Men who have been diagnosed with BPH (benign prostatic hyperplasia), also known as an enlarged prostate, are familiar with the symptoms: the sudden, urgent need to urinate, difficulty urinating, dribbling, and pain when urinating. What they may not be familiar with, however, are the available treatments. Fortunately there are a number of choices, including watch and wait, various lifestyle changes, medications, and surgical options.
Selecting the optimal treatment approach is a task that men and their doctors should make together after a thorough discussion of all the factors involved. Among those considerations are the severity of the symptoms, impact on lifestyle, one’s personal preferences, and the presence of other health problems.
Why Choose Surgical Options for BPH?
After talking with their doctor, some men are advised to undergo one of the various surgical options for BPH. This is a decision that should not be made without fully understanding the reasons why surgery has been recommended, as well as what the procedure involves, its side effects, prognosis, and cost. Men who are facing the possibility of noninvasive or invasive surgery for BPH may be in this position for one of the following reasons:
- They have failed to respond to drugs for BPH. Along with lifestyle changes, many men choose to try one or more of the different drugs available for treatment of BPH, including alpha blockers, 5-alpha reductase inhibitors, a combination of these two drugs, and phosphodiesterase-5 inhibitors (e.g., Viagra). Unfortunately, they don’t always provide the relief they are looking for.
- The sexual side effects of BPH drugs are unacceptable to them. Erectile dysfunction, retrograde ejaculation, reduced libido, orgasm difficulties, and breast enlargement—these are the sexual side effects associated with BPH drugs like Finasteride. For some men, these drug responses are extremely disruptive for both them and their partners, prompting them to choose a surgical procedure rather than put up with these problems.
- They have not responded to other treatments for BPH. In addition to medications, other treatments for BPH include lifestyle changes (e.g., adequate sleep, regular exercise, not smoking, healthful diet, maintain healthy weight, limiting alcohol), use of natural and/or herbal supplements, acupuncture, prostate massage, and stress management, among others. While these approaches can be quite effective for many men, others continue to have unresolved symptoms.
- They have health issues that make surgical options the wisest choice. For example, if you are unable to urinate (an emergency situation), have a partial blockage of your urethra that causes you to experience bladder stones or repeated urinary tract infections, present with blood in your urine that does not go away, or have kidney damage, then surgery is recommended.
- They want to avoid the unacceptable side effects of BPH drugs other than sexual ones. These can include fatigue, fainting, headache, nasal congestion, testicular pain, swelling of hands and feet, and dizziness. In the case of finasteride (Proscar) and other 5-alpha reductase inhibitors (i.e., Avodart, Jalyn), there is also an increased risk of developing high-grade prostate cancer.
What Are the Surgical Options for BPH – And What Questions Should I Ask?
If you have been advised to consider any of the surgical options for BPH, you have numerous procedures from which to choose. The two categories of surgical options for BPH include minimally invasive procedures (during which no incisions are made in the skin) and surgical or invasive procedures (most of which involve removing the enlarged part of the prostate). The options in both categories are discussed below in detail, so you will have a basis for conversation with your doctor. The final decision should be made after you review all the pros and cons with your doctor and your partner or family so everyone fully understands what to expect.
Before you choose your surgeon and surgical procedure, ask the following questions:
- How frequently has the physician performed the procedure?
- What are the complications and side effects and risk of experiencing each one?
- Will I need to take any precautions because of other health problems I have?
- Will I need to stop taking any of my medications or supplements before the procedure? (Some medications and supplements can increase your risk for bleeding.)
- Will I need to fast before the procedure, and for how long?
- What is the rate of reoperations for this procedure?
- Where will the procedure be performed?
- How long will I need to be in the hospital?
- How long is the recovery period? (Procedures involving laser usually have a shorter recovery time.)
- What restrictions will I have during my recovery regarding return to work, sexual activity, and exercise?
As with many medical procedures, modifications and advances are being made all the time. Therefore, be sure to ask your doctor about any new developments and keep up with them by doing your own research and taking notes. Arming yourself with information before having surgery will facilitate your recovery and help you feel more confident about your decision.
While going through the following surgical options for BPH, keep in mind that those performed under general or spinal anesthesia are typically performed in hospital or outpatient operating facilities, such as an ambulatory surgery center. Some office setting are equipped to do laser procedures while others are not. Much depends on what is available in your area and your doctor.
TURP: Transurethral Resection of the Prostate.
This is an invasive surgical procedure that can be used if your prostate is larger than 30 grams and/or your symptoms are severe. According to a Harvard Medical School article, it is the most common form of surgery for BPH, although its popularity is declining as other surgical options enter the playing field. The article notes that “TURP is often inelegantly referred to as the ‘Roto-Rooter’ technique.” You can expect the following:
- The procedure is done under general or spinal anesthesia
- The surgeon threads a thin instrument called a resectoscope through the urethra to the prostate so he can view the gland.
- A thin wire loop is then threaded through the urethra and an electrical current is passed along the wire. The surgeon uses the electrified loop to slice away prostate tissue that is blocking the urethra.
- Once the instruments are removed, a catheter is placed in the urethra and you will remain in the hospital for about two days or until there is no significant blood or clots in your urine
- Symptom improvement rate is about 70 to 85 percent and relief is usually good for 15 years or more
- Side effects include retrograde ejaculation (25-99%), erectile dysfunction (3-35%), urinary tract infections immediately after surgery (5-10%), and urinary incontinence (5-10%). Other possible complications include rectal perforation, ruptured bladder, sepsis, sphincter damage, and a condition (TUR syndrome) in which the sterile irrigation fluid used during surgery gets into the bloodstream and reduces sodium levels, resulting in nausea, vomiting, disorientation, and possible seizures.
- The need for reoperation occurs in up to 10 percent of men within a decade.
- Full recovery takes about four to six weeks
TUIP: Transurethral Incision of the Prostate.
TUIP is a surgical procedure that is typically recommended for men whose prostate is only slightly enlarged (less than 30 g). Here’s what to expect if you’re having TUIP.
- You will be given either general or spinal anesthesia
- The doctor will insert a narrow instrument through the urethra and thread it to where the prostate and bladder meet.
- The instrument delivers a laser beam or electrical current that makes several cuts in the prostate muscle tissue. These cuts relax the muscles that control the opening and closing of the bladder neck, which in turn allows for urine to flow easier into the urethra.
- After the procedure, you will stay in the hospital one day and a catheter will be placed. Often the catheter is needed for up to three days, so you may be released home with the catheter still intact.
- About 80 percent of men who undergo TUIP experience symptom relief
- Possible side effects include retrograde ejaculation (6-55%), erectile dysfunction (4-25%), and urinary incontinence (<1%).
- About 10 percent of men will need another TUIP in about 15 years
PVP: Photoselective Vaporization of the Prostate.
This surgical procedure involves the use of a laser (also known as Green Light laser or the Green Light procedure) to remove excess prostate tissue. Because it is virtually bloodless, PVP may be a good option for men who are taking blood thinners. Here’s what you can expect.
- The procedure is done under general or spinal anesthesia
- The surgeon guides a thin tube (cystoscope) into the urethra until it reaches the prostate gland
- A fiberoptic device is then guided through the cystoscope to send high-intensity light pulses, which simultaneously vaporize the excess prostate tissue and cauterize it to stop bleeding
- A catheter may be placed after the procedure and is usually removed within 24 hours, but some men may need it for a longer time.
- Men typically can go home within a few hours of the procedure
- Side effects and complications may include bloody urine, burning sensation when urinating, retrograde ejaculation, urinary tract infections, and a frequent need to urinate
- Urinary urgency and/or frequency may be more bothersome during the first month after the procedure than after TURP, but it typically resolves after that time
HoLAP: Holmium Laser Ablation of the Prostate.
The basic difference between HoLAP and PVP is the type of laser used to remove the excess prostate tissue (see PVP). Otherwise, the procedure and results are similar. However, here are a few more things to know about HoLAP:
- In HoLAP, the laser energy can be absorbed by water, which prevents the energy from penetrating deep into the tissues and damaging them.
- The retreatment rate is less than 2 percent
- The impact on erectile function is virtually zero.
- Although some urinary incontinence is common, less than 1 percent of men have permanent incontinence one year after the procedure. Both sepsis and bladder perforation are rare.
HoLEP: Holmium Laser Enucleation of the Prostate (HoLEP).
One of the newer surgical options for BPH is HoLEP, which can be used to treat an enlarged prostate of any size. A better potential complication rate can make HoLEP a more attractive choice than other BPH treatments. You can expect the following:
- Men are placed under general anesthesia
- The surgeon threads a thin, flexible fiber through the urethra to the prostate gland
- Holmium laser is used to remove the prostate gland tissue that is blocking the urethra, which leaves just the prostatic capsule behind.
- The surgeon then inserts another instrument, called a morcellator, which grinds the prostate tissue to make it easy to remove
- The recovered tissue fragments can be examined for other conditions, such as prostate cancer, if necessary
- A catheter is placed after surgery and can be removed the next day because this procedure involves limited swelling
- Reoperation rate is less than 2 percent because HoLEP completely removes the obstructing prostate tissue.
- Complication risk is lower than other procedures because the holmium laser causes little damage to healthy prostate tissue.
- Among the side effects are retrograde ejaculation, which occurs in nearly all cases, but erectile function has actually been shown to improve after HoLEP. All men experience some blood in their urine for one to two weeks after surgery, but the need for a blood transfusion is only about 1 percent. Although urinary incontinence is common, it is temporary in all but 1 to 2 percent of men. If the prostate was larger than 100 grams, stress incontinence occurs in about 10 to 15 percent of men, but it usually goes away within six weeks. About 5 percent of patients experience urethral stricture.
TVP/TUVP: Transurethral Vaporization of the Prostate.
TVP/TUVP is also called transurethral electrovaporization of the prostate and is a surgical procedure. Unlike TURP, which uses an electrified coil or loop to cut away excess prostate tissue, TUVP involves a tiny electrified cylindrical roller or loop electrode. TUVP is best for men whose prostate is 30 g or less. Here’s what else you should know.
- The procedure can be done under general or local anesthesia
- The electrified roller or electrode is attached to a resectoscope that the surgeon guides through the urethra to the prostate.
- Once the roller reaches the prostate, the roller is heated up to vaporize the excess tissue. During this process, tiny blood vessels in the prostate are cauterized, which reduces the risk of bleeding during and after the procedure
- A continuous flow of water is passed through the resectoscope to reduce the heat
- The surgeon will place a urinary catheter that may be removed within 24 hours or more
- Men typically can go home within 1 to 3 days
- Retrograde ejaculation is a common side effect. Others can include erectile dysfunction, blood in the urine (usually goes away within 3 weeks), clotting (men may need recatheterization), and urethral stricture (rare).
- Because of a lower risk of bleeding, TUVP may be used for men who are taking blood thinners
Simple Prostatectomy – Removal of the Prostate.
A prostatectomy means removal of the prostate, making it the most radical of the surgical options for BPH. A simple prostatectomy for BPH is typically reserved for men who have a severely enlarged prostate, a damaged bladder, or other serious health problems. Only about 2 to 3 percent of men with BPH get this procedure.
There are three simple prostatectomy approaches to remove the prostate in men with BPH:
- Open retropubic simple prostatectomy, in which the surgeon makes an incision below your belly button. Once inside, the surgeon moves your bladder to the side, cuts into the prostate, and removes the core of the gland.
- Open suprapubic simple prostatectomy, in which the surgeon makes an incision just below your belly button, cuts into your bladder, and removes the prostate tissue through the bladder.
- Laparoscopic simple prostatectomy, in which the surgeon makes five tiny incisions in your abdomen. He or she than inserts lighted magnifying instruments and cameras into the incisions to guide the way to the prostate and removal of its core. Of the three approaches, this one is the least painful and requires the least recovery time. Laparoscopic simple prostatectomy also can be performed using robotic tools.
You should also know that:
- During any of these prostatectomy procedures, you will have a drain tube inserted near the surgical site that will remove any fluid that accumulates around the prostate shell and let it collect in a bulb attached to a tube on the outside of your body.
- Complications following simple prostatectomy may include bleeding, urinoma (encapsulated urine), and accumulation of urine in the scrotum or penis. Urinary incontinence is rare, and erectile dysfunction and bladder neck contracture occur in about 2 to 3 percent of patients who have suprapubic prostatectomy.
- Retrograde ejaculation has occurred in up to 80 to 90 percent of men after prostatectomy
The “Urolift” System.
The Urolift System is a relatively new minimally invasive procedure that can be an option for men with a small to moderate size prostate gland. Rather than zap or cut away excess prostate tissue, the Urolift System involves placing minute implants in the lobes of the prostate gland to keep the urethra open. What else should you know about the Urolift System?
- The procedure can be performed under local anesthesia in a doctor’s office
- The surgeon guides a cystoscope through the urethra and places the implants, which are sutured to the prostate
- No prostate tissue is destroyed during the procedure
- Study results show that only 7.5 percent of men who underwent this procedure needed additional treatment for BPH
- The same research findings reported that men were able to return to normal activity within 8 days and experienced a significant improvement in their symptoms by 14 days. In addition, none of the men experienced erectile dysfunction or retrograde ejaculation
TUMT: Transurethral Microwave Thermotherapy.
Heat is the destroyer of prostate tissue in this minimally invasive technique. The men most suited for TUMT are those with a prostate of 20 grams or larger. Here’s what to expect.
- TUMT can be done in the office under local anesthesia and sedation
- The doctor inserts a special catheter that contains a miniature microwave generator through the urethra to the prostate.
- Once in position, the high-temperature microwaves destroy the excess prostate tissue, which dies off over a period of several days. A cooling jacket around the generator protects the urethra from the heat and cold water circulating around the catheter protects the prostate and reduces the risk of side effects.
- Another catheter containing a thermometer is placed in the rectum during the procedure to monitor the amount of heat in your body.
- Once the procedure is done, the doctor will place a urinary catheter that will need to stay in for 24 hours or more.
- Patients typically can go home the same day as the procedure
- Men can expect to experience some symptom relief within a few days or weeks of the procedure as the excess prostate tissue dies off and any swelling declines. It can take up to 90 days for full improvement to occur.
- Short-term side effects include blood in the urine, which usually lasts a few days, and problems with urinating (painful, urgent, and/or frequent urination) which usually improves within a few weeks.
- Urinary tract symptoms occur in about 25 percent of men.
- Rates of other side effects/complications are low and may include urinary tract infections, narrowing of the bladder neck, urinary stricture, urinary incontinence, and retrograde ejaculation.
- Most men who have TUMT will eventually need further treatment with TURP or another procedure. Research shows that TUMT doesn’t improve BPH symptoms as effectively as TURP but it is more effective than medication
TUNA: Transurethral Needle Ablation.
Rather than lasers, TUNA involves the use of radio waves that burn away excess prostate tissue. The best patients for TUNA are men with a prostate of 60 grams or less and who have symptoms of urinary obstruction. Here’s what to expect:
- You can have the procedure performed in the office under local anesthesia
- The doctor inserts a long thin tube with a light on the end (a cytoscope) through the urethra to the prostate so the gland can be viewed before the treatment begins.
- A special catheter with twin needles on the end is then guided through the cytoscope until it reaches the prostate. High temperature from low-level radio waves is emitted from each needle to destroy excess prostate tissue around the gland. Each needle is held on a treatment location for 90 to 180 seconds. The number of needles necessary to complete the treatment depends on the size and shape of the prostate.
- Once the treatment catheter is removed, the doctor may insert a urinary catheter that will need to stay in for 24 hours or longer
- Symptoms of BPH should improve significantly, although until the treated area heals, you will need to urinate frequently
- About 30 percent of men need retreatment after 5 years
- Side effects/complications can include blood in the urine, infection, difficulty urinating (because of swelling from the heat; this is temporary), and in rare cases, erectile dysfunction or urethral stricture
- Compared with TURP, research shows that men who undergo TUNA have fewer sexual complications and less postoperative bleeding. At the same time, TUNA has a higher failure rate than does TURP.
TUBD: Transurethral Dilation.
This procedure, also known as transurethral balloon dilation or transurethral dilation of the prostate (TUDP), is unique because it involves literally pushing the excess prostate tissue away from the urethra to help improve urine flow—no cutting or heat is involved. However, TUDP “has been abandoned in clinical application because of its unsatisfying treatments benefit and severe complications,” according to a recent report in the Journal of Endourology. Now, some experts have redesigned this procedure by replacing the traditional balloon with a different (columnar) one. This new approach is called TUSP—transurethral split of the prostate—and is being studied in both men and animals. TUSP could become part one of the surgical options for BPH.
HIFU: High-Intensity Focused Ultrasound.
This noninvasive 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. Men who are considering HIFU should know the following:
- HIFU can be conducted under general anesthesia or intravenous sedation
- The surgeon guides a probe into the rectum, which delivers the ultrasound waves. These waves 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 one study
- Side effects include blood in the semen in 28 percent of patients, blood in the urine in 23 percent, and erectile dysfunction in 1 to o7 percent. Ten percent or fewer experience urinary retention, transient urinary incontinence, and urinary tract infections.
ILT: Interstitial Laser Therapy.
This procedure is also referred to as interstitial laser coagulation (ILC) and involves using laser energy to heat and destroy excess prostate tissue. Men who have larger prostate who don’t want to undergo a more invasive procedure may choose this option. Here’s what else you should know.
- ILT can be performed under local anesthesia
- The surgeon threads a metal tube (cystoscope) that has a laser and lens through the urethra to the prostate
- Once the cystoscope reaches the prostate, laser is used to burn away excess tissue
- After the procedure is done, the surgeon inserts a catheter, which may need to stay in place for three days or longer
- The procedure involves minimal blood loss and is not associated with erectile dysfunction or retrograde ejaculation
- This procedure has lost popularity because of infection rates, the need for long catheterization, irritating urinary symptoms, and the availability of newer techniques
Prostate Artery Embolization – A New Procedure With Minimal Side Effects.
Also referred to as PAE, this is one of the most recent additions to the BPH surgical option slate. A big plus for PAE is that it is effective in treating an enlarged prostate less than 50 g to greater than 80 g, providing significant improvement in symptoms and quality of life regardless of prostate size, based on results from a study at Inova Alexandria Hospital in Virginia. In that study, the authors showed continued improvement in symptoms six months after the procedure had been performed.
In another study involving 67 men, one-third continued to have significant symptoms after one year and had to seek other treatment options. The good news, however, was that the study participants didn’t experience any major complications or side effects, such as erectile dysfunction, retrograde ejaculation, or urinary tract infections. Minor effects did include mild pain in the pubic and perineal areas and temporary blood in sperm.
Here are a few other things you should know about PAE:
- The procedure can be done under local anesthesia
- The surgeon inserts a catheter into the femoral artery and guides it to the prostate artery that lies on both sides of the enlarged gland.
- Microscopic spheres are sent through the catheter to block blood flow, which then causes the prostate to shrink.
- Postsurgery, the risk of bleeding, erectile dysfunction, and urinary incontinence is less than that associated with other BPH treatments
- The specialists most qualified to perform PAE are interventional radiologists, because they have an intimate knowledge of the arteries, microcatheter techniques, and embolization procedures.
- Men who are interested in prostate artery embolization may need to look outside of their area as the procedure is not yet available in many hospitals.
- Since PAE is relatively new, studies comparing the procedure with other surgical options for BPH, such as TURP, have not yet been done, and the long-term consequences of the procedure have not been determined.
FLA: Focal Laser Ablation.
This is a new approach involving use of a laser that coagulates rather than vaporizes the excess prostate tissue. FLA causes scar tissue that the body absorbs while allowing the prostate to shrink. So far this technique is not widely available. Here’s some information about FLA.
- FLA is performed under a local anesthetic
- An MRI is done first to determine the exact location of the excess tissue restricting the urethra
- The surgeon inserts a hollow needle guide (with a laser fiber optic) through the rectum until it reaches the prostate.
- Once the fiber has reached its target, the laser is activated for 2 to 3 minutes. During this process, a computer monitors temperature changes in the treatment area to prevent tissue damage
- Once the procedure is done, the surgeon may use an MRI to verify all the excess tissue has been removed
- Patients can leave after the procedure and no catheter is required
- Side effects are minimal and may include some blood in the urine. Erectile dysfunction, retrograde ejaculation, as well as urinary tract irritation or infections have not been reported
- BPH symptoms typically begin to improve within a few weeks as the scar tissue is absorbed by the body
For men who cannot or do not want to take medication, who are high-risk patients (including elderly men), or who don’t want to undergo other procedures that involve lasers, cutting, or heating, stents may be the answer. Stents are spring- or coil-like devices that hold the urethra open so urine can flow more easily. What else should you know about stents for BPH?
- Placement of stents in the urethra does not require anesthesia, but sedation is used.
- Stents can be implanted by guiding them through the urethra and placing them in the appropriate locations.
- One major problem with stents is that they are not a long-term solution. Although they are effective in 50 to 90 percent of cases, the complication rate is high.
- Stents have a habit of breaking, shifting, and triggering infection and/or pain. Stones also can form on them, causing the urethra to become blocked.
- Other complications include urinary incontinence, difficulty urinating, light bleeding, and pain.
Which BPH Surgical Option is Right for You? Comparison of Treatment Options.
Only you and your doctor can answer that question. The size of your enlarged prostate, severity of your symptoms, your desire to retain or maintain sexual function, your age, presence of other health problems, and your lifestyle are all factors to be considered. Before you make any decision, however, be sure to review all of your alternatives, talk with loved ones who may be impacted by your decision, and select a surgeon who is knowledgeable, receptive to your questions, and experienced in your chosen procedure.
As a general rule:
- Surgical procedures offer the best relief of BPH symptoms but side effects and complications are more common
- TURP and laser procedures (i.e., PVP, HoLAP, HoLEP) have similar significant improvement in urinary symptoms and long-term outcomes
- Laser procedures have fewer short-term side effects compared with TURP
- TURP results can last up to 15 years, but erectile dysfunction and retrograde ejaculation occurrence are high
- Most men can stop taking BPH medications after TUNA or TUMT
- TUNA, TUMT, and ILT are equally effective in relieving symptoms of BPH
- The options associated with the lowest occurrence of erectile dysfunction include Urolift, prostate artery embolization, HoLAP, HoLEP, and PVP
- Looking at the short-term (24 month) need for reoperation, the four more common procedures come in at 2.09% for PVP, 2.2% for TURP, 11.9% for TUMT, and 14% for TUNA.
- Stents are a short-term solution with a high complication rate and usually reserved for men who cannot or will not undergo other surgical procedures
- Prostate artery embolization is a relatively new procedure that has provided good symptom relief, offered no problems with erectile dysfunction, incontinence, or retrograde ejaculation, but is still under investigation and not widely available
- Urolift System has a low retreatment rate, no occurrence of erectile dysfunction and retrograde ejaculation, and good symptom relief, but it is relatively new and needs long-term studies. At this time, not all Medicare carriers cover this treatment.
- BPH symptom relief is similar between TURP and TUIP, but men who choose TUIP are more likely to need a repeat procedure yet less likely to experience retrograde ejaculation.