Determine suitable BPH treatment options

Overview by
Professor Richard Hindley
Consultant Urological Surgeon
Hampshire Hospitals NHS Foundation Trust

Chair of the Get It Right First Time (GIRFT)
BPH Academy
National Clinical Improvement Program

Minimally Invasive treatments – which one may be appropriate for you?

(Robotic and Open prostatectomy are included for completeness)

*We recommend you read the BPH and Information Collection pages in the first instance.

For larger volume prostates:

The chart gives a guide to the treatments that are suitable depending on the prostate volume and the severity of the symptoms.

For mild symptoms (IPSS symptom score 7 or less), then lifestyle changes, pelvic floor exercises and bladder training are the recommended treatment. Should improvements not be forthcoming, then treatment with medication is usually the next option. However some patients taking medication experience side effects, for example, headaches, dizziness as well as disturbing changes in sexual function including dry ejaculation and erectile dysfunction.  (See the treatment of BPH -Medication page).

Please note:

* Aquablation is water based and does not cauterize tissue. Therefore it causes some bleeding and requires an overnight stay in hospital. However, It is quicker to perform than HoLEP

** Urolift is not ideal if the middle (median) lobe is involved unless performed by an experienced expert surgeon, when outcomes mirror that of Rezum.

*** iTind is not suitable for men with an obstructive median lobe or previous prostate surgery but is suitable for prostates up to 60cc in volume

There are then a set of questions that need to be answered to narrow down the best options.

Is Fertility Important?
(Avoidance of dry or retrograde ejaculation where semen goes into the bladder rather than being ejected out of the penis.)

Incidence of dry or retrograde (backwards) ejaculation:

• “>0% with Urolift, iTind and PAE
• 4% with Echolaser
• 5% with Rezum
• 7% with Aquablation
• 45% with HoLEP, GreenLEP and Greenlight laser
• 45%+ with TURP
• 75%+ with Open Prostatectomy

So for moderate symptoms and a prostate volume of less than 100ml, REZUM, Urolift and Echolaser are the best treatment options.

Is Erectile Function Important?

• With PAE, 60% of patients report an improvement in erectile function.

Incidence of erectile dysfunction with other treatments is as follows:

• 0% with Urolift, iTind and Echolaser
• 1% with REZUM and Aquablation
• 1-2% with Greenlight laser, GreenLEP and HoLEP
• 5 – 10% with TURP
• 65%+ with Open Prostatectomy, 40% with robotic surgery with nerve sparing

So for moderate symptoms and a prostate volume of less than 100ml, Rezum, Urolift and Echolaser are the best treatment options. For larger prostates Greenlight, or HoLEP or Echolaser for very large prostates are the low risk options. For the elderly or frail  with potential risks from anaesthesia, PAE is a good option as it is very low risk as well as being a good treatment for moderately large prostates.

The other factor you may want to consider are recurrence rates for BPH symptoms.
They are as follows:

• 10% recurrence after 10 years for Greenlight laser, HoLEP, GreenLEP and TURP
• 5-10% recurrence after 5 years for REZUM (in the Pivotal 2 study it was 4.4%)
• 12.5% recurrence after 5 years for Urolift
• 20% recurrence after 1 year for PAE. however the procedure can be repeated
• 5% after 2 years with Echolaser. As with PAE, the procedure can be repeated
• <5% recurrance at 2 years for Aquablation but will probably mirror TURP and Greenlight laser at 10 years