Patient Case Introduction
When helping patients with LUTS secondary to prostate enlargement choose the right treatment there are many factors that should be considered.
Published algorithms, such as this one from the article by Kaplan and Rieken (Rieken, 2018) help to identify one or more suitable treatments based on high risk of bleeding or complications, prostate size and desire for ongoing antegrade ejaculation.
Fig.1 - Decision flow chart. LUTS = lower urinary tract symptoms; EEP = endoscopic enucleation of the prostate; PVP = photoselective vaporization of the prostate; TURP = transurethral resection of the prostate.
Rieken M., Kaplan S. A., Enucleation, Vaporization, and Resection: How to Choose the Best Surgical Treatment Option for a Patient with Male Lower Urinary Tract Symptoms, European Urology Focus, 2018 Jan.
While treatment algorithms are a good way to consider a range of possible treatments, they may still offer more than one appropriate treatment option.
Where this is the case, the decision is a shared one, between the urologist and the patient, relying on the urologist’s experience and the patients’ perceptions of the therapies and his individual desire for certain treatment outcomes or the avoidance of some possible adverse events.
We asked three urologists how they would counsel and discuss treatment options with three different men, all of whom have symptomatic prostate enlargement.
The three urologists we invited to share their opinions on how to manage the three cases all have a special interest in the treatment of male LUTS and have been instrumental in the introduction of techniques that provide alternatives to monopolar and bipolar transurethral resection. In their own practice few men choose TURP. Whilst three of them offer a number of different treatments options, they don’t offer all available therapies for BPE/BPH, this may mean that treatment options with which they are less personally familiar are not discussed in great depth.
When considering each case, we asked them to think about the following factors:
- Describe how you would most likely treat the patient (in accordance with your local practise, or in consideration to any clinical guidelines)
- Highlight the key elements of the discussion you would have with the patient in order to determine his outcome priorities and risk tolerance
- Finally, could you recommend which technology (based on your own practise) you would offer to the patient and why this offers benefits to the patient.
First patient case
A 68-year-old man with an IPSS score of 21, after a digital rectal examination (DRE) his prostate size was established at 60g. He suffers from atrial fibrillation and hypertension and takes warfarin and coumadin for stroke prevention. Moreover, this patient suffers from erectile dysfunction. He is currently not sexually active.
The key question is relating to his sexual dysfunction. Although he may not be sexually active, any chance of retaining or improving his erectile capabilities may still be paramount. Usually having explained the comparative likelihood of problems with the laser options, a patient will select a laser therapy because of the other additional benefits (evidence of safety for PVP in higher risk patients for example). Therefore, I would most likely treat this patient with a GreenLightTM PVP in accordance with my practice. Given his problems with ED and his increased bleeding risk (and possible hospital readmission), I would anticipate that the modest increased risk of sexual dysfunction with a PVP vs RezūmTM or Urolift® would not put him off proceeding with a laser therapy. I would favour PVP over HoLEP or TURP because of the lower risk of incontinence as well as the reduced bleeding tendency. 1
This patient is a good example for our management of LUTS especially in regard to nocturia, research tells me that in men with AF and hypertension, common indications for anticoagulation, there is an association with Obstructive Sleep Apnea Syndrome which itself is a cause of nocturia. I would discuss this with him and recommend sleep-studies, prior to consideration of any surgical option for his LUTS.
Once this evaluation has been made, we must treat his other LUTS on their own merits and according to his priorities. He isn’t sexually active, but I would still ask him about the importance of ejaculatory function, if this also isn’t his priority then we need to consider surgical options that are safe for anticoagulated men.
In my practice, I prefer to use GreenLight PVP for such men in whom stopping oral anticoagulants is not always feasible. GreenLight has demonstrated good safety in relation to post-operative bleeding2 whereas Holmium laser being associated with a 5-10% risk of bleeding requiring transfusion in the literature.3,4
Going by prostate volume alone this man would theoretically be suitable for any MIT, TURP and HoLEP. The key considerations here though are the fact he is anti-coagulated (i.e. TURP not recommended) and is not sexually active (i.e. MITs that preserve sexual function are not so relevant given they provide less symptom improvement than surgical options). Due to his anticoagulation and comorbidities the fewer procedures he needs to have the better and therefore durability is valuable. I would recommend HoLEP as it is suitable for use in men who are anticoagulated (although I would ask him to stop his warfarin 5 days before surgery and restart it the day after, as long as his GP/physician was in agreement), HoLEP is also likely to improve his symptoms to a greater degree than any other BPH treatment, and has a durability of outcome as good as open prostatectomy.5
BPH specialist panel:
Richard Hindley was an early adopter of GreenLight Laser Vaporization of the prostate and has performed over 1000 procedures. He performs both classic PVP and Anatomical Vaporization and is happy to treat gland volumes up to 150mls. He also offers Urolift and was the first UK surgeon to perform Rezūm in 2017 and has already performed over 500 procedures. For the small proportion of men with very large glands requiring enucleation he will refer on to an expert colleague. He publishes widely on BPH and prostate cancer diagnostics and focal therapy. He is an advocate for patient choice in the treatment of male LUTS.
Vincent Misrai is a pioneer of anatomical enucleation of the prostate using GreenLight laser, having performed more than 1000 procedures. In his practice he also offers Aquablation. Academically he publishes on BPH topics, with special attention to outcomes and learning curve assessments of each technology.
Tevita Aho developed the Holmium Laser Enucleation of the Prostate service in Cambridge, UK, after training with Peter Gilling and Mark Fraundorfer in New Zealand. He has treated more than 2,000 men with this modality, he also offers Urolift and will begin to offer Rezūm. He has done 10 Aquablation cases as part of the first randomized study (WATER study). Academically he publishes widely on Anatomical Endoscopic Enucleation of the Prostate (AEEP), believing firmly that “enucleation is enucleation is enucleation”. He is a pioneer in approaching patient choice in treatment of male LUTS.
AEEP – Anatomical Endoscopic Enucleation of the Prostate
AF – Atrial Fibrillation
OSP – Open Simple Prostatectomy
PAE – Prostate Artery Embolization
PVP – Photoselective Vaporization of the Prostate - standard GreenLight XPS vaporization of the prostate
TURP – Transurethral Resection of the Prostate
PSA –Prostate-Specific Antigen
LUTS – Lower Urinary Tract Symptoms
MIT – Minimally Invasive Therapy
TRUS – Transrectal Ultrasound
1. Thomas, J.A. et al., 2015. A Multicenter Randomized Noninferiority Trial Comparing GreenLight-XPS Laser Vaporization of the Prostate and Transurethral Resection of the Prostate for the Treatment of Benign Prostatic Obstruction: Two-yr Outcomes of the GOLIATH Study. European Urology, pp.1–9.] and Cornu, J.-N. et al., 2015. A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update. European Urology, 67(6), pp.1066–1096.
Direct comparison with HoLEP has not been made as yet in an RCT therefore comparison is made on the basis of transfusion rates in unrelated trials.
2. Sachs B, Misrai V, Tabatabaei S, Woo HH. Multicenter experience with photoselective vaporization of the prostate on men taking novel oral anticoagulants. Asian J Urol 2019
3. Becker B, Netsch C, Hansen J, Böhme A, Gross AJ, Zacharias M, et al. Perioperative Safety in Patient Under Oral Anticoagulation During Holmium Laser Enucleation of the Prostate. J Endourol 2019; 33:219–24
4. Bishop CV, Liddell H, Ischia J, Paul E, Appu S, Frydenberg M, et al. Holmium Laser Enucleation of the Prostate: Comparison of Immediate Postoperative Outcomes in Patients with and without Antithrombotic Therapy. Curr Urol 2013; 7:28–33
5. Jones, P. e. (2016.). Holmium laser enucleation versus simple prostatectomy for treating large prostates: Results of a systematic review and meta-analysis. ARAB JOURNAL OF UROLOGY, 14(1), 14(1), 50-58.