Treatments for BPH
What Are My Nonsurgical BPH Treatment Options?
Medically reviewed by Dr. J. Kellogg Parsons M.D
If medications for BPH fail to keep your urethra open, then your doctor may suggest a minimally invasive nonsurgical treatment option. These procedures are performed on an outpatient basis, which means no overnight stay in the hospital is required. In fact, some doctors are equipped to perform the procedure in their office.
The minimally invasive nonsurgical options include the following:
- Transurethral needle ablation (TUNA)
- Transurethral microwave thermotherapy (TUMT)
- Photoselective vaporization (PVP)
- Interstitial laser therapy
- Transurethral dilation (TUBD)
- Prostatic urethral lift
- Prostatic arterial embolization (PAE)
- High-intensity focused ultrasound (HIFU)
- Rezum therapy
- Focused laser ablation
What Is Transurethral Needle Ablation (TUNA)?
TUNA is a procedure that uses radio waves to “burn away” excessive prostate tissue. Before treatment, the clinician will determine the length and width of your prostate. To perform TUNA, the clinician inserts a catheter into the tip of the penis and pushes it through the urethra until it reaches the spot where the urethra is surrounded by and “squeezed” by the prostate. Once the catheter is in place, the needles on its tip send out high-temperature (110 degrees F), low-level radio waves that destroy selected prostate tissue. This allows the “strangled” urinary passageway to enlarge.
You may notice a significant improvement in symptoms, but they won’t happen overnight. Until the area heals completely, you can also expect to need to urinate frequently. Another drawback is that you may need to have TUNA repeated every several years as the prostate continues to grow.
A 2005 study found that 46.3 percent of men who has undergone TUNA three years earlier needed retreatment: 21 were treated with drugs and 17 were treated surgically (one patient had both).
TUNA also does not work well in men who have large prostates, and it is generally considered to be less effective than prostate surgery. Other complications may include blood in the urine, infection, and rarely, sexual dysfunction or urethral stricture.
What Is Transurethral Microwave Thermotherapy (TUMT)?
TUMT combines heat and cold to relieve BPH symptoms with a minimum of side effects. Similar to TUNA, the clinician needs to know the length and width of the prostate prior to the procedure. Once again, a catheter is threaded through the penis until it reaches the part of the urethra that is being strangled by the prostate. This catheter contains a special antenna that sends out microwaves into the prostate to destroy excess tissue. At the same time, cold water is circulated through the catheter to protect healthy prostate tissue from being damaged by the heat, to reduce any discomfort associate with the procedure, and to reduce the risk of side effects.
TUMT takes about one hour and can be performed while you are fully awake or under light sedation. A catheter is needed for one to three days after the procedure.
Potential side effects include needing to urinate frequently, inflammation of the urethra, and a pink discharge in the urine.
This procedure works best for men who have mild BPH symptoms or who have no history of urinary retention. You should notice some improvement after several week, but it will be about 90 days before you experience the full benefits
What Is Photoselective Vaporization (PVP)?
PVP is a procedure that allows clinicians to vaporize excess prostatic tissue and heat seal the site simultaneously. Photoselective vaporization is approved for prostates that up to 60 grams and is performed via a high-energy holmium or GreenLight laser. The laser is inserted into the penis and threaded through the urethra to the part where the urethra is surrounded by the enlarged prostate. The laser light vaporizes the excess prostate tissue so there is no “dying” prostate tissue left behind to clean up later. The heat generated by PVP seals (cauterizes) the blood vessels so bleeding is kept to a minimum.
The entire procedure takes about 30 to 60 minutes to perform and is done under spinal or general anesthesia. A catheter may be placed for 24 hours, although some men need it for a little longer. The holmium laser ablation of the prostate (HoLAP) and GreenLight lasers are used for small to medium-sized prostates, while GreenLight is also safe and effective for men who have a large-sized prostate.
The main side effect is blood in the urine, and others may include burning sensation when urinating, retrograde ejaculation, urinary tract infections, and a frequent need to urinate. Urinary incontinence is common, but permanent incontinence at one year occurs in only about 1 percent of men. The retreatment rate is less than 2 percent, and both bladder perforation and sepsis are rare.
What Is Interstitial Laser Therapy?
Interstitial laser therapy, also known as interstitial laser coagulation, involves using laser energy to heat and destroy overgrown prostate tissue. The laser energy is delivered to the prostate through a cystoscope that is inserted through the penis, where it destroys the cells that are blocking the flow of urine. Interstitial laser therapy is associated with minimal blood loss, does not cause retrograde ejaculation or erectile dysfunction, and can be performed with a local anesthetic. A catheter is usually required for three days after the procedure, and symptoms should improve over six to twelve weeks.
What Is Transurethral Dilation (TUBD)?
TUBD is occasionally still performed for BPH. The procedure involves literally pushing your enlarged prostate tissue away from the urethra. To accomplish this, it is necessary to insert a small balloon into the penis and push it through the urethra until it is in the part of the urethra that passes through the prostate. The balloon is then inflated and the big push occurs. Although the idea is intriguing—to eliminate the prostate’s stranglehold on the urethra without burning or cutting anything—the results of the TUBD are usually not all that impressive, which is why it is not often used.
What is Prostatic Urethral Lift?
Prostatic urethral lift is a relatively new and minimally invasive implant procedure for treating urinary tract symptoms of BPH. It is best if you have a small to medium sized prostate. The prostatic urethral lift is a less-invasive procedure than TURP that provides symptom relief and improved voiding flow as seen in an international study of patients.
The prostatic urethral lift mechanically opens the prostatic urethra with minute UroLift implants. The UroLift System is designed to open the urethra without incisions, surgical resection, or causing thermal injury to the prostate. Obstructive prostate lobes are pushed aside and small permanent UroLift implants are sutured to the prostate to keep the lobes in the retracted position. This opens the urethra while leaving the prostate intact; that is no prostate tissue is destroyed during the procedure.
The prostatic urethral lift does not appear to cause retrograde ejaculation or cause problems with sexual function. Less than 8 percent of men who underwent this procedure needed additional treatment for BPH, according to one study.
What Is a Stent?
A stent is a device that is placed in the urethra to keep it open so urine can flow freely. To implant a stent, it is necessary to insert it through the tip of the penis and guide it to the appropriate spot in the urethra. No cutting, heating, or lasering is involved in this process. However, stents are not a long-term solution, as they can be either temporary or permanent, and they don’t work at all for some men. The success rate ranges from 50 to 90 percent, and there is a high rate of complications.
Some of those complications include stents that shift position, break, or cause pain or infection, and there’s a good chance tissue will grow over the stent, transforming the stent into a kind of dam in the urethra. Stents are an alternative for men who cannot or will not take medications or go under the knife to treat BPH. A stent can be used in high-risk patients or in men who are experiencing urinary retention and awaiting other treatment.
What Is Prostatic Arterial Embolization?
If you are looking for a minimally invasive nonsurgical treatments for BPH that could actually improve your sexual function rather than damage it, then prostatic arterial embolization could be your choice. Also referred to as PAE, this new surgical treatment for BPH has been shown to be both safe and effective in a growing number of studies around the world. Prostatic artery embolization is being performed by a limited number of physicians in the United States and other countries, and it is gradually becoming more readily available.
Prostatic arterial embolization, which boasts a success rate of about 85 percent or better, works like this. First, men undergo ultrasound or an MRI (magnetic resonance imaging) to map the blood supply to the prostate gland. Then a clinician accesses the blood flow to the prostate through a percutaneous puncture and catheter placed into the prostate artery in the groin. He or she then introduces Embosphere® Microspheres, minute spherical particles engineered to block the blood supply to the prostate, causing the gland to eventually shrink. In most cases, the entire procedure takes just under 1.5 hours (mean, 86 minutes; range of 25-185 minutes).
A significant advantage of prostatic arterial embolization is the absence of both urinary incontinence and sexual side effects. Some men even report an improvement in sexual function after the procedure. As for other side effects, you may notice bladder spasm, infection of the puncture site or prostate, or some blood in your urine, semen, or stool. Some men even experience an improvement in their sexual function.
Since prostatic arterial embolization has not yet been approved by the Food and Drug Administration for treatment of BPH, many insurance plans (including Medicare) will not cover the cost.
What Is High-Intensity Focused Ultrasound (HIFU)?
This radiation-free BPH treatment option is unlike the others in that is uses ultrasound (high-powered sound waves), which heat and destroy the excess prostate tissue. HIFU is also used to kill prostate cancer cells. Currently there are two HIFU systems approved for use in the United States: SonaCare’s Sonablate and EDAP’s Ablatherm.
HIFU can be conducted under intravenous sedation or general anesthesia. Once you are ready, the surgeon uses real-time imaging to guide the focused beam of ultrasound energy from a probe that is guided into the rectum. The energy wave heat up the targeted excess prostate tissue but does not damage adjacent healthy cells. A cooling balloon is positioned in the probe to keep the temperature in a safe zone.
Once the procedure is done, a urinary catheter is inserted and typically remains for several days or longer, although men can usually go home within hours of the procedure. Symptom improvement after one year was 63 percent in a study presented at the American Urological Association annual meeting. Side effects include blood in the semen (28% of patients), blood in the urine (23%), and erectile dysfunction (30-70%). Ten percent or fewer experience urinary retention, transient urinary incontinence, and urinary tract infections.
What is Rezum Therapy?
Rezum therapy, also known as convective radiofrequency water vapor thermal therapy, is a transurethral needle ablation (TUNA) method that differs from the traditional TUNA, which delivers heat to the excess tissue in the prostate. Rezum provides radiofrequency generated thermal energy in the form of water vapor, or steam. The energy transported by the water damages the offensive cells, which in turn causes them to die. During the months following the treatment, the body absorbs the dying cells as part of the natural healing process. As the cells are absorbed, the symptoms of BPH are relieved.
Because Rezum is a relatively new procedure, no long-term studies have evaluated its effect on symptoms beyond two years. The most recent study, published in April 2017, noted that the therapy “results in a significant early onset and enduring relief of BPH symptoms with preservation of erectile function in subjects followed up for 2 years.”
What is Focused Laser Ablation?
Focused laser ablation is a minimally invasive procedure that combines magnetic resonance imaging (MRI) and laser (electromagnetic radiation) to effectively treat an enlarged prostate in a single session. After the patient is given a local anesthetic, he is slid into an MRI tunnel, where clinicians use real-time 3T multiparametric MRI to identify the exact location where the enlargement is squeezing the urethra.
Once the affected site is located, the surgeon threads a hollow needle guide through the rectum to the prostate. Then he passes a laser fiber optic through the guide and activates the laser for two to three minutes to reduce the excessive tissue.
Throughout the procedure, special software is used to monitor the temperature of the prostate tissue to ensure no damage occurs. After the laser treatment is done, the MRI is used to check whether all the excessive tissue has been removed.
Because the procedure does not involve accessing the prostate through the urethra, no urinary catheter is needed after the procedure. Men also do not risk experiencing the side effects associated with procedures that compromise the urethra, such as erectile dysfunction, urinary incontinence, and retrograde ejaculation.