What’s the Best Way to Treat Prostate Enlargement?

Since I love animals, the following proverb makes me cringe: “There’s more than one way to skin a cat.” And so, there are many options to treat the annoying urinary symptoms that occur due to an enlarging prostate (BPH — benign prostate hyperplasia).

There is NO best way to treat BPH, and it is of benefit to patients to have choices. Many options are effective, and a good urologist will work with the patient to determine which option works best for the individual (“shared decision making”), depending upon careful consideration of a number of factors.

These decision-making factors include the following:

—The extent and bother of the urinary symptoms

–Prostate size and the nuances of the prostate anatomy

–The presence or absence of prostate tissue within the bladder (intravesical median lobe)

–The presence of concomitant bladder pathology, e.g. bladder stones

–The desire to preserve ejaculation that may be compromised with some medications and many surgical procedures

–Patient tolerance for side effects

–Patient’s anti-coagulation (blood thinner) status

–General health status of the patient

–Patient expectations regarding symptom improvement, re-treatment and failure rates

–Patient’s desire for immediate versus delayed results

–The length of time that the patient is willing to have a catheter after the procedure

–The desire for tissue sampling

–Patient’s preference for an outpatient versus an inpatient procedure

–The skill and experience of the urologist with any given procedure (some of the newer procedures have prolonged learning curves)

–The availability of the required equipment for a particular technique

Nothing irks me more than a urologist who offers one and the same option to every patient. This urologist commonly has a cult-like belief in this one technology and is typically a “darling” of industry — the company that provides the specific equipment needed to perform the technique — and supplements his/her income by enthusiastically advocating and marketing this solitary method with industry sponsored paid talks to other urologists. One size does not fit all!

Simple is Good

I advocate simple solutions before complex and aggressive ones — the “simple is good” philosophy. If simple is ineffective or has intolerable side effects, more complex and aggressive solutions are in order. No one desires to be rushed and pushed into aggressive solutions. To paraphrase my mentor – Dr. Alan Wein – professor of surgery, emeritus chief of urology, co-director of voiding dysfunction program at University of Pennsylvania where I undertook my residency: “Test aggressively to ensure making the proper diagnosis but treat conservatively. Patients will let you know when they are ready for surgery.” This philosophy has served me and my patients well.

Many Ways to Skin the BPH Cat

Watchful Waiting  This is the preferred option for men with mild symptoms or those with more severe symptoms who are not bothered by them. When and if circumstances change, more aggressive management can be offered.

Phytotherapy  Many men desire to try “natural” approaches that may improve urinary symptoms such as plant based herbal therapy: saw palmetto, beta sitosterol, etc.

Medications: Alpha blockers (tamsulosin, alfuzosin, silodosin, etc.) relax muscle tone in the prostate and urethra and can be highly effective in improving symptoms. 5-alpha-reductase inhibitors (finasteride, dutasteride) slowly and gradually shrink the prostate and can reverse the natural history of prostate enlargement while offering other advantages as well. Daily tadalafil (Cialis) relaxes muscle tone within the prostate, similar to alpha blockers. Combined medications that include tamsulosin plus dutasteride (Jalyn) and finasteride plus tadalafil (Entadfi) offer patients the convenience of dual medications in one pill.

MORE INVASIVE TECHNIQUES: Electricity, Implants, Steam, Water Jets, Laser, Robot, etc.

For many years, the TURP (transurethral resection of the prostate), a.k.a. roto-rooter, was the standard of care. Nowadays, there are a multitude of alternative options. Surgical options can be divided into incision, resection, vaporization, enucleation, and robotic techniques. Incision: cutting into the obstructing prostate without removing tissue; resection: removing some of the obstructing prostate tissue; vaporization: like resection but without tissue sampling since the tissue is vaporized; enucleation: separation and removal of the entire benign prostate growth from the capsule of the prostate.

Alternative mechanical techniques include using implants to compress obstructing tissue, steam to destroy prostate tissue, water jets to ablate prostate tissue, and occluding the blood supply to the prostate.

Urolift  – This is a prostate “lift” in which permanent implants are deployed within the prostate to mechanically compress the lateral lobes of the prostate. Although conceptually a brilliant idea, it can only be used for certain very specific prostate anatomies, and I have seen significant side effects including bleeding and large stone formation on the permanent implants. An additional concern is that the implants can compromise future MRI imaging of the prostate.

Rezum  – Radio-frequency energy is used to convert a small volume of water to steam (convective water vapor thermal energy) that is injected within the prostate via a retractable needle under direct visual guidance. Although the needle is placed under direct vision, precisely where the steam travels is uncertain. The prostate tissue that is steamed dies slowly and thus it can take an extended amount of time before symptomatic relief occurs.

Aquablation – This uses direct visualization of the prostate via the cystoscope in combination with ultrasound imaging prior to using a robotic controlled high velocity water jet to ablate the prostate tissue targeted for removal. The procedure is rapid and uniquely image-guided using both cystoscopy and ultrasound; the downside is bleeding that often requires an additional technology to control.

TUIP Transurethral incision of the prostate – This procedure uses electrical energy to make incisions in the bladder neck and prostate to alleviate obstruction.

TURP Transurethral resection of the prostate – This is the historical “gold standard” for treatment of BPH that uses a wire loop attached to electrical current to remove prostate tissue in piecemeal fashion under direct vision. The same technology is used to remove bladder tumors.

TUEP Transurethral electro-vaporization of the prostate – This procedure uses electrical energy under direct vision using a roller ball that vaporizes prostate tissue as it is directed through the prostate.

PVP Photo vaporization of the prostate – This Greenlight procedure has largely supplanted the TURP as a commonly used standard for BPH treatment. Under direct vision, laser energy is used to vaporize obstructing prostate tissue.

HoLEP Holmium laser enucleation of the prostate – Laser energy is used to cut and remove (enucleate) bulky prostate tissue. This tissue is deposited in the bladder and a morcellator is used to suction it out.

RASP Robot-assisted simple prostatectomy – This procedure is reserved for men with very large BPH. The latest technical iteration is an approach via a single trans-vesical (through the bladder) laparoscopic port. The benign prostatic growth is enucleated and removed. This procedure has largely supplanted simple open prostatectomy, the procedure that for many years was the standard approach for management of large prostate glands.

PAE Prostate arterial embolization An interventional radiologist can selectively occlude the prostate arterial supply, resulting in damage to the prostate blood flow and ischemic necrosis (prostate tissue death) with gradual reduction in the volume of the prostate gland. It can be useful for symptomatic patients with large prostates who have significant medical problems. Downsides are patient exposure to a substantial dose of radiation, a prolonged time before symptomatic relief, and a high re-treatment rate.

Bottom Line: Urologists and their patients have many therapeutic options for managing BPH. Choice of management is predicated on careful integration of a numerous factors and shared decision making. Clearly, one size does not fit all.