The updated guidelines focus on appropriate pre-procedure evaluation and novel surgical enhancements, according to Matthew D. Houlihan, DO, and Tobias S. Köhler, MD, MPH.
AUA guidelines on benign prostatic hyperplasia (BPH) have evolved with the constantly changing practice of surgical treatment for BPH. Contemporary guidelines were published in 2010, with a necessary validity review being performed in 2014. The most recent AUA BPH guidelines were issued in 2018 and subsequently amended in 2019 to reflect further advancements in the field.
In 2018, important additions to the AUA BPH guidelines focused on both the appropriate pre-procedural diagnostic evaluation and novel surgical enhancements. Available surgical BPH data from 2007 onward were meticulously analyzed and used to develop the current guidelines. All surgical approaches were compared to transurethral resection of the prostate (TURP) as the gold standard.
The guidelines stress a shared decision-making model in which clinicians discuss key treatment classes (medical, minimally invasive, endourologic, open/robotic) and thoroughly review risks and benefits for all treatment options. Patients can then make an informed decision on their selection, which may necessitate a referral to another clinician.
Updated BPH guidelines focusing on medication updates are anticipated in 2021.
The pendulum has swung from the 1960s era where 50% of a urologist’s surgical day involved TURP to a medication-first approach since the development of these drugs in the 1980s. Data from the Medical Therapy of Prostate Symptoms (MTOPS) trial tell us dual medical therapy is an excellent therapy for some men, as they avoid the potential TURP side effects of incontinence, bleeding, or recalcitrant stricture (N Engl J Med 2003; 349:2387–98).
Medications are excellent if they have minimal side effects, treat the patient’s lower urinary tract symptoms (LUTS) well, and the patient follows up with his medical care provider to monitor for bladder decompensation. Indeed, pharmacotherapy for BPH has decreased the utilization of surgical intervention in the last 2 decades but has also resulted in surgery being performed more often in older patients with larger glands and inherently higher perioperative risk factors, often including active anticoagulation (Curr Urol Rep 2017; 18:72).
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TURP is an excellent therapy but carries the risk of well-known side effects. Patients who undergo surgical intervention earlier for LUTS have greater degrees of improvement than those undergoing late surgical intervention for BPH (J Urol 1998; 160:12–17). With the advent of minimally invasive surgical therapy (MIST), BPH treatments with tolerable side effect profiles, minimal anesthesia requirements, and decreased post-procedural sexual dysfunction, surgical intervention can be considered at an earlier time point for patients with BPH.
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Initial workup for BPH patients with bothersome LUTS should include a thorough medical history, AUA-Symptom Index, and urinalysis. Patient goals for treatment should be obtained and side effects of various treatment modalities discussed. A recent publication revealed a lack of crucial understanding and patient counseling by urologists and other providers about the potential sexual side effects of medical and surgical BPH management (World J Urol 2018; 36:1449–53). The AUA guideline inclusion of MIST for BPH with sexual side effect-sparing approaches (prostatic urethral lift, water vapor thermal therapy) makes this discussion more relevant.
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Guideline amendments have also emphasized the importance of preoperative evaluation of prostatic size to ensure appropriate selection of treatment modality. Again, the new MIST therapies influence workup, as prostate size and anatomy alter treatment options. Ideal imaging in preparation for BPH surgical treatment should include ultrasound of the prostate to afford optimal evaluation of prostatic size along with assessment of a median lobe component of the prostate. Additionally, cystoscopy is recommended, as it affords the clinician important understanding of prostatic urethral anatomy, identification of urethral stricture disease, and assessment of patient tolerance of local anesthesia procedures should the patient desire intervention with MIST. Providers who desire transrectal ultrasound (TRUS) of the prostate and cystoscopy can proceed with both.
Additionally, patients can undergo size assessment with cross-sectional imaging (CT vs. MRI). Providers are encouraged to perform post-void residual, and utilization of pressure flow studies is recommended when the voiding symptoms present diagnostic uncertainty. Urodynamic studies are a reasonable adjunct to guide treatment when patients have neurologic conditions affecting the bladder (multiple sclerosis, Parkinson’s), have failed previous BPH procedures, have a history of pelvic or spinal cord surgery, have had pelvic radiation, or have diabetes. Novel, noninvasive pressure flow studies utilizing a penile cuff while voiding have demonstrated a 92% positive predictive value and sensitivity of 75% in detecting bladder outlet obstruction when compared to formal catheter-based pressure flow studies (Can J Urol 2015; 22:7896–7901).
The updated BPH guidelines remind us that TURP either with monopolar or bipolar energy remains an excellent treatment approach. As a point of reference, a recent Canadian registry study of nearly 46,000 TURPs from 2003 to 2016 revealed a transfusion rate of 2.6%, 30-day ER visit rate of 22.5% with approximately half being admitted, a stricture/bladder neck contracture rate of 11.2%, and a surgical retreatment rate of 10.9% at a median follow-up of 4.42 years (BJU Int 2019; 124:1047-54). These numbers are important to keep in mind as patients begin to choose from a menu of options that minimize certain side effects, perhaps at the expense of treatment durability.
Prostatic urethral lift (PUL [UroLift]) can be considered as an option for LUTS from BPH in men who have prostate glandular size of 30-80 grams and absence of a median lobe (Moderate Recommendation, Evidence Level C). As recently as January 2020, PUL gained FDA approval for glandular size of up to 100 grams. No studies that met eligibility criteria attempting to utilize PUL for the median lobe or sized 80-100 grams were available at the time of guideline publication. Prostatic urethral lift utilizes a minimally invasive, office-based approach to resolve prostatic urethral bilobar hyperplasia with mechanical clips providing treatment of outlet obstruction (figure).
Patients who request intervention with prostatic urethral lift should be advised that improvement in symptoms and flow rate are decreased as compared to transurethral resection of the prostate (Can J Urol 2017; 24:8802–13). Prostatic urethral lift can be offered to patients who have concerns of ejaculatory function, as it is likely to have little impact on a patient’s erectile or ejaculatory function (Cochrane Database Syst Rev 2019; 5:CD012832). Indeed, prostatic urethral lift remains a good option for the patient with mild to moderate LUTS with BPH without a median lobe component in whom sexual health and functionality are a priority in the treatment setting.
However, the guidelines also state that evidence of efficacy and retreatment rates are poorly defined since one trial demonstrated about one-third of the study population experienced unsatisfactory results necessitating additional treatment at 5 years (both surgical and medical) (Can J Urol 2017; 24:8802–13). Refinement of patient selection and procedural experience may improve these outcomes.
Water vapor thermal therapy of the prostate (Rezum System) is an alternative minimally invasive approach to prostatic urethral lift. Water vapor thermal therapy harnesses the high energy potential of steam delivered through a cystoscopic probe to illicit local tissue cellular death. Prostatic cellular apoptosis and subsequent local tissue reabsorption affords treatment of the bladder outlet obstruction (figure). Water vapor thermal therapy can be performed in a minimally invasive fashion under local anesthesia in the clinic for the appropriately selected patient.
The guidelines state this therapy may be offered to patients with LUTS attributed to BPH provided prostate volume is <80 grams; however, patients should be counseled regarding efficacy and retreatment rates (Conditional Recommendation; Evidence Level: Grade C). The conditional recommendation was based on a less robust body of evidence as 5-year outcomes and retreatment rates were not yet available at time of guideline publication. Water vapor therapy treatment may also be offered to men who desire preservation of ejaculatory and erectile function (J Urol 2016; 195:1529–38).
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Aquablation, delivered by the AquaBeam Robotic System, is another new therapy introduced in the updated guidelines (Urology 2019; 125:169–73). Aquablation utilizes high-pressure waterjet technology, real-time ultrasonographic imaging, and robotically guided water jets for prostatic resection (figure) (Urology 2019; 125:169–73). The procedure typically requires utilization of general anesthesia and thus should not be considered minimally invasive. As with the other modalities of treatment reviewed herein, the procedure is optimally utilized in patients with a prostate size of 30-80 grams. Additionally, given the relative novelty of Aquablation with only 1 year of data to review at the time of guidelines creation, patients should be counseled that long-term evidence regarding outcomes and retreatment rates remains limited. Some sexual side effect advantages have been demonstrated with Aquablation compared to TURP (Urology 2019; 125:169–73).
Other treatments. Several other BPH surgical treatments were addressed in the new guidelines. Transurethral incision of the prostate (TUIP) remains a great treatment for prostates <30 grams and carries a lower rate of retrograde ejaculation compared to TURP. Holmium laser enucleation of the prostate (HoLEP), photoselective vaporization of the prostate (PVP), and thulium laser enucleation of the prostate (ThuLEP) are also viable options and are cited as considerations for patients on anticoagulation drugs.
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Consideration of simple prostatectomy (open, laparoscopic, robotic) should be given to patients with larger glands. Transurethral needle ablation (TUNA) is not recommended for BPH treatment. Citing heterogeneity in the literature, post-embolization syndrome, vascular access, technical feasibility, radiation exposure, and quality control at lower volume centers, the panel deemed prostate artery embolization as not recommended for the treatment of LUTS attributed to BPH outside the context of a clinical trial.
The progressive nature of the field of surgical intervention for BPH necessitates that urologists remain up to date on the most recent advancements. The AUA guidelines continue to evolve consistent with the most recent evidence-based practices, affording practitioners the ability to offer cutting-edge technology to their patients. While technological advancement has been a cornerstone of the advancement of urologic practice, appropriate patient selection, diagnostic evaluation, and preoperative counseling profiles remain paramount in providing excellent care for the patient with lower urinary tract symptoms.
Matthew D. Houlihan, DO
Tobias S. KÃ¶hler, MD, MPH
Dr. Houlihan is an andrology fellow, and Dr. KÃ¶hler is director of Men’s Health, Mayo Clinic, Rochester, MN. Dr KÃ¶hler is a member of the AUA BPH surgical and medical guidelines panel but is not a spokesperson for the AUA.
Section Editor Christopher M. Gonzalez, MD, MBA, is professor and chair of the department of urology at Loyola University Chicago Stritch School of Medicine, Maywood, IL.