By: Dan Sperling, MD

Benign prostatic hyperplasia (BPH, also called benign prostatic hypertrophy) is a common enlargement of the prostate gland as a man ages. A gradual change occurs in the types of tissue that make up the three prostate zones. BPH typically begins around age 40, and can increase as a man grows older. It is estimated that 60% of men in their sixties have BPH, and by age 90 it is almost universal.

The prostate has three zones: Peripheral Zone (PZ), Transitional Zone (TZ), and Central Zone (CZ). In young men, the TZ occupies about 20% of the gland, and this is where BPH begins. From midlife on, the volume of the whole gland increases. Because the TZ surrounds the urethra, BPH can compress the passage for urinary flow out of the bladder. This results in lower urinary tract symptoms (LUTS). Common BPH-related LUTS include difficulty starting urination, interrupted or weak flow, sense of urgency even when the bladder is not full, incomplete emptying of the bladder, and nighttime sleep disruption. Most men with BPH eventually have symptoms, but it’s important to obtain a diagnosis as other conditions can also cause LUTS. Oral medication may control BPH symptoms, but if they are severe enough, surgical intervention will be warranted.

There are three conventional surgical procedures to widen the urethral passage. All of them access the prostatic urethra by means of inserting tiny instruments through the tip of the penis.

1. Transurethral resection of the prostate (TURP, or what some patients call “reaming out”) – TURP, done under anesthesia, uses very small instruments to scrape away excess tissue. It usually involves an overnight hospital stay. Healing may take up to 3 weeks. Side effects: difficulty controlling urine stream, erectile dysfunction (ED), retrograde ejaculation (semen flows backward into the bladder), urinary blockage, and infertility.
2. Photoselective vaporization of the prostate (PVP or Green Light Laser) – PVP applies laser energy to generate sufficient heat to result in controlled vaporization of prostate tissue. It is done outpatient under anesthesia. Side effects may be less severe than TURP, and healing usually takes less time.
3. Holmium laser enucleation of the prostate (HoLEP or Indigo Laser) – Unlike PVP, HoLEP uses a different type of laser that coagulates small volumes of tissue. Because the tissue clumps and scars, the small bits of tissue must be passed out through the urethra to “hollow out” or enucleate the passage. Patients wear a catheter for several days to a week to avoid urine blockage. Improvement in symptoms may occur over 6-12 weeks.

Published clinical literature demonstrates a range of treatment side effects:

TURP

Chughtai et al. (2014) found that up to a third of post-TURP patients continue to have LUTS.[i]

Durrani et al. (2014) report hospital stays of 1-4 days, indwelling catheter 1-5 days.[ii]

Favilla et al. (2013) note that men > 65 years old have greater risk of post-TURP ED at 12 mos.[iii]

Zhao et al. (2013) observed a small incidence of 3-month post-TURP ED due to capsule perforation and post-op stress.[iv]

PVP

Hu et al. (2013) demonstrated a rate of 13.7% ED six months following PVP.[v]

Cho et al. (2012) report that 40% of PVP patients did not maintain initial results at 3 years.[vi]

Bruyere et al. (2010) found that post-PVP patients with normal sexual function before treatment showed significant decrease at 6, 12 and 24 mos. post-PVP.[vii]

HoLEP

Li et al. (2014) reviewed published literature for a comparison of HoLEP and surgical TURP. They found “…no clinically relevant difference in early and late postoperative complications between the two techniques, but HoLEP is preferable due to advantage in the curative effect, less blood transfusion rate, shorter catheterization duration time and hospital stay. However, trial sequential analysis does not allow us to draw any solid conclusion in overall clinical benefit comparison between the two approaches.”[viii]

Abdel-Hakim et al. (2010) noted that after HoLEP, 36.4% of patients experienced irritative symptoms and 9% had stress urinary incontinence, both of which were helped with medication and Kegel exercises.[ix]

There is a trend toward favoring HoLEP over TURP and PVP because of procedure-related advantages and shorter hospital time than with TURP.

A new minimally invasive therapy is MRI-guided interstitial focal laser ablation (FLA), which utilizes transrectal placement of a single laser optic fiber into a strategic BPH location near the urethra. Activating the laser creates a controlled ablation of tissue that heals into scar tissue, resulting in shrinkage of the ablated tissue and thus reducing compression of the urethra. Unlike cutting, vaporization, or enucleation, the principle of FLA is the natural reduction of tissue within the prostate itself. This effectively widens the urethral passage, thus alleviating LUTS related to BPH. There is no published literature at this time, and it is available only at the Sperling Prostate Center. However, early experience shows FLA to be a safe and effective treatment with minimal side effects. As such, it is a promising alternative to medications and procedures that require a hospital stay and take days, weeks, or even months to see results.

[i] Chughtai B1, Simma-Chiang V, Kaplan SA. Evaluation and management of post-transurethral resection of the prostate lower urinary tract symptoms. Curr Urol Rep. 2014 Sep;15(9):434.

[ii] Durrani SN, Khan S, Ur Rehman A. Transurethral resection of prostate: early versus delayed removal of catheter. J Ayub Med Coll Abbottabad. 2014 Jan-Mar;26(1):38-41.

[iii] Favilla V, Cimino S, Salamone C et al. Risk factors of sexual dysfunction after transurethral resection of the prostate (TURP): a 12 months follow-up.  J Endocrinol Invest. 2013 Dec;36(11):1094-8.

[iv] Zhao QQ, Meng XH, Xue J. [Impact of transurethral resection of the prostate on erectile function: a report of 64 cases]. [Article in Chinese] Zhonghua Nan Ke Xue. 2013 Aug;19(8):710-3.

[v] Hu XT, Yang GS, Zeng XY et al. [Influence of photoselective vaporization of prostate on erectile function in patients with benign prostatic hyperplasia]. [Article in Chinese] Zhonghua Nan Ke Xue. 2013 Oct;19(10):918-22.

[vi] Cho SY, Park S, Jeong MY et al. 120W GreenLight High Performance System laser for benign prostate hyperplasia: 68 patients with 3-year follow-up and analysis of predictors of response. Urology. 2012 Aug;80(2):396-401.

[vii] Bruyère F, Puichaud A, Pereira H et al. Influence of photoselective vaporization of the prostate on sexual function: results of a prospective analysis of 149 patients with long-term follow-up. Eur Urol. 2010 Aug;58(2):207-11.

[viii] Li S, Zeng XT, Ruan XL et al. Holmium laser enucleation versus transurethral resection in patients with benign prostate hyperplasia: an updated systematic review with meta-analysis and trial sequential analysis. PLoS One. 2014 Jul 8;9(7):e101615.

[ix] Abdel-Hakim AM, Habib EI, El-Feel AS et al. Holmium laser enucleation of the prostate: initial report of the first 230 Egyptian cases performed in a single center. Urology. 2010 Aug;76(2):448-52.

Li S, Zeng XT, Ruan XL et al. Holmium laser enucleation versus transurethral resection in patients with benign prostate hyperplasia: an updated systematic review with meta-analysis and trial sequential analysis. PLoS One. 2014 Jul 8;9(7):e101615.