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.
Second patient case
Imagine treating a 72-year-old man suffering from acute urinary retention. He failed a trial without a catheter (TWOC) on alpha blockers. He has a PSA of 7ng/ml. His prostate size was established at 80g. The patient suffers from type 1 diabetes mellitus.
Assuming the PSA is not on an upward trend or the DRE abnormal (suggestive of cancer), I would not be worried about the PSA given the prostate volume. Given the diagnosis of diabetes and his age it is likely that there may be impaired detrusor function and erectile dysfunction. I would discuss with the patient the need for outflow surgery and the options available. I would want to know if there were any particular patient concerns or issues which we need to address. I would have an exchange with the patient and try and facilitate with regards to decision making.
I would be directing the patient towards a laser treatment and the favoured tool in my toolbox for this would be a GreenLightTM PVP. Depending on the shape of the gland this would be as either a classical or anatomical vaporisation (possibly with vapoenucleation of the median lobe if large). I would make the patient aware of the enucleation techniques and TURP but would caution them on the risk of incontinence and ED post-surgery with these options.1 The history of type 1 diabetes would push me more towards recommending a technique which is better at disobstructing than the MIT options.2 If having counselled him as above he was still reluctant to proceed with a laser therapy, I would with caution offer him the Rezūm procedure, however he would need to be aware of the disadvantages of a more minimally invasive option. The infection risk might also be higher given the diagnosis and presence of an indwelling catheter. Hence, I would recommend a PVP. I would not feel the need with this gland size to refer on for AEEP unless the patient wished to pursue this further. However, if the waiting list was prohibitively long, a discussion would have to be had about this and the MIT options which wouldn’t require an inpatient bed.
The priority in this patient is to relieve his bladder outflow obstruction. According to EAU guidelines3 (EAU Guidelines Office, 2018), for an 80ml prostate gland, we could offer OSP, AEEP or Vaporization, e.g. Anatomical PVP.
His PSA is relatively high, and we should consider whether he should be investigated for prostate cancer prior to treatment of his LUTS or whether a surgical specimen should be taken for analysis during his prostate surgery for LUTS. If we decide that prostate biopsy is not the correct course of action and which to have tissue for examination from his BPH surgery, then OSP or AEEP are the best options, given that Urolift for instance may impair subsequent MRI imaging due to artefact4 and in general vaporization does not provide a tissue specimen.
In this patient, avoiding an open surgical procedure due to issues of wound healing or risk of surgical site infection due to his diabetes would be preferred and therefore I would recommend AEEP.
This man has refractory urinary retention despite a trial of Tamsulosin. He has a large prostate which although within the size recommendations for MITs such as Rezūm and Urolift®, I feel it would be better treated with another option. PAE has not been well studied yet in terms of treating urinary retention and neither have Urolift or Rezūm.
In addition to bladder outlet obstruction due to BPH, he might also have a degree of bladder hypocontractility as a consequence of his diabetes. This might decrease the chance of becoming catheter free with all the MITs and TURP but is not a predictor of reduced effectiveness for HoLEP.
Acute urinary retention is an unpleasant medical emergency for those who experience it and most men dislike catheters. If this man’s main priorities are to be freed of his catheter and to have the best likelihood that he would never go back in to urinary retention or require any BPH medication in future, (and if these considerations are of greater priority to him than preserving ejaculatory function), then I would recommend HoLEP. HoLEP would give him the best chance of becoming catheter free and of staying that way. I use Holmium for Anatomical Endoscopic Enucleation of the Prostate (AEEP) as I prefer to use an end fire fibre and I find that my view during the procedure is clearer than with the other energy sources. High power holmium is not necessary to perform an efficient, safe and effective HoLEP. Thulium, GreenLight and diode lasers, and mono and bipolar diathermy can also be used for AEEP. Technique is more important than energy source for AEEP.
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. Transient Incontinence of urine is a recognized and common consequence of anatomical enucleation of the prostate regardless of the energy source used in the technique. Estimates of its frequency range from 1.3-16% (Nam, 2015)]. Unresolving (non-transient) Stress Urinary Incontinence occurs in approximately 1.5% of men undergoing TURP or HoLEP, with some studies showing higher ratesof SUI following TURP There are no strong comparative studies of GreenLight XPS Therapy compared to HoLEP, however the GOLIATH study (Thomas, 2015) showed low rates of non-transitory incontinence in both the TURP and GreenLight arms, it was not possible to differentiate well between OAB and SUI.
Erectile Dysfunction is commonly reported following surgical treatment for BPH, with rates reported of 62-75%
Leong, J. P. (2019). Minimizing Sexual Dysfunction in BPH Surgery. Current Sexual Health Reports, 11(3), 190-200.
2. In a patient with diabetes who may have both bladder outflow obstruction and bladder hypocontractility secondary to diabetic neuropathy the patients best option for getting free of his catheter is likely provided by the treatment option which most satisfactorily reduces outlet obstruction, given that the detrusor hypocontractility is likely to persist post operatively. The literature is full of complaints about the lack of formal urodynamic outcome assessment in BPH surgical studies (men don’t enjoy it much) and therefore high-quality comparative data to identify the most disobstructing technique is not available. A Systematic review of the literature sides with common sense – the more tissue that is removed, the lower the likelihood of recurrence of urinary retention or symptomsAizawa, N. &. (2017). Pathophysiology of the underactive bladder. Investigative and Clinical Urology, 58(Supplement 2), S82-8.
La Taille, d. A. (2018). Conséquences de l'obstruction prostatique sur le fonctionnement vésical, impact de la désobstruction, et prise en charge des récidives après chirurgie. Progres en Urologie, 28, 813-820.
3. EAU Guidelines Office, A. T. (2018). EAU Guidelines. Edn. presented at the EAU Annual Congress Copenhagen 2018. Copenhagen. doi: ISBN 978-94-92671-01-1.
4. Persaud, S. e. (2019). Signal voids created by prostatic urethral lift implants - a reminder in the era of multiparametric MRIs of the prostate. International Journal of Medical Reviews and Case Reports, 1-4.