Alternative to Risky Invasive Treatment for BPH
By: Dan Sperling, MD
Benign prostatic hyperplasia, or BPH, is a common noncancerous increase in the number of prostate cells as men age. The exact cause has not been identified, but one theory is that the natural programming for cell death begins to malfunction during aging. As a result, new cells continue to develop but the old cells fail to die off. Hence, the total number of cells increases and the prostate gland enlarges. While this is not a life-threatening condition, it can gradually squeeze off the passage of urine out of the bladder. When this occurs, urinary symptoms develop. Medications can often alleviate these symptoms, but when they are no longer effective, a treatment to widen the urinary passage may be necessary. Some of these treatments are less invasive, such as green light laser or TUNA. However, invasive surgical approaches are still routinely done.
The most invasive treatment is an open surgery called an open simple prostatectomy (OSP). It is different from a radical prostatectomy (RP), which is a prostate cancer treatment that removes the entire prostate gland, seminal vesicles and vas deferens plus a margin of surrounding tissue. Keep in mind that BPH is not cancerous, so it is not necessary to remove the whole gland. OSP accomplishes what is called “enucleation,” which means carving out most of the interior prostate tissue. What is left behind is the outermost capsule and a portion of tissue in the posterior (rear) zone. There is also a minimally invasive simple prostatectomy (MISP) which is usually more available at academic medical institutions rather than community hospitals. Patients who undergo MISP have, on average, one less day of in-hospital recovery (3.7 days vs. 4.7 days for OSP).
According to Dr. C. Lowell Parsons of the University of California/San Diego Health System, both OSP and MISP have a “relatively high rate of perioperative transfusion,” with no significant differences between the rates of blood transfusion during the operation or perioperative outcome.[i] He cited a 21% transfusion rate for OSP, and 10% for MISP. His data was based on a study of 34,611 patients who underwent simple prostatectomy between 1998 and 2010. Interestingly, the number of annual cases decreased over time from 3,150 cases in 1998 to 2,230 cases in 2010, but the researchers noted that after a gradual decline to a low point in 2008, the number of cases had begun to climb. Dr. Parsons also noted the scarcity of Level 1 or 2 research comparing the more invasive procedure with the less invasive one. In fact, the raw numbers make comparisons difficult, based on numbers from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization: Between 2008 and 2010, there were 6,027 OSP cases and 182 MISP cases.
OSP is a conventional treatment for BPH, and there are three different surgical approaches (suprapubic, retropubic and transperineal) to accessing the gland. Depending on factors such as the size and shape of the gland, and other considerations such as patient age and body weight, one approach might be favored over another. While the removal of so much interior gland tissue gives OSP an advantage over transurethral resection of the prostate (TURP) it is important to keep in mind that future prostate cancer cannot be ruled out because of the gland portion left behind. If cancer is already suspected, it must be ruled out by biopsy and imaging prior to OSP. A disadvantage of OSP is the longer hospitalization and recovery associated with the open procedure, and the risk for blood loss during the surgery sufficient to require transfusion. The transperineal approach would be contraindicated for patients who wish to preserve erectile function, as that approach disrupts the neurovascular structures more than the other two. Finally, because of the duration of the surgery, patients with preexisting cardiovascular conditions may not be candidates for OSP.
The groundbreaking work of Dr. Sperling in applying MRI-guided focal laser ablation to the treatment of BPH brings an entirely new approach to reducing prostate size without drugs or surgery. The type of laser employed is delivered by means of an image-guided fiber optic; the thermal effect when the laser is activated results in the formation of scar tissue that rapidly shrinks, thus diminishing the size and mass of the gland. It is an outpatient, bloodless procedure that is done under local anesthesia.
Focal laser ablation for BPH provides treatment and recovery advantages to patients. In addition, it saves medical costs. Interestingly, MISP is more expensive than OSP ($47,423 vs. $32,462).
With the increasing physician and patient interest in minimally invasive alternatives to procedures that lead to longer hospital stays (risk of infection, high costs) and disfiguring or lifestyle impairing side effects, MRI-guided focal laser ablation for BPH is expected to gain a wide and appreciative following.
[i] Krader, Cheryl Guttman. “Transfusion rate high with prostatectomy for BPH.” March 1, 2015. http://urologytimes.modernmedicine.com/urology-times/news/transfusion-rate-high-prostatectomy-bph?page=0,0