Surgical treatment for Benign Prostatic Hyperplasia of the Prostate

Surgeries for BPH, with the exception of minimally invasive treatments and transurethral prostatic incision, aim to remove the prostatic adenoma and leave the prostatic capsule intact. We can imagine that the prostate is an orange and BPH surgery consists of removing the flesh of the orange while keeping the peel as undamaged as possible, without damaging important structures around the prostate capsule such as the nerves that allow erections or the muscles that prevent urine from escaping. To better understand this concept we spoke with Dr. Schwartzmann, a specialist in Urology.

What are the most common endoscopic techniques?

Endoscopic surgery is surgery performed through natural orifices or through a small incision. In urology and in the case of prostate surgery, this term is used to refer to operating through the urethra with instruments specially designed for this purpose. The most frequent endoscopic prostate surgery techniques are:

  • Transurethral resection of the prostate: It consists of resecting or cutting small fragments of prostate from the prostatic urethra to the prostatic capsule. The cuts are made with a loop with electricity that also serves to coagulate and control bleeding. The main immediate complications are bleeding (which may require a blood transfusion), not being able to urinate after surgery (acute urinary retention) or urinary tract infection, although these complications usually occur in less than 5% of cases. Possible long-term complications include narrowing of the urethra which can make urination difficult and urinary incontinence, but they occur in about 3% of cases.
  • Transurethral prostatic incision: Consists of making an incision in the neck of the bladder and prostate. In this technique no prostate tissue is removed. It is indicated especially for prostates of less than 30 ml and that do not have a middle lobe.
  • Prostatic Vaporization: Consists of vaporizing the prostate tissue. It can be performed either with electricity or with a laser. Prostatic vaporization presents less bleeding during surgery and less hospitalization time. On the other hand, it has been observed that prostatic vaporization has a longer surgery time and a higher risk of needing a new surgery in the future.
  • Endoscopic Prostatic Enucleation: It consists of separating the prostatic capsule from the prostatic adenoma, that is to say, separating the orange pulp from the orange peel, in 1 or 2 complete pieces, and then leaving them inside the bladder and extracting them with an apparatus called a morcellator that suctions and cuts the prostatic tissue. When comparing the results of endoscopic enucleation with open surgery (which we will see later) it is observed that they are similar in terms of results, with endoscopic surgery being less aggressive and therefore with a faster recovery and less bleeding. The main disadvantage of endoscopic enucleation is that it is a complex technique and difficult to learn.

What does open laparoscopic surgery consist of?

There are two types of open surgery:

  • Simple Open Prostatectomy or Adenomectomy: it is the oldest and most aggressive type of surgery, since it presents more bleeding, a larger wound and more hospitalization time. However, it is an effective method with very good long-term results. It consists of making an incision in the lower abdomen to access the prostate, then, through an incision in the bladder or in the prostate capsule, the prostatic adenoma is removed. It is the treatment of choice for prostates > 80 ml if the equipment or expertise to perform an endoscopic enucleation is not available.
  • Simple Laparoscopic or Robotic Prostatectomy: these are relatively new techniques. The available studies show functional results similar to open prostatectomy, with the advantage of less bleeding and less time in the hospital and less time carrying a bladder catheter.
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What are minimally invasive procedures?

Minimally invasive techniques are treatments that allow improving urine flow with shorter and usually less aggressive interventions than conventional surgery. They have the advantage of preserving ejaculation in most cases. On the other hand, by removing less prostate tissue, minimally invasive techniques may have a less lasting effect over time.

What are minimally invasive procedures?

The most commonly used in our environment and those for which there is the most scientific evidence are:

  • Rezüm: This consists of the injection of water vapor into the prostate. The energy released by the steam produces a reduction in the size of the prostate. It has the advantage that it can be performed under local anesthesia, outside the operating room and the patient goes home the same day. It has the disadvantage that, after the procedure, it is necessary to wear a bladder catheter for 3 to 5 days.
  • Prostatic urethral lift: Consists of applying a permanent suture implant that compresses the prostatic lateral lobes. The functional results are worse than those of TURP and it is more frequent that the patient requires a new surgery after 5 years, but it does not affect ejaculation and recovery after the procedure is faster.
  • iTIND: It consists of placing a device that expands inside the prostatic urethra and bladder neck, putting pressure on these areas for 5 days, after which it is removed. It would appear to be effective, but we are awaiting more robust studies to evaluate its effectiveness.
  • Aquablation: It consists of applying a jet of serum at high speed that destroys prostate tissue. It has the advantage of reducing surgery time and of having a greater preservation of ejaculation than TURP. However, it requires general anesthesia and presents some problems in controlling bleeding, with a greater need for transfusion than TURP in the available studies.

Whenever we talk about surgical techniques we must always remember the importance of the experience of a surgical team or a surgeon specialized in a particular technique. The sub-specialization of medicine and the development of different technologies makes that more and more surgeons sub-specialize in one technique or group of surgical techniques and dedicate their medical activity mainly to this subtype of surgeries.