A critical evaluation of technological innovations in the treatment of symptomatic benign prostatic hyperplasia

A Systematic Review of Holmium Laser Prostatectomy for Benign Prostatic Hyperplasia

PURPOSE

We undertook a systematic review to assess the safety and efficacy of holmium laser prostatectomy compared to transurethral resection of the prostate.

MATERIALS AND METHODS

We searched literature databases through August 2002. Holmium laser studies, including holmium laser resection of the prostate (HoLRP) and holmium laser enucleation of the prostate (HoLEP), of any design, and the transurethral prostatectomy (TURP) arms of randomized controlled trials (RCTs) with sample sizes greater than 50 patients, date restricted to 1995 onward, were included for comparison.

RESULTS

Three RCTs comparing HoLRP and TURP, and 2 RCTs comparing HoLEP and TURP were identified. For each of the holmium procedures there was also 1 nonrandomized comparative study and a number of case series (HoLRP 13, HoLEP 10). With the exception of 1 randomized trial the quality of the available evidence was poor, with the other RCTs lacking information regarding methods of randomization, allocation concealment and blinding. The majority of studies were characterized by relatively short followup periods and significant losses to followup. In terms of safety the data suggest that the holmium laser procedures are superior to TURP with regard to a number of key indicators of blood loss (transfusion rates, postoperative bladder irrigation, duration of catheterization and length of hospital stay), although amount of blood loss was rarely reported. In terms of efficacy the holmium laser procedures appear to be similarly effective to TURP in relieving the symptoms of benign prostatic hyperplasia.

CONCLUSIONS

Holmium laser prostatectomy is at least as effective as TURP for managing the symptoms of benign prostatic hyperplasia. However, at the present time the long-term durability of the holmium procedures with respect to TURP cannot be determined due to a lack of published studies with sufficient followup.

Transurethral vaporisation of the prostate and irrigating fluid absorption

Transurethral vaporisation of the prostate gland (TUVP) is an emerging surgical alternative to conventional electroresection (TURP). This study examined vesical pressure and fluid absorption during TUVP in 35 patients with benign prostatic hypertrophy. The irrigating fluid was a solution of glycine 1.5% and ethanol 1%. Intraoperative intravesical pressure was monitored continuously and absorption of irrigating fluid was detected by ethanol analysis in expired breath. The incidence of absorption during TUVP was 34%. Intravesical pressures were higher amongst patients who went on to absorb than amongst patients who did not. Combining data from the current study and from 35 patients in our previous investigation into TURP (Gray et al.: Anaesthesia 2001; 56: 461-4), urological trainees operated at higher mean pressure and for longer than their consultant colleagues and their resections were significantly more likely to result in absorption. The incidence of irrigating fluid absorption during trainees' operations appeared to be less using TUVP than using conventional TURP.

Sexual function in patients with benign prostatic hyperplasia

Sexual health has significant impact on quality of life among men with benign prostatic hyperplasia (BPH). The degree of sexual dysfunction matches the severity of lower urinary tract symptoms (LUTS). Treatment of BPH affects not only LUTS, but sexual function as well. Medical, surgical, and minimally invasive therapies differ in their effect on erectile function, ejaculation, and sexual satisfaction. Choice of treatment modality takes into account baseline sexual function and patient expectations. This review outlines the relationship between LUTS and sexual function and how they change with the currently available treatments.

High intensity focused ultrasound in benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is an extremely common condition and represents a major health issue in terms of patient numbers and treatment cost. Traditionally, the choice of treatment has been between watchful waiting and surgery, however, the side effects of surgery lead to reluctance for treatment in many men, other than those with severe symptoms and complications. In the last 2 decades there has been a rapid expansion in the number of treatments being offered and the number of patients submitting to novel therapies. Medical management has evolved to achieve a central role in the management of BPH. Heat based treatments are also being investigated with considerable interest. Transrectal high intensity focused ultrasound (HIFU) is one such treatment, which allows radiation-free treatment, without the need for intra-urethral manipulation. Imaging can be performed during treatment and treatment results in symptomatic improvement, which is retained with medium-term follow-up. It involves a brief hospital stay and post-operative complications are few. The use of HIFU has also been extended to the treatment of renal, prostatic and bladder tumours and the results in these areas suggest further expansion of its role in urological practice.