Surgery for benign prostatic hyperplasia

Minimally invasive therapies

Prostate laser surgery

• VLAP technique involving the with contact on the prostatic tissue.
• Photoselective Vaporisation of the Prostate. A laser is used to melt away excess prostate tissue and enlarge the urinary channel. A high-power 180-watt 532 nm wavelength laser with a 650-micrometre laser fiber is used. This fiber has an internal reflection with a 70-degree deflecting angle. It is used to vaporize the tissue to the prostatic capsule. GreenLight 532 nm lasers target haemoglobin as the chromophore and typically have a penetration depth of 0.8 mm.
• Holmium Laser Ablation of the Prostate is similar to PVP but uses a different type of laser. HoLAP uses a 550 um disposable side-firing fiber that directs the beam from a high-power 100-watt laser at a 70-degree angle from the fiber axis. The holmium wavelength is 2,140 nm, which falls within the infrared portion of the spectrum and is invisible to the naked eye. Whereas GreenLight relies on haemoglobin as a chromophore, water within the target tissue is the chromophore for Holmium lasers. The penetration depth of Holmium lasers is <0.4 mm, avoiding complications associated with tissue necrosis often found with the deeper penetration and lower peak powers of Nd:YAG lasers used in the 1990s.
• * Holmium Laser Enucleation of the Prostate is used to cut and remove the excess tissue that is blocking the urethra. Another instrument is then used to cut the prostate tissue into small pieces that are easily removed. HoLEP can be an option for men who have a severely enlarged prostate. HoLEP is largely similar to the HoLAP procedure; the main difference is that this procedure is typically performed on larger prostates. Instead of ablating the tissue, the laser cuts a portion of the prostate, which is then cut into smaller pieces and flushed with irrigation fluid. As with the HoLAP procedure, there is little bleeding during or after the procedure. Three 2015 reviews found that HoLEP is superior to TURP in some respects and for some patients.

Non-laser treatments

• Transurethral microwave thermotherapy was originally approved by the United States Food and Drug Administration in 1996, with the first generation system by EDAP Technomed. Since 1996, other companies have received FDA approval for TUMT devices, including Urologix, Dornier, Thermatrix, Celsion, and Prostalund. Multiple clinical studies have been published on TUMT. The general principle underlying all the devices is that a microwave antenna that resides in a urethral catheter is placed in the intraprostatic area of the urethra. The catheter is connected to a control box outside of the patient's body and is energized to emit microwave radiation into the prostate to heat the tissue and cause necrosis. It is a one-time treatment that takes approximately 30 minutes to 1 hour, depending on the system used. It takes approximately 4 to 6 weeks for the damaged tissue to be reabsorbed into the patient's body. Some of the devices incorporate circulating coolant through the treatment area with the intent of preserving the urethra while the microwave energy heats the prostatic tissue surrounding the urethra.
• Transurethral needle ablation operates with a different type of energy, radio frequency energy, but is designed along the same premise as TUMT devices, that the heat the device generates will cause necrosis of the prostatic tissue and shrink the prostate. The TUNA device is inserted into the urethra using a rigid scope much like a cystoscope. The energy is delivered into the prostate using two needles that emerge from the sides of the device, through the urethral wall and into the prostate. The needle-based ablation devices are very effective at heating a localized area to a high enough temperature to cause necrosis. The treatment is typically performed in one session, but may require multiple sticks of the needles depending on the size of the prostate. The most recent American Urological Association Guidelines for the Treatment of BPH from 2018 stated that "TUNA is not recommended for the treatment of LUTS/BPH".

Invasive therapies

• Transurethral resection of the prostate : In general prior to emergence of laser technologies, TURP had been considered the gold standard of prostate interventions for people who require a procedure. This involves removing the prostate by inserting a resectoscope through the urethra. However, after this endoscopic surgery the ejaculations are dry in about 65% of patients, unless a novel, ejaculation preserving, altered technique of TURP is applied.
• Simple prostatectomy can also be offered to men who have large prostates. This can be done by open technique, laparoscopically, or with robotic assistance.

Complications of Prostate Surgery

• Urinary incontinence can happen after prostate surgery, especially stress urinary incontinence. The prostate is located right beneath the bladder, and surrounds the urethral sphincter. Any damage to the sphincter or surrounding muscles and nerves can lead to urinary incontinence. The problem is most severe in the first 6 to 12 months after treatment, but usually resolves on its own within this time. If the problem persists, conservative management is the first line treatment. This includes lifestyle modifications, kegel exercises, and bladder training. Artificial urinary sphincter implantation is considered the gold standard in moderate to severe cases if conservative management fails.
• About 50% of patients who undergo prostatectomy will have some degree of erectile dysfunction. Treatment options include the use of oral drugs, vacuum devices, or a penile implant.

  Other

• Urolift System
• Aquablation therapy
• Prostate steam treatment

• High-intensity focused ultrasound

  General prospects of surgery success