UroLift for the enlarged prostate – a promising ‘middle step’ in the treatment spectrum

Mr Alan Doherty

By Alan Doherty

In our field, we see something of a regular conveyor belt of new treatments promising “revolutionary” results for patients. I see my professional stance towards new developments as being that of the informed cynic – I am always keen to learn and utilise technology that improves outcomes for patients. But I have seen many “ground-breakers” come and go. I want to see evidence for claims made (and I know claims are often made on the basis of small, narrow studies). I also know that in surgery, the skill of the surgeon is at least as important as the approach itself, so training and full evaluation is critical.

This was my stance when I recently undertook training in the new UroLift system. There is certainly a treatment need: this is an extremely common condition, with prevalence increasing with age. Four out of 10 men aged over 50, and three quarters of men in their seventies have urinary symptoms caused by an enlarged prostate. The first line treatment for these men is daily alpha blockers, aimed at relaxing the prostate in order to ease the flow of urine, or another medication based approach, using inhibitors to slow down the hormones causing the prostate to grow.

This can work fairly well for many men. But others find medication ineffective in reducing the symptoms and some experience bothersome side-effects. If this is the case, there is then a significant ‘jump’ in terms of the next line treatment. At BPC, we are one of the highest volume centres for GreenLight laser surgery. When laser surgery was first introduced (in 2002 for the UK and at our clinic in 2007), it provided a far less invasive alternative to the traditional TURP (transurethral resection of the prostate), in which surplus tissue is cut from the prostate. In fact due to the impact of a traditional TURP on the patient, it is not a procedure we routinely offer.

Nevertheless, laser surgery is still a major step for patients, usually involving a general anaesthetic, an overnight hospital stay and with a recovery period of several weeks. For many patients, this makes it difficult to weigh up the relative pros and cons of remaining on medication, putting up with bothersome side-effects, versus going ahead with having laser surgery. I was interested in UroLift as a potential ‘middle step’.

UrolLift is not based on lasering or cutting out surplus tissue. Instead, small implants are used to pull apart the two prostate lobes, creating a larger opening for urine to more freely flow. The lobes are clipped in place; the procedure can be compared to opening curtains. The idea behind it is a good, simple one. But does it work?

I recently attended a UroLift training course, completing five procedures. My observations from this training would be that it is not suitable for all men with BPH. It won’t be sufficiently durable for large prostates (above 100ml), nor will it work for men who have a middle prostate lobe. But there is a clear benefit for men who are not happy with medication for BPH and want to try the least invasive second line intervention.

UroLift can easily be done as a day case, with men returning home within hours and normally without a catheter. Side-effects are likely to be a small amount of bleeding and some discomfort when passing urine, noticeable for no more than two or three weeks.

Because the system was first used in 2011, there is no long term data for overall durability. Equally, my view would be that UroLift is half as good as laser surgery or TURP in terms of improving the urinary flow. We need to be completely transparent with patients about what this treatment choice entails: you would certainly be choosing a smaller intervention and as such, that intervention is likely to be less effective than a larger intervention. However, I would argue that for patients with moderately bothersome symptoms on medication, the correct pathway is to first try the smaller intervention of UroLift. Importantly, having UroLift does not compromise the patient’s choice of laser surgery at a later stage if required.

Ultimately, it brings to mind the traditional doctor’s Hippocratic oath: “First, do no harm.” Providing the evidence is there, we should always progress with interventions step-by-step, aiming to achieve effective an effective solution using the least invasive option. On this basis, we are pleased to be offering UroLift at BPC.”