AUA: Surgical Management of LUTS due to BPH (2018)

See Original Guidelines Part 1 & Part 2

See CUA Male LUTS/BPH Guidelines 2018

Background

• Prevalence of BPH is 60% at age 60, 80% at age 80
• The enlarged gland has been proposed to contribute to male LUTS via at least 2 routes:
  • Direct BOO/BPO from enlarged tissue (static component)
  • Increased smooth muscle tone and resistance within the enlarged gland (dynamic component).
• The complex of storage symptoms that can occur is often referred to as overactive bladder (OAB). In men, OAB may be the result of primary detrusor overactivity/underactivity or develop secondary to the obstruction induced by BPE and BPO.

Evaluation and preoperative testing

• Recommended initial evaluation of patients presenting with bothersome LUTS possibly attributed to BPH (3):
  1. History and physical exam
  2. Urinalysis
  3. AUA-Symptom Index (AUA-SI) [For CUA, mandatory: H+P, U/A; recommended: questionnaire, PSA]
• Optional:
  • Post-void residual (PVR)
    • There is no universally accepted definition of a clinically significant residual urine volume
  • Uroflowmetry
    • The generally accepted minimum threshold voided volume for adequate interpretation is 150 cc
    • The likelihood of obstruction is greatly increased in patients with a Qmax <10mL/s.
  • Pressure flow studies
• Prior to surgery for LUTS attributed to BPH
  • Recommended:
    • PVR [not part of CUA guidelines]
  • Optional:
    • Assessment of prostate size and shape via abdominal or transrectal ultrasound, or cystoscopy, or by pre-existing cross- sectional imaging (MRI/CT).
      • Intravesical protrusion (e.g., intravesical lobe, ball-valving middle lobe) and presence of urodynamic obstruction predict poor outcomes from watchful waiting and most medical therapies.
      • Prostate size may direct the clinician as to which intervention to consider. Currently available minimally-invasive surgical therapies, such as water vapor thermal therapy and prostatic Urolift are only indicated for prostates between 30-80g, and some very large prostates should be treated with open, laparoscopic, or robotically assisted laparoscopic enucleation.
      • DRE is unreliable in estimating prostate size and PSA is only a rough indicator of prostate size
    • Uroflowmetry
• Prior to surgical intervention for LUTS attributed to BPH when diagnostic uncertainty exists
  • Optional:
    • Pressure flow studies

First-line: lifestyle changes

• See CUA Male LUTS/BPH Guidelines 2018

Second-line: pharmacological management

• See Pharmalogical Managements of LUTS Chapter Notes, CUA Male LUTS/BPH Guidelines 2018

Third-line: Surgical therapy        

• Patients should be counselled about the sexual side effects of any surgical intervention and should be made aware that surgical treatment can cause ejaculatory dysfunction (EjD) and may worsen ED.
• Indications (same as CUA):
  1. Renal insufficiency secondary to BPH
  2. Refractory urinary retention secondary to BPH
  3. Recurrent urinary tract infections (UTIs)
  4. Recurrent bladder stones
  5. Gross hematuria due to BPH
  6. LUTS attributed to BPH refractory to and/or unwilling to use other therapies
  • In these clinical scenarios, conservative management including lifestyle changes or pharmacological management are either inadequate or inappropriate
• An asymptomatic bladder diverticulum is not an indication for surgery; however, evaluation for the presence of BOO should be considered.

UrologySchool.com summary

• Size considerations:
  • TURP/TUVP/PVP/HOLEP/TUNA: not explicitly stated
  • Simple prostatectomy: large prostate
  • TUIP: <30g
  • Urolift/water ablation: <80g
• Ejaculatory preserving (4): PUL, water vapor thermal therapy, TUIP

TURP

• Should be offered as a treatment option
• Clinicians may use a monopolar or bipolar approach to TURP, depending on their expertise with these techniques
  • No differences in efficacy
  • Bipolar TURP associated with reduced risk of hyponatremia and TUR syndrome allowing for longer resection time and thereby treatment of larger glands compared to monopolar TURP

Simple prostatectomy (open, laparoscopic or robotic assisted prostatectomy)

• Should be offered as a treatment option for patients with large prostates [CUA recommends simple prostatectomy as first-line >80cc), depending on the expertise of the surgeon
  • Large is a relative term as some providers have excellent results utilizing transurethral approaches (e.g., bipolar TURP, HoLEP) in prostates > 60g.

Transurethral incision of the prostate (TUIP)

• Should be offered as a treatment option for patients with prostates ≤30g
• Associated with lower risk of retrograde ejaculation compared to TURP

Transurethral vaporization of the prostate (TUVP)

• Bipolar TUVP may be offered as a treatment option
• Can utilize a variety of energy delivery surfaces including amongst others: a spherical rolling electrode (rollerball), grooved roller electrode (vaportrode), or hemi-spherical mushroom electrode (button).
• Typically uses saline and is powered with a bipolar energy source.
  • Bipolar TUVP has similar efficacy to bipolar TURP; however, need for transfusion is lower for TUVP

Photoselective vaporization of the prostate (PVP)

• Should be considered as a treatment option
• A 120W or 180W platform should be used
• The procedure is generally performed with saline irrigation, eliminating the possibility of TUR syndrome
• Men considering PVP should be informed of the generally similar outcomes with regards to symptomatic, urinary improvement in LUTS/BPH and complication rates between TURP and PVP. However, PVP may be more efficacious for smaller volume prostates
• Other laser technologies (Nd:YAG, Diode) are considered investigational or have results that were not considered sufficient or safe to recommend them for routine use

Prostate urethral lift (PUL)

• PUL should be considered as a treatment option for prostates <80g and absence of an obstructive middle lobe; however, patients should be informed that symptom reduction and flow rate improvement is less significant compared to TURP.
  • PUL works by altering prostatic anatomy without ablating tissue; the T-shaped sutures are placed [anterolaterally] such that there is sufficient tension on them thus pulling the lumen of the prostatic urethra towards the capsule, compressing the tissue, and opening the prostatic urethral lumen.
• PUL may be offered to eligible patients concerned with erectile and ejaculatory function for the treatment of with LUTS attributed to BPH.
  • In the BPH6 Study, no participants in the PUL group experienced adverse events related to sexual function. In comparison, ED and RE occurred in 9% and 20%, respectively, of the participants in the TURP group.

Transurethral microwave therapy (TUMT)

• TUMT may be offered as a treatment option; however, patients should be informed that surgical retreatment rates are higher compared to TURP

Water vapor thermal therapy

• Water vapor thermal therapy may be offered as a treatment option for prostates <80g; however, patients should be informed that evidence of efficacy, including longer-term retreatment rates, remains limited
• Water vapor thermal therapy may be offered to eligible patients who desire preservation of erectile and ejaculatory function

Transurethral needle ablation (TUNA)

• TUNA is not recommended for the treatment of LUTS attributed to BPH

Laser enucleation

• Holmium laser enucleation of the prostate (HoLEP) or thulium laser enucleation of the prostate (ThuLEP), depending on their expertise of the surgeon, should be considered as prostate size-independent suitable treatment options
  • HoLEP and ThuLEP have similar efficacy when compared to TURP; however, blood transfusion risk is lower with HoLEP and ThuLEP compared to TURP

Prostate artery embolization

• Not recommended for the treatment of LUTS attributed to BPH outside the context of a clinical trial

Medically complicated patients

• PVP, HoLEP, and ThuLEP should be considered in patients who are at higher risk of bleeding, such as those on anti-coagulation drugs
  • Overall, Greenlight PVP with the 180W laser unit on patients therapeutic on heparin, warfarin, clopidogrel, dipyridamole, or new oral anticoagulant drugs revealed good safety outcomes.