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

'''See Original Guidelines [https://pubmed.ncbi.nlm.nih.gov/34384237/ Part 1] & [https://pubmed.ncbi.nlm.nih.gov/34384236/ 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):'''
*# '''History and physical exam'''
*# '''Urinalysis'''
*# '''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):'''
*# '''Renal insufficiency secondary to BPH'''
*# '''Refractory urinary retention secondary to BPH'''
*# '''Recurrent urinary tract infections (UTIs)'''
*# '''Recurrent bladder stones'''
*# '''Gross hematuria due to BPH'''
*# '''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.