Understanding and choosing between the different treatments for the enlarged prostate (BPH) 

Mr Alan Doherty

By Alan Doherty

Until quite recently, men seeking treatment for BPH (benign prostatic hyperplasia) had just two options: medication or the TURP procedure. This was a stark choice; medication is not always effective, particularly over time and can cause troublesome side-effects. The TURP (trans-urethral resection of the prostate) has serious potential complications, common side-effects and involves a significant period of recovery.

How this has all changed in recent years. We were one of the first services to introduce the GreenLight laser operation in 2007, providing an alternative surgical method of removing surplus tissue that is more easily tolerated than the TURP. We have now carried out more than 1,000 GreenLight laser operations, one of the largest caseloads in the country.

Our clinicians were also the first to introduce the UroLift in 2014: instead of removing surplus tissue, the two lobes of the prostate are lifted and clipped apart, like opening a pair of curtains. The UroLift provides an option which is less invasive still than the GreenLight laser, taking place as a day case procedure with almost immediate resumption of usual activities.

But the UroLift is not suitable for all men; it depends upon the size and shape of their prostate. We are currently trialling another new approach called Rezum which uses water vapour (steam) to damage the surplus prostate tissue and in so doing, create the void for urine to flow more effectively. This seems a promising option at the most minimally invasive end of the scale. Another option used elsewhere is called the iTind, based on using an implant to reshape the prostate.

With this proliferation of choices, how are patients to decide? There is a challenge for urologists too in terms of properly evaluating the different options, not becoming too much the ‘enthusiast’ for one over all others and supporting patients to make an informed, balanced evaluation.

Reflecting on all of this, at BPC we have developed this framework for understanding all the different choices in treatments for the enlarged prostate and making the right decision for each person. It helps us to quickly identify what group of treatments are unlikely to be effective (for example, the patient who has read a newspaper article about the iTind but has a large prostate and is in retention). There will be many patients who do have choices: their clinical assessment and preferences may indicate a displacement/damage and option is best and if so, we can guide them through the choices they have.

Removal of surplus tissue

These approaches are based on creating a void for urine to flow by permanently removing the surplus prostate tissue. These approaches are: the TURP, the GreenLight laser and the hybrid GreenLight laser with ‘trim’ TURP, developed by our surgeons.

Advantages: removal-based procedures provide the best opportunity of achieving a full, lasting and durable solution with symptoms addressed

Disadvantages: a longer period of recovery, particularly with the full TURP.

Considerations: all three of these approaches are likely to cause retrograde ejaculation (dry orgasm) so would not be suitable for men who may wish to have children in the future and some men are not comfortable with this outcome.

Displacing or damaging surplus tissue

These approaches do not cut out or laser the surplus tissue. They create the void for urine to flow by either displacing or damaging surplus tissue. These approaches are: the UroLift, the Rezum and the iTind.

Advantages: these approaches can be effective for men with small to medium sized prostates. Procedures are undertaken as day case procedures and patients can return to work and continue their usual activities almost immediately.

Disadvantages: unlikely to be effective for men with severe BPH (for example, wearing a catheter), very large prostate or complications (for example, previous prostate surgery). UroLift is not suitable if a man has a middle prostate lobe

Considerations: good for a patient who is working, active and wants to avoid having a period of recovery but is keen to find a solution, rather than long term use of medication. Having these procedures will not rule out future options (for example, UroLift can be repeated, removal-based procedures can be offered if these approaches are not effective). There is a lack of data to measure durability in the longer term because these are new procedures, although a little more for UroLift.

Medication

Surplus prostate tissue remains intact and in situ, but the medication works by relaxing the muscles in your bladder and prostate and this eases the flow of urine (thus easing your symptoms).  This form of medication is called Alpha Blockers and your urologist will advise on the best type. There is also medication called 5-Alpha Reductase Inhibitors which acts on the hormones that make the prostate grow, with the aim of stopping the growth and sometimes even achieving a degree of shrinkage. These two types of medication can be combined.

Advantages: medication is often considered the least invasive approach and it is generally used as the first line of treatment for patients with mild and medium BPH

Disadvantages: there are side-effects to medication, notably dizziness and headaches from Alpha Blockers and erectile dysfunction and loss of libido from the medication used to slow the growth of the prostate.

Considerations: side-effects are experienced to a different extent by each patient and personal choice is an important aspect (some patients find erectile dysfunction and loss of libido very difficult). The increase in displace/damage options provide a valuable alternative for men who are not getting on well with medication but want a minimally invasive approach.

Read more about these treatments