Surgical treatment of benign prostatic hyperplasia.
1. Purpose of surgical treatment.
Benign prostatic hyperplasia is a progressive disease and some patients eventually require surgical treatment to relieve lower urinary tract symptoms and their impact on quality of life and complications.
2. Indications for surgical treatment.
Patients with severe BPH or those whose lower urinary tract symptoms have significantly affected their quality of life may opt for surgical treatment [1,2], especially in patients who have had poor results with medication or refuse to receive medication.
Surgical treatment is recommended when BPH leads to the following complications.
1, recurrent urinary retention (inability to urinate after at least one extubation or two urinary retention)
2.Recurrent hematuria and ineffective treatment with 5α reductase inhibitors
3.Recurrent urinary tract infection
4.Bladder stone
5, secondary upper urinary tract hydrocele (with or without renal impairment)
Patients with benign prostatic hyperplasia combined with large bladder diverticula, inguinal hernia, severe hemorrhoids or prolapse, and those who are clinically judged to be difficult to achieve therapeutic effect without relieving lower urinary tract obstruction should be considered for surgical treatment.
The measurement of residual urine volume has some reference value for the degree of lower urinary tract obstruction due to BPH, but because of the instability of repeated measurements, inter-individual variability, and the inability to distinguish lower urinary tract obstruction from bladder contraction weakness, it is not considered possible to determine the upper limit of residual urine volume that can be used as a surgical guideline. However, surgical treatment should be considered in patients with BPH who have significantly increased residual urine to the point of overflow incontinence.
The choice of treatment by the urologist should respect the patient’s wishes. The choice of surgical treatment should take into account the surgeon’s personal experience, the patient’s opinion, the size of the prostate, as well as the patient’s concomitant disease and general condition.
3. Surgical treatment modalities.
The surgical treatment of benign prostatic hyperplasia includes general surgical treatment, laser treatment and other treatment modalities. The effect of BPH treatment is mainly reflected in the change in the patient’s subjective symptoms (e.g. I-PSS score) and objective indicators (e.g. maximum urinary flow rate). The evaluation of treatment methods, on the other hand, should take into account a combination of factors such as treatment effects, complications, and socioeconomic conditions.
(1) General surgery.
The classical surgical methods include Transurethral Resection of the Prostate (TURP), Transurethral Incision of the Prostate (TURP), and open prostate removal. Currently, TURP remains the “gold standard” of treatment for BPH. Various surgical approaches are close or similar to TURP, but the scope of application and complications vary. As an alternative to TURP or TUIP, transurethral electrovaporization of the prostate (TUVP) and transurethral electrocautery of the prostate (PKRP) are now also used in surgery. Treatment.
All of these treatments have been shown to improve lower urinary tract symptoms in more than 70% of patients with BPH.
①TURP is mainly indicated for the treatment of BPH patients with prostate volume below 80 ml, and the limit of prostate volume can be relaxed by skilled operators. The incidence of dilated blood volume and dilutional hyponatremia (transurethral resection syndrome, TUR-Syndrome, TURS) due to excessive absorption of flushing fluid is about 2%, with risk factors such as high intraoperative bleeding, long operative time and large prostate volume [1,2].The risk of transurethral resection syndrome increases significantly with prolonged TURP operation time. The chances of needing blood transfusion are about 2-5%. The incidence of various postoperative complications [1,2-6]: urinary incontinence about 1-2, 2%, retrograde ejaculation about 65-70%, bladder neck contracture about 4%. Urethral stricture is about 3,8%.
② TUIP is indicated for patients with prostate volume less than 30 ml and without middle lobe hyperplasia. the degree of improvement of patients’ lower urinary tract symptoms after TUIP treatment is similar to that of TURP [3,6]. Complications were less frequent, the risk of bleeding and the need for blood transfusion was reduced, the incidence of retrograde ejaculation was lower, and the duration of the procedure and hospital stay was shorter compared to TURP. However, the rate of distant recurrence is higher than that of TURP [3].
(iii) Open prostatectomy is mainly suitable for patients with prostate volume greater than 80 ml, especially those with combined bladder stones, or combined bladder diverticula requiring surgery together [4,5]. The most commonly used procedures are suprapubic prostatectomy and retropubic prostatectomy. The incidence of postoperative complications is higher than that of TURP [4,5]: urinary incontinence about 1%, retrograde ejaculation about 80%, bladder neck contracture about 1,8%, urethral stricture about 2,6%. The effect on erectile function may not be related to the procedure.
④TUVP is indicated for BPH patients with poor coagulation and small prostate volume. It is an alternative to TUIP or TURP and has a better hemostatic effect compared to TURP [6]. The long-term complications are similar to those of TURP.
⑤ TUPKP is a transurethral resection of the prostate using a plasma bipolar electrosurgical system and performed in a similar manner to the monopolar TURP. Saline is used as the intraoperative irrigation fluid. Intraoperative bleeding and the occurrence of TURS are reduced [7,6].
(2) Laser therapy.
Laser treatment of the prostate is aimed at relieving obstruction through tissue vaporization or delayed tissue loss after coagulative necrosis of the tissue. Modalities that have shown positive efficacy include transurethral holmium laser prostate enucleation, transurethral laser vaporization of the prostate, and transurethral laser coagulation of the prostate.
Transurethral Holmium Laser Resection/Enucleation (HOLRP): the peak energy produced by the Ho:YAG laser leads to vaporization of the tissue and precise and effective removal of the prostate tissue [9]. Postoperative dyspareunia is the most common complication with an incidence of approximately 10% [9]. retrograde ejaculation occurs in 75-80% of patients and no postoperative erectile dysfunction has been reported [9].
② Transurethral Laser Vaporization (TLV) is similar to electroprostatic vaporization of the prostate, in which laser energy is used to vaporize the prostate tissue for surgical treatment. Short-term improvements in IPSS scores, urinary flow rate, and QOL index are comparable to TURP [10]. The incidence of postoperative urinary retention requiring catheterization is higher than that of TURP [10]. There was no postoperative pathological tissue. Long-term efficacy awaits further study.
(iii) Transurethral Laser coagulation, an effective surgical procedure for BPH [11,12]. A distance of approximately 2 mm is maintained between the fiber tip and the prostate tissue, and the energy density is sufficient to coagulate the tissue but not vaporize it. The coagulated tissue eventually necroses and falls off, thus reducing obstruction. Advantages include its simplicity, risk of bleeding, and low water absorption rate. Using meta-analysis, the incidence of urinary retention and urinary tract irritation requiring catheterization after transurethral laser coagulation of the prostate was found to be 21% and 66%, respectively, significantly higher than the 5% and 15% rates for TURP.
(3) Other treatments.
① Transurethral Microwave Therapy (TUMT), which can partially resolve the urinary flow rate and LUTS symptoms in patients with BPH. It is suitable for patients who do not respond to medication (or are unwilling to take long-term medication) and are unwilling to undergo surgery, and for high-risk patients with recurrent urinary retention who cannot undergo surgery.
The principles of various microwave therapies are similar. Above 45°C is hyperthermia. Low-temperature therapy is ineffective and not recommended. Its 5-year re-treatment rate is as high as 84,4%; among them, the drug re-treatment rate is 46,7% and the surgical re-treatment rate is 37,7% [13].
② Transurethral Needle Ablation (TUNA), is a simple and safe treatment method. It is indicated for high-risk patients who cannot undergo surgical procedures and is not recommended as first-line treatment for general patients. The postoperative improvement in lower urinary tract symptoms is about 50-60%, the mean increase in maximum urinary flow rate is about 40-70%, and the need to receive TURP at 3 years is about 20% [14]. Long-term outcomes need to be further observed.
(iii) Prostatic stents (Stents) are metal (or polyurethane) devices placed endoscopically in the urethra of the prostate [15]. It can relieve lower urinary tract symptoms due to BPH. It is only indicated as an alternative treatment to catheterization in high-risk patients with recurrent urinary retention who cannot undergo surgical procedures. Common complications include stent migration and calcification, stent occlusion, infection, and chronic pain [15].
There is no clear evidence to support the use of high-energy focused hyperplasia, chemical ablation therapy with prostate alcohol injection as an effective option for the treatment of benign prostatic hyperplasia.