Over the past several years, urologists and men suffering from BPH have been introduced to a growing number of alternatives for managing this disease. In addition to the gold-standard transurethral resection of the prostate (TURP) and the simple prostatectomy (for larger prostates), urologists can now present men with symptomatic bladder outlet obstruction a variety of newer management options including UroLift and Rezum for prostate volumes 30-80 grams. In clinical practice, some urologists are also performing these procedures in men with prostates >80 grams.
Other treatment options include photoselective vaporization of the prostate, holmium laser enucleation of the prostate (HoLEP), and variations of the more conventional treatments, such as the bipolar/button TURP and robot-assisted laparoscopic simple prostatectomy.
Each of these treatments has shared and individual risks and benefits that must be weighed and, of course, compared to the more conservative alternatives when considering “what to do next” in the personalized care of men with BPH requiring or desiring intervention. This article focuses on Aquablation, a newer approach to treatment involving the use of robotically controlled waterjet ablation for prostate tissue removal.
Deciding on surgery: Factors to weigh
BPH is a prevalent disease affecting approximately 50% of men age 60 years and older and up to 90% of men after the age of 85. Many factors must be weighed when considering the surgical management of BPH, including whether such treatment is necessary or whether more conservative options can be continued or initiated instead. If the decision to pursue surgery is made, the size and shape of the prostate play an important role in selecting the appropriate therapy to not only optimize efficacy but also minimize complications.
It’s important for patients to know that each individual’s prostate can have a different size and shape. The larger a man’s prostate, the longer it will take the surgeon to resect the obstructive tissue. In terms of shape, while every prostate has two lateral lobes, some men develop an additional median lobe that protrudes into the bladder and increases the complexity of the procedure. Although we know that appropriately removing the obstructive tissue provides patients with BPH effective symptom relief, prostates with increased size and complex shape can lead to suboptimal outcomes, longer operative times, and higher risks during surgery.
Additionally, more and more patients with BPH are asking for less invasive procedures expecting comparable outcomes to the more classic alternatives with less side effects and a more rapid return to their preoperative daily activities.
Over the course of my career, I have predominantly performed bipolar/button TURP, as my practice and referral patterns seemingly led themselves to the management of larger prostates (often with large and complex median lobes) in men with moderate to severe bladder outlet obstruction symptoms. In men with prostates <80 grams, I also perform and discuss the UroLift procedure as an option to consider.