How do you choose between all the different treatments for Benign Prostatic Hyperplasia (BPH), the enlarged prostate? By Alan Doherty, consultant urologist, BPC.

Mr Alan Doherty

As a clinic offering nearly all the different treatments for BPH, we are in a unique position to observe how patients weigh up the options; what matters to them and how they prioritise the many considerations involved.

BPH treatment is a field which has seen very rapid changes in recent years: we introduced GreenLight laser surgery at an early stage, back in 2007, and now have a caseload experience of more than 1,000 procedures. GreenLight laser surgery provided the first surgical alternative to the TURP (trans urethral resection of the prostate), which was recognised for its effectiveness, but involved side-effects that many patients found unacceptable.

More recently, other approaches have been introduced, offering options which are even less invasive than GreenLight laser surgery. We have one of the largest experiences in our region in the new approaches UroLift and in Rezum.

We consistently maintain the same position in terms of how we explain and offer the different treatments: we are not enthusiasts for one particular approach over the others. We are committed to good, open dialogue with our patients setting out the considerations for each procedure, its advantages and disadvantages, so they can make a fully informed and personalised decision.
What have we learnt so far from our dialogue with patients and experience of all the treatment options for BPH? If your priority is having the most minimally invasive procedure so you can get back to work and/or all normal activities straight away. UroLift is the most minimally invasive option of all. It involves using an implant to lift the two lobes of your prostate apart, creating a space to allow urine to flow more effectively. You will be able to go home on the same day as your procedure (once we have checked you can pass urine normally) and unlike other procedures, you will not need to wear a catheter. Discomfort is usually minimal and addressed by paracetamol, if needed.

Bear in mind studies show UroLift does improve urinary symptoms although not to the same extent as other procedures in terms of degree of impact and durability. You may, at a later stage, need further treatment. It depends how severe your symptoms are and what sort of outcome you want. Patients with a large prostate and three lobes (called trilobar, which refers to a middle lobe) will not be suitable for UroLift. Interestingly, one study showed one in ten patients needed another procedure after having UroLift and half of those chose another UroLift, so providing patients are properly counselled about the procedure, it is well-tolerated and many choose it again, if further treatment is needed.

If your priority is having treatment for BPH that does not affect your sexual function in any way (including dry orgasms) Rezum or UroLift would be recommended, as treatments which do not affect ejaculation in any way. GreenLight laser, in most cases, causes permanent retrograde ejaculation (dry orgasms) due to the changes which occur in the bladder neck as a result of treatment and this means ejaculate flows back into the bladder. Many patients are not bothered by this; the sensation of orgasm is not diminished. But it is a very important aspect if you think you may want to have children in the future and some patients do not feel this is an acceptable side-effect.

Bear in mind you will need to wear a catheter for five to seven days after Rezum, and additionally, for up to four weeks, you may have urinary symptoms including passing debris (surplus prostate tissue) destroyed during the procedure via your urine. The improvement in your urinary flow is gradual, taking full effect at around for to six weeks, once the debris has passed through your body.
If your priority is having the treatment that gives you the greatest probability of a full and permanent improvement in your symptoms GreenLight laser surgery is the option we would recommend if permanent and full symptom improvement is your main priority. We regularly undertake GreenLight laser (occasionally with a ‘trim’ TURP if we judge this to be the most effective way of completing the procedure), creating a durable space for urine to flow. You will spend a night in hospital and will come round from surgery wearing a catheter, but this is removed once you are ready and patients regularly find the improvement in urinary flow is immediate and dramatic.

Bear in mind the recovery period from GreenLight laser surgery is a little longer than from UroLift or Rezum, though significantly shorter than from a full, traditional TURP. You must wait 48 hours to drive after having a general anaesthetic (by law) and there will be a little blood in your urine for one to two weeks. You will be able to resume all normal activities two to four weeks after your procedure.