BPH treatment options when drugs are not enough

Most men develop some degree of prostate enlargement as they age. In many cases, the enlarged gland presses against the passage that leads out of the bladder, making it hard to urinate. This noncancerous condition, called benign prostatic hyperplasia (BPH), is treatable with medications and lifestyle changes (such as limiting fluids before bed). But if urinary symptoms worsen despite these strategies, or if treatment side effects become too bothersome, the next step is surgery.

Surgical procedures physically remove or reposition prostate tissues that block urine flow, and they can provide lasting relief. With the number of surgical options growing steadily, choosing among them can be a daunting prospect.

"There isn't one surgical approach that's right for all men," says Dr. Heidi Rayala, an assistant professor of surgery at Harvard Medical School and a urologist at Beth Israel Deaconess Medical Center. "Men really need to think about their priorities and do a bit of self-education, then sit down with a urologist to talk through which options make the most sense for them."

A question of trade-offs

All BPH procedures involve a trade-off between benefits and side effects. Many men worry especially about a common side effect that reduces the amount of semen they will eject during an orgasm. That can happen if surgeons remove or alter muscles that propel semen through the penis. Men can still have erections, but they have "dry" orgasms.

Dr. Rayala explains that the BPH procedures that offer the longest-lasting relief of urinary symptoms are also the ones most likely to disrupt ejaculation. In a procedure called holmium laser enucleation of the prostate, or HoLEP, for instance, surgeons pass a laser through the penis and use it to "core out" the inside of the prostate, leaving the outer shell in place. Because HoLEP disrupts muscles near the bladder, the loss of visible semen is very common. But HoLEP is also, as Dr. Rayala puts it, a "one-and-done procedure" offering symptom relief that can last several decades.

That's also true of another BPH operation called simple prostatectomy, which also has high rates of ejaculatory side effects. (A simple prostatectomy, which, like HoLEP cores out the prostate, should not be confused with a cancer surgery known as radical prostatectomy, used to completely remove the gland.) A simple prostatectomy is performed robotically, with the surgeon controlling robotic arms and tiny instruments inserted through small abdominal incisions.

Size matters

HoLEP and simple prostatectomy are recommended especially for men with very large prostates. A normal adult prostate weighs between 20 and 30 grams, but an enlarged gland in someone with BPH can weigh 200 to 300 grams or more. Men whose prostates are moderately enlarged - up to 80 or 90 grams - have more diverse options. Here are some of the most common:

Wire loops and lasers. Until recently, a procedure called transurethral resection of the prostate (TURP) was considered the gold standard treatment for men with moderate prostate enlargement. Unlike HoLEP and simple prostatectomy, both of which hollow out the prostate entirely, TURP shaves a channel through the gland using a heated loop of wire. A variation on the procedure, called photoselective vaporization of the prostate (PVP), works the same way, but uses a laser to eliminate obstructing tissues. TURP and PVP can provide a decade or more of symptom relief, but ejaculatory side effects are also common, affecting between 65% and 90% of patients.

Saline jets. A newer alternative, called aquablation, preserves ejaculation in about 80% of men, far better than traditional options. Aquablation removes prostate tissues with jets of pressured saline (salt water), and it works well for larger glands weighing up to 120 grams. "It's a good alternative if preserving the ability to ejaculate is a big priority," says Dr. Rayala. However, men still have a one-in-five chance of developing ejaculatory side effects, she emphasizes, and long-term data on symptom relief with this technique are still limited.

Most of the major BPH surgeries are done in an operating room under general or regional anesthesia. An overnight stay in the hospital is common, and men usually go home with a catheter that may remain in place for one or several days. In the first days and weeks, frequent and urgent needs to urinate - along with burning during urination - are typical as the bladder and the urethra (the tube that carries urine) heal. Long-term incontinence is rare, affecting fewer than about 2% of men.

Minimally invasive procedures

The latest trend in BPH treatment entails office-based procedures such as Rezum, UroLift, and prostate artery embolization (PAE). Performed under local anesthesia, light sedation, or a combination, they're "more likely to spare ejaculation," Dr. Rayala says. Minimally invasive methods aren't as good as more traditional surgeries for removing obstructions, and it's uncertain how long the benefits will last. Dr. Rayala suggests they're suitable mainly for younger, sexually active men, who accept that they might need a bigger procedure later, or older men who are too frail for more invasive surgery.

Final thoughts

Dr. Rayala urges men to keep in mind that BPH is a progressive condition. "If you wait too long for surgical treatment, the bladder can be damaged from years of pushing against a blockage," she says. "That's why we're more proactive now about considering procedures while men are still healthy enough to really benefit."

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