Minimally-Invasive Treatments for Lower Urinary Tract Symptoms in People with Benign Prostatic Hyperplasia: A Review of Clinical Effectiveness [Internet]

Excerpt

Benign prostatic hyperplasia or hypertrophy (BPH) refers to the enlargement of the prostate gland in men due to an overgrowth of cells. Although it is not a life-threatening condition, BPH causes serious morbidity in the form of lower urinary tract symptoms (LUTS) in an estimated 50% of men older than 75 years. As the prostate gland grows, it presses against the urethra and may partially obstruct the flow of urine from the bladder causing dribbling or a weak urine stream, the urge to urinate, and incomplete voiding or urine retention.

The first line of treatment for LUTS involves lifestyle changes. Drinking less fluids, avoiding fluids that contain caffeine or alcohol, reducing the intake of certain medications, and conducting specific exercises may alleviate some mild BPH symptoms. If symptoms progress, alpha-blockers, 5-alpha-reductase inhibitors, phosphodiesterase-5 inhibitors, or muscle relaxants may be offered.

For moderate to severe cases of LUTS that are unresponsive to medical management, surgery is the primary choice of treatment, the most common form being transurethral resection of the prostate (TURP). Prostatectomy (or a complete removal of the prostate) may be considered if the urethra is completely blocked or the prostate is extremely enlarged.

Side effects of surgery such as bleeding, infection, retrograde ejaculation, erectile dysfunction, and incontinence have been reported. To limit the occurrence of side effects, several minimally-invasive treatments have been developed. They include, but are not limited to, aquablation, prostatic artery embolization or embolotherapy (PAE), prostate urethral lift (PUL), and water vapour thermal therapy (WVTT). Each of these techniques is based on a unique technology. Aquablation for example, uses water under high pressure to resect tissue from the prostate under ultrasound image guidance.^, Also under image guidance, PAE entails injecting an embolizing agent or pharmaceutical into prostatic arteries via a catheter to block blood flow to the prostate, cause tissue death and consequently reduce the size of the prostate. PUL involves the use of a needle-shaped probe to deliver permanent or temporary mechanical implants into the urethra to relieve obstructions. The implants pull back the lateral lobes of the urethra causing the latter to widen and lower resistance to the flow of urine. Another water-based technique, WVTT, uses a radiofrequency system to generate and deliver water vapour to the transition zone of the prostate. Through convection, heat from the steam transfers to the prostate tissue and gradually causes cell death. Other minimally-invasive options involve the use of lasers to resect prostate tissue.

This review aims to summarize evidence regarding the clinical effectiveness of select minimally-invasive techniques for the treatment of LUTS associated with BPH.