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.
Third patient case
Imagine treating a 68-year-old man, whose prostate size is estimated at 80g after digital rectal examination (DRE). This patient has a PSA of 3.0 ng/ml. His IPSS score is 21. He is sexually active and has no other significant comorbidity.
I would certainly want an accurate size estimation (usually by TRUS) and this would also give me some idea as to the shape of the gland. Whilst he could have a TURP, HoLEP or PVP (or even PAE), it would only be by running through these options, and the relative pro’s and con’s of each that we would arrive at what was the right option for this individual patient. The discussion would need to explore the importance of retaining ejaculatory as well as erectile function post procedure. From experience I would anticipate that one of the MIT would be the chosen procedure, given his age and the fact that he is sexually active, and unless there were concerns regarding having a catheter for a few days then I would favour RezūmTM. I agree with Vincent – volume measurement is key here – particularly so when the estimate is 80ml, as the finger tends to underestimate. Given the favourable PSA density I would not organise an MRI unless there was a high index of suspicion for prostate cancer.
I would want to discuss with the patients a little more about his priorities for treatment – especially balancing the opportunity to retain his ejaculatory function with his desire for complete dis-obstruction and durability of outcome of the surgery. In most cases, I will not rely on digital rectal examination and prefer the anatomical insights from transrectal ultrasound, especially in regard to the presence of a large median lobe, which helps guide some of the treatment options. If he has a substantial median lobe then I would offer an exclusive median lobe vaporization or enucleation, because it is easy to remove the whole median lobe this way and in my hands, this works the best.
If there was no substantial median lobe, then I would discuss RezūmTM, Urolift®, Aquablation, ejaculation sparing PVP (I don’t believe AEEP offers satisfactory durability when performed in an ejaculation sparing manner).
Ultimately, I would help the patient to decide which treatment is best for him based on his desire for maintaining his sexual function, balanced against durability for outcome and requirement for a second procedure, along with how effectively each procedure can relieve his obstructive symptoms.
In my practice, this man’s prostate volume is towards the upper limit for me to consider Urolift, Rezūm and TURP however he is potentially a candidate for any of these procedures and also HoLEP.
The key is to identify what his main treatment objectives are and how he prioritises them. Treatment objectives might include: Degree of symptom improvement, chance of being able to stop any BPH medications, durability, catheter time and length of hospital stay post procedure, incidence and duration of dysuria post procedure, time until return to normal activities post procedure, chance of urinary incontinence and sexual dysfunction, and whether or not tissue is sent for histology.
I would tailor his treatment to his objectives and priorities.
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