Editorials

Managing BPH: When to Consider Surgery



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Am Fam Physician. 2008 May 15;77(10):1375-1377.

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In this issue of American Family Physician, Dr. Edwards presents an excellent overview of the management options for benign prostatic hyperplasia (BPH).1 Family physicians commonly counsel patients on surgical options when symptoms do not resolve with medical therapy. Clearly, surgical intervention is necessary in patients with urinary retention or recurrent urinary tract infections; however, the decision is not as clear in other patients. Dr. Edwards accurately reviews the effectiveness of BPH management options. It is also essential that family physicians understand the inherent risks of each option.

Medical therapy for BPH has several risks (Table 1).2 Combination therapy with alpha blockers and 5-alpha reductase inhibitors is an option when monotherapy fails. In one trial, the risk of adverse reactions with combination therapy (terazosin [Hytrin] and finasteride [Proscar]) was similar to the baseline risk with each drug alone.3 The exception was ejaculatory abnormalities, which were reported at a rate of 7 percent in the combination therapy group compared with up to 2 percent in the other groups. During the one-year trial, approximately 8 percent of patients discontinued combination therapy because of adverse reactions, which was comparable with discontinuation rates in the alpha-blocker group. Adverse reactions in patients taking selective alpha blockers with 5-alpha reductase inhibitors are undocumented.3

Table 1

Adverse Reactions Associated with Medical Therapies for Benign Prostatic Hyperplasia

Therapy Adverse reactions (% of patients)

Alpha blockers

Dizziness (19)

Fatigue/malaise (12)

Edema (2.7)

Dyspnea (2.6)

Hypotension (1.7)

Selective alpha blockers

Dizziness (14 to 17)

Retrograde ejaculation (8 to 18)

First-dose orthostasis/syncope (7)

Somnolence (3 to 7)

5-Alpha reductase inhibitors

Erectile dysfunction (1 to 10)

Decreased semen production (1 to 10)

Decreased libido (1 to 10)

Gynecomastia (0.1 to 1)

Ejaculation disorders (0.1 to 1)


Information from reference 2.

Table 1   Adverse Reactions Associated with Medical Therapies for Benign Prostatic Hyperplasia

View Table

Table 1

Adverse Reactions Associated with Medical Therapies for Benign Prostatic Hyperplasia

Therapy Adverse reactions (% of patients)

Alpha blockers

Dizziness (19)

Fatigue/malaise (12)

Edema (2.7)

Dyspnea (2.6)

Hypotension (1.7)

Selective alpha blockers

Dizziness (14 to 17)

Retrograde ejaculation (8 to 18)

First-dose orthostasis/syncope (7)

Somnolence (3 to 7)

5-Alpha reductase inhibitors

Erectile dysfunction (1 to 10)

Decreased semen production (1 to 10)

Decreased libido (1 to 10)

Gynecomastia (0.1 to 1)

Ejaculation disorders (0.1 to 1)


Information from reference 2.

Transurethral resection of the prostate (TURP) is the standard to which other surgical procedures are compared. However, several alternatives have emerged (Table 2).411 The rate of erectile dysfunction in patients undergoing TURP is difficult to interpret. Although some studies report a rate of up to 70 percent,6 the only high-quality study found no significant difference between TURP and watchful waiting.4 This finding raises the important point that some patients develop erectile dysfunction even without surgery. However, interpretation of the results is complicated by the heterogeneous methods of assessing erectile function.

Although standardized scores of erectile function are convenient for statistical purposes, they may not accurately convey the patient-oriented experience of postoperative treatment. The best evidence supports transurethral needle ablation and transurethral incision of the prostate over TURP for erectile dysfunction prevention.811

Although medical therapy generally should be initiated before considering surgical therapy, the benefits must be balanced against adverse reaction profiles. Combination therapy is reasonable in patients who do not respond to monotherapy; however, the additional risk of adverse reactions deters many patients. TURP is the most effective technique for reducing the risk of reoperation and urinary symptoms, although several alternative procedures achieve similar short-term relief with fewer complications.

Patients considering surgery should be reminded that the adverse effects of medications are generally reversible after discontinuation of therapy (e.g., dizziness, fatigue, erectile dysfunction), whereas many surgical complications are irreversible (e.g., erectile dysfunction, retrograde ejaculation). As Dr. Edwards states, the therapeutic decision should depend on the individual patient's history, surgical risks, and willingness to tolerate specific adverse effects and complications.

Table 2

Complications of Surgical Procedures for Benign Prostatic Hyperplasia

Procedure Description Short-term complications Occurrence of short-term complications Risk of retreatment or resurgery Risk of sexual dysfunction

TURP

Recommended surgical technique because of the extensive data validating its effectiveness

Urinary retention or recatheterization

4 percent

0 to 8 percent6 (most trials show 2 to 5 percent)

Erectile dysfunction: 0 to 70 percent (most trials show 10 to 20 percent) 410 Retrograde ejaculation: 57 percent 4,5

TURP syndrome*

1 percent

UTI4,5

1 to 13 percent 4,5

Transfusion4,5

1 to 6 percent 4,5

Transurethral incision of the prostate

Incision from the urethra to the external capsule in each lobe of the prostate; may be performed under regional anesthesia; only appropriate for prostate size less than 30 mL

Urinary retention or recatheterization

Reduced incidence of all short-term complications; precise incidence not reported7

Comparable with TURP 7,11

Erectile dysfunction: less than TURP; precise incidence not reported 7 Retrograde ejaculation: comparable with TURP11

TURP syndrome*

UTI (comparable with TURP, trend favors transurethral needle ablation)

Transfusion

Transurethral needle Ablation

Placement of radio frequency needles in the prostate to ablate tissue

Urinary retention or recatheterization

Comparable with TURP, trend favors TURP

10 percent

Erectile dysfunction: 0.3 percent; odds ratio compared with TURP: 0.29 (95% CI, 0.13 to 0.63)10 Retrograde ejaculation: 0.2 percent; odds ratio compared with TURP: 0.03 (95% CI, 0.01 to 0.06)10

TURP syndrome*

Not reported

UTI

Comparable with TURP, trend favors transurethral needle ablation

Transfusion

0 percent8

Transurethral Microwave thermotherapy

Minimally invasive outpatient treatment; microwave antenna irradiates the prostate to decrease prostate size

Urinary retention or recatheterization

23 percent

Odds ratio compared with TURP: 10.05 (P < .001)

Erectile dysfunction: 5 percent5 Retrograde ejaculation: 22.2 percent5

TURP syndrome*

0 percent5

UTI

18 percent5

Transfusion

0 percent5

Laser prostatectomy

Inpatient procedure using a variety of laser techniques to ablate the prostate tissue

Urinary retention or recatheterization

Similar to TURP

7 to 20 percent8

Erectile dysfunction and retrograde ejaculation: not significantly different than with TURP8

TURP syndrome*

Not reported

UTI

Two times more likely than with TURP; P < .05

Transfusion

0 percent8

Transurethral Electrovaporization of the prostate

Endoscopic electrosurgical equipment is used to destroy prostatic tissue with limited coagulation

Urinary retention or recatheterization

Pooled difference estimate compared with TURP: 2.89; P = .001

Pooled difference estimate compared with TURP: 2.57; P = .0019 Pooled difference estimate favors TURP if greater than 1, favors transurethral electrovaporization if less than 1

Erectile dysfunction and retrograde ejaculation: not significantly different than with TURP8,9

TURP syndrome*

Comparable with TURP

UTI

Comparable with TURP

Transfusion

Pooled difference estimate compared with TURP: 0.16, P < .0019


CI = confidence interval; TURP = transurethral resection of the prostate; UTI = urinary tract infection.

*— Hyponatremia related to the hypotonic rinse solution

Information from references 4 through 11.

Table 2   Complications of Surgical Procedures for Benign Prostatic Hyperplasia

View Table

Table 2

Complications of Surgical Procedures for Benign Prostatic Hyperplasia

Procedure Description Short-term complications Occurrence of short-term complications Risk of retreatment or resurgery Risk of sexual dysfunction

TURP

Recommended surgical technique because of the extensive data validating its effectiveness

Urinary retention or recatheterization

4 percent

0 to 8 percent6 (most trials show 2 to 5 percent)

Erectile dysfunction: 0 to 70 percent (most trials show 10 to 20 percent) 410 Retrograde ejaculation: 57 percent 4,5

TURP syndrome*

1 percent

UTI4,5

1 to 13 percent 4,5

Transfusion4,5

1 to 6 percent 4,5

Transurethral incision of the prostate

Incision from the urethra to the external capsule in each lobe of the prostate; may be performed under regional anesthesia; only appropriate for prostate size less than 30 mL

Urinary retention or recatheterization

Reduced incidence of all short-term complications; precise incidence not reported7

Comparable with TURP 7,11

Erectile dysfunction: less than TURP; precise incidence not reported 7 Retrograde ejaculation: comparable with TURP11

TURP syndrome*

UTI (comparable with TURP, trend favors transurethral needle ablation)

Transfusion

Transurethral needle Ablation

Placement of radio frequency needles in the prostate to ablate tissue

Urinary retention or recatheterization

Comparable with TURP, trend favors TURP

10 percent

Erectile dysfunction: 0.3 percent; odds ratio compared with TURP: 0.29 (95% CI, 0.13 to 0.63)10 Retrograde ejaculation: 0.2 percent; odds ratio compared with TURP: 0.03 (95% CI, 0.01 to 0.06)10

TURP syndrome*

Not reported

UTI

Comparable with TURP, trend favors transurethral needle ablation

Transfusion

0 percent8

Transurethral Microwave thermotherapy

Minimally invasive outpatient treatment; microwave antenna irradiates the prostate to decrease prostate size

Urinary retention or recatheterization

23 percent

Odds ratio compared with TURP: 10.05 (P < .001)

Erectile dysfunction: 5 percent5 Retrograde ejaculation: 22.2 percent5

TURP syndrome*

0 percent5

UTI

18 percent5

Transfusion

0 percent5

Laser prostatectomy

Inpatient procedure using a variety of laser techniques to ablate the prostate tissue

Urinary retention or recatheterization

Similar to TURP

7 to 20 percent8

Erectile dysfunction and retrograde ejaculation: not significantly different than with TURP8

TURP syndrome*

Not reported

UTI

Two times more likely than with TURP; P < .05

Transfusion

0 percent8

Transurethral Electrovaporization of the prostate

Endoscopic electrosurgical equipment is used to destroy prostatic tissue with limited coagulation

Urinary retention or recatheterization

Pooled difference estimate compared with TURP: 2.89; P = .001

Pooled difference estimate compared with TURP: 2.57; P = .0019 Pooled difference estimate favors TURP if greater than 1, favors transurethral electrovaporization if less than 1

Erectile dysfunction and retrograde ejaculation: not significantly different than with TURP8,9

TURP syndrome*

Comparable with TURP

UTI

Comparable with TURP

Transfusion

Pooled difference estimate compared with TURP: 0.16, P < .0019


CI = confidence interval; TURP = transurethral resection of the prostate; UTI = urinary tract infection.

*— Hyponatremia related to the hypotonic rinse solution

Information from references 4 through 11.

Address correspondence to Drew Keister, MD, at drew.keister@offutt.af.mil. Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

1. Edwards JL. Diagnosis and management of benign prostatic hyperplasia. Am Fam Physician. 2008;77(10):1403–1410,1413.

2. Sanborn KD, LaGow B. Physicians' Desk Reference. 61st ed. Montvale, N.J.: Thomson PDR; 2007:471, 850, 2067.

3. Lepor H, Williford WO, Barry MJ, et al., for the Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group. The efficacy of terazosin, finasteride, or both in benign prostatic hyperplasia. N Engl J Med. 1996;335(8):533–539.

4. Wasson JH, Reda DJ, Bruskewitz RC, Elinson J, Keller AM, Henderson WG, for the Veterans Affairs Cooperative Study Group on Transurethral Resection of the Prostate. A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. N Engl J Med. 1995;332(2):75–79.

5. Hoffman RM, MacDonald R, Monga M, Wilt TJ. Transurethral microwave thermotherapy vs transurethral resection for treating benign prostatic hyperplasia: a systematic review. BJU Int. 2004;94(7):1031–1036.

6. Poulakis V, Ferakis N, Witzsch U, de Vries R, Becht E. Erectile dysfunction after transurethral prostatectomy for lower urinary tract symptoms: results from a center with over 500 patients. Asian J Androl. 2006;8(1):69–74.

7. Shabbir M, Kirby RS. Fact or fiction: what do the benign prostatic hyperplasia data tell us? Curr Urol Rep. 2005;6(4):243–250.

8. Hoffman RM, MacDonald R, Wilt TJ. Laser prostatectomy for benign prostatic obstruction. Cochrane Database Syst Rev. 2004;(1):CD001987.

9. Poulakis V, Dahm P, Witzsch U, Sutton AJ, Becht E. Transurethral electrovaporization vs transurethral resection for symptomatic prostatic obstruction: a meta-analysis. BJU Int. 2004;94(1):89–95.

10. Bouza C, López T, Magro A, Navalpotro L, Amate JM. Systematic review and meta-analysis of transurethral needle ablation in symptomatic benign prostatic hyperplasia. BMC Urol. 2006;6:14.

11. Tkocz M, Prajsner A. Comparison of long-term results of transurethral incision of the prostate with transurethral resection of the prostate, in patients with benign prostatic hypertrophy. Neurourol Urodyn. 2002;21(2):112–116.


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