International Prostate Symptom Score (scale 0 to 35; higher score indicating more severe symptoms) at follow-up intervals from 2 weeks to 24 months. The mean score improved from 22 at baseline to 13 at 2-year follow-up (n=33; p<0.001). After the procedure, men typically return to all normal activities within just nine days.

While there is clearly enough evidence of efficacy to justify the use of the procedure in the NHS, it should also be noted that overall, efficacy rates for UroLift are in some cases lower than we would expect from either the TURP or a GreenLight laser procedures. The worldwide LIFT study will provide a much more detailed verdict on efficacy and over time, we will have a clearer picture on long term durability. The NICE guidance concludes:

“The Committee recognised that, in common with other treatment options,
insertion of prostatic urethral lift implants is not likely to offer permanent relief
of symptoms. Some patients may prefer it to other procedures that have a
greater risk of causing sexual dysfunction. Certain patients may also prefer this
procedure to prolonged drug therapy.”

This seems a very fair and well-judged conclusion. The UroLift has clear advantages in terms of a rapid recovery and very low complications rates, but we should also be aware that it is not a perfect procedure and long term durability is not yet known or proven.

Our view at BPC is that there is not a clear enough rationale to offer UroLift alongside GreenLight laser. Years of data show the laser procedure is well tolerated by patients, with low complications and clear long term effectiveness, provided it is carried out by an experienced surgeon using sufficient energy during the procedure.

See the full NICE guidance on UrolLift here:
http://www.nice.org.uk/guidance/ipg475/resources/guidance-insertion-of-prostatic-urethral-lift-implants-to-treat-lower-urinary-tract-symptoms-secondary-to-benign-prostatic-hyperplasia-pdf

Read about Greenlight laser here