Surgical Management of Benign Prostatic Hyperplasia: Understanding the Pros and Cons of Several Minimally Invasive Surgery Options

Are you currently suffering from Benign Prostatic Hyperplasia (BPH) and contemplating whether to undergo surgery? If so, this article will provide you with the valuable guidance that you are seeking.

BPH is a prevalent non-cancerous condition in which the prostate gland enlarges to more than 20-25 g, often resulting in several bothersome lower urinary tract symptoms for men. Although there is no permanent cure for prostate enlargement, BPH’s symptoms can be alleviated by undergoing treatment from a urologist. Some patients may experience a significant improvement in urinary symptoms with interventions like medications, lifestyle modifications, and surgical procedures. 

When non-surgical treatments prove ineffective and patients suffer from the complications of BPH, urologists will typically recommend surgery. This article will focus on the advantages and disadvantages of three prominent surgical approaches:

• Transurethral Resection / Laser Vapourisation of the Prostate
• Minimally Invasive Surgical Therapies (MIST) such as Convective Water Vapour Energy Ablation (Rezum) 
• Robot-Assisted Simple Prostatectomy

When should BPH surgery be considered?

One of the symptoms of BPH is haematuria, which refers to blood in the urine.

Besides conservative management, such as behavioural changes and reduction in caffeinated drinks, drugs like Alpha-blockers and 5-alpha reductase inhibitors, are the first line of BPH treatment. After these conservative treatment options have failed, urologists will usually advise patients with moderate to severe urinary tract symptoms and those experiencing the following BPH-related complications to go under the knife, especially if their quality of life is compromised. 

• Having trouble peeing or experiencing accidental leaks (urinary retention or overflow)
• Repeated urinary tract infections (UTIs)
• Presence of bladder stones or bladder pouches (diverticula)
• Repeated bleeding from the enlarged prostate when passing urine (haematuria) 
• Swelling in the kidneys or in the tubes that carry urine from the kidneys due to an enlarged prostate, with or without kidney problems

How can moderate to severe lower urinary tract symptoms be treated surgically?

Transurethral Resection / Laser Vapourisation of the Prostate

TURP refers to the surgical removal of excess prostate tissue to mitigate symptoms of BPH.

Transurethral Resection of the Prostate (TURP) is a safe and effective minimally invasive surgical procedure that is commonly used in alleviating BPH symptoms when the prostate size is 30-100ml. This procedure involves the removal of excess prostate tissue with an instrument known as a resectoscope. The resectoscope, which contains a thin electric-heated cutting loop with a light source as well as a camera at its tip, is inserted into the bladder through the urinary passage in the penis during the surgical treatment. Pieces of prostatic tissues around the prostatic urethral are scraped off to recreate a clear and unobstructed urinary channel. An alternative to using the electric-heated loop will be using a laser fibre (Greenlight Laser) to vapourise the prostate tissues.

In the beginning, certain individuals might experience transient changes in urinary function, like increased frequency or urgency. Nevertheless, as time passes, normal urinary patterns usually resume. Adhering to post-operative care guidance, such as refraining from strenuous activities and adhering to prescribed medication, from your urologic surgeon is crucial.

Pros

• Effective relief of urinary symptoms: TURP can substantially alleviate urine-related problems. Specifically, TURP has a success rate of >90% for patients whose enlarged prostate is causing an obstruction. 
• Short hospital stay and quick recovery: The minimally invasive nature of TURP translates into brief hospitalisation periods and fast postoperative recovery, minimising disruption to patients’ lives. The procedure is typically performed under spinal or general anaesthesia and may involve an inpatient stay of one to two days. Laser vapourisation has the added benefit of less blood loss during and after surgery, which may be useful in patients taking blood thinners.
• Long track record of success: TURP’s widespread adoption underscores its reliability and effectiveness in managing BPH and is widely considered the gold standard to which other BPH therapies are compared with.

Cons

• Risk of complications: As with any surgery, TURP is not without risks. A small percentage of patients experience side effects such as bleeding, and infection. A major downside of TURP or laser vapourisation is that up to 80% of patients will experience retrograde ejaculation after the procedure.
• Limited suitability for larger prostates: TURP may be less suitable for addressing larger prostates > 120g and Laser Vapourisation >80g, prompting the need for alternative approaches in such cases.

Minimally Invasive Surgical Therapy (MIST) – Convective Water Vapour Energy Ablation (Rezum)

Convective Water Vapour Energy Ablation (Rezum) is a treatment option that can shrink the prostate.

If TURP is not what you prefer due to the sexual side effects, you can consider its alternative the Convective Water Vapour Energy Ablation, which represents a relatively novel procedure for BPH patients with a prostate volume of 30-80mls. Rezum employs convective water vapour to treat BPH by injecting steam into the enlarged prostate tissue. As a result, the treatment will shrink the prostate. It can be performed very quickly with sustained effect, and ejaculatory function can also be preserved.

Pros

• Good medium-term improvements in symptom relief: For example, it can open up the urinary passage, improving urinary flow. 
• Shorter recovery time compared to TURP: The lower invasiveness of Rezum translates into lesser transient side effects such as bleeding, thus generally leading to a faster recovery than TURP. This procedure is usually done as a Day Surgery.
• May be more cost-effective than medication: Since this one-time treatment leads to a smaller risk of disease progression, it can be more affordable compared to long term medicine consumption per se.

Cons

• Risk of side effects: a minority of patients experience painful urination (dysuria), blood in their urine (hematuria), problems holding in pee and sudden difficulty urinating.
• Need for urinary catheterisation post surgery : Although the procedure is quick, patients will need to have a urine tube for about 1 week after surgery to allow recovery to occur.

What about larger prostates like those more than 150g?

Robot-Assisted Simple Prostatectomy / Laser Enucleation Of Prostate

Dr Terence Lim operating the da vinci robotic surgery system

In instances when TURP might be less effective due to the large size of the prostate (>150g), Laser Enucleation of Prostate or Robot-Assisted Simple Prostatectomy are viable alternatives. 

Laser Enucleation of Prostate is performed via an Endoscope with the help of high powered lasers. The whole adenoma (prostate tissues causing urinary obstruction) is removed enbloc and later morcellated by a special morcellator for removal. Recovery is similar to TURP.

Robot-Assisted Simple Prostatectomy represents an advanced surgical procedure merging the precision of robotic technology to remove excess prostate tissue. This minimally invasive surgical technique removes the entire benign tumour but only requires small keyhole incisions. It allows for magnified 3D visualisation of the operative field and dexterity in instrument handling, simulating the surgeon’s hands in the body, all done through keyhole-sized incisions. This procedure is not commonly performed as it is reserved for the largest of prostates. 

Pros

• Speedier recovery relative to open surgeries: Not only are robotic urologic surgery’s cure rates similar to open surgery, but the integration of robotic technology allows for enhanced precision, which is necessary since the prostate is deep down in the pelvis. This results in less postoperative pain, reduced blood loss, and lower risk of wound infection. Hence, patients can go through shorter hospitalisation periods.
• Less noticeable scars than open surgeries: As smaller incisions are needed to access the site of operation, this results in less obvious scars.

Cons

• Longer recovery time relative to less invasive procedures: Despite its advantages, Robot-Assisted Simple Prostatectomy typically involves a more prolonged recovery period than less invasive procedures such as vapourisation, laser enucleation and TURP.
• Limited availability to urology specialist clinics: The requirement for advanced equipment and in-depth robotic urologic surgery expertise limits the accessibility of Robot-Assisted Simple Prostatectomy to fewer clinics and specialists.

Summary

Visit Assure Urology & Robotic Centre 

When considering surgical management for BPH, the choice of surgical management depends on various factors, including prostate size, patient preferences, and the expertise of the urology team. It is imperative for individuals to engage in thorough discussions with their urologists, ensuring a comprehensive understanding of each option’s implications and potential outcomes. By doing so, patients can make informed decisions tailored to their unique circumstances, ultimately enhancing their overall quality of life.

In order to gain more tailored insight into which treatment or surgical option is most suitable for your BPH condition, you can book an appointment with Senior Consultant Urologist Dr Terence Lim from Assure Urology & Robotic Centre. Not only is Dr Lim well-versed in prostate health, but he is also an expert in robotic urologic surgery. The veteran robotic urologic surgeon has been involved in over 700 robotic surgeries. He has operated on all three generations of the da Vinci Robotic Surgical System and is amongst the first few urologists in Singapore to operate using the latest generation of this technology, and perform a robot-assisted Retzius-sparing Prostatectomy. Moreover, he is an appointed Visiting Urology Consultant to CGH and is frequently asked to proctor his colleagues in robotic surgeries.

References

1. “Benign Prostatic Hyperplasia (BPH): Symptoms & Treatment” Cleveland Clinic. (Accessed: 6 December 2023)
2. “Transurethral resection of the prostate (TURP) – Recovery.”  NHS UK. (Accessed: 6 December 2023)