Benign prostatic hyperplasia: from bench to clinic

Benign prostatic hyperplasia (BPH) is a prevalent disease, especially in old men, and often results in lower urinary tract symptoms (LUTS). This chronic disease has important care implications and financial risks to the health care system. LUTS are caused not only by mechanical prostatic obstruction but also by the dynamic component of obstruction. The exact etiology of BPH and its consequences, benign prostatic enlargement and benign prostatic obstruction, are not identified. Various theories concerning the causes of benign prostate enlargement and LUTS, such as metabolic syndrome, inflammation, growth factors, androgen receptor, epithelial-stromal interaction, and lifestyle, are discussed. Incomplete overlap of prostatic enlargement with symptoms and obstruction encourages focus on symptoms rather than prostate enlargement and the shifting from surgery to medicine as the treatment of BPH. Several alpha antagonists, including alfuzosin, doxazosin, tamsulosin, and terazosin, have shown excellent efficacy without severe adverse effects. In addition, new alpha antagonists, silodosin and naftopidil, and phosphodiesterase 5 inhibitors are emerging as BPH treatments. In surgical treatment, laser surgery such as photoselective vaporization of the prostate and holmium laser prostatectomy have been introduced to reduce complications and are used as alternatives to transurethral resection of the prostate (TURP) and open prostatectomy. The status of TURP as the gold standard treatment of BPH is still evolving. We review several preclinical and clinical studies about the etiology of BPH and treatment options.

Comparison of effectiveness of monopolar and bipolar transurethral resection of the prostate and open prostatectomy in large benign prostatic hyperplasia

PURPOSE

Transurethral resection of the prostate (TURP) is still considered the gold standard in the treatment of benign prostatic hyperplasia (BPH). However, open prostatectomy is indicated for prostate glands over 75 ml. There have been few reports concerning the use of TURP for large prostate glands over 100 ml. Herein we compared the effectiveness of monopolar TURP, bipolar TURP, and open prostatectomy in prostate glands larger than 100 ml.

MATERIALS AND METHODS

We reviewed the data of 48 patients with prostate glands larger than 100 ml. A total of 19, 17, and 12 patients underwent monopolar TURP (group A), bipolar TURP (group B), or open prostatectomy (group C), respectively. Preoperative International Prostate Symptom Score (IPSS), maximal flow rate (Qmax), prostate volume, resected tissue volume, resection velocity, and operative time were documented. Postoperative hemoglobin, serum sodium change, hospital stay, and postoperative 6-month IPSS and Qmax were evaluated.

RESULTS

The prostate volumes did not differ significantly among the three groups. Operative time was similar in the two TURP groups, but open prostatectomy required a longer operative time. There was no significant difference in the resected prostate tissue or resection velocity between the two TURP groups. There was a marked decrease in postoperative serum sodium in the monopolar group compared with the other two groups. Among the groups, bipolar TURP required a shorter hospitalization. Postoperative IPSS, quality of life (QoL), and Qmax improved significantly in all groups.

CONCLUSIONS

Even for large prostate glands, the results of this study suggest that bipolar TURP is an effective and safe operation owing to the significant improvements in voiding symptoms, shorter hospitalization, and fewer complications such as transurethral resection syndrome.

Early Experience with Laparoscopic Retropubic Simple Prostatectomy in Patients with Voluminous Benign Prostatic Hyperplasia (BPH)

Purpose

Laparoscopic simple prostatectomy was recently developed to treat voluminous benign prostatic hyperplasia (BPH). We describe the surgical technique and assess the feasibility of laparoscopic simple prostatectomy through our early experience.

Materials and Methods

The medical records of 11 patients who underwent laparoscopic simple prostatectomy between March 2008 and January 2010 were retrospectively analyzed. The subjects were limited to the patients who satisfied the following conditions: prostate volume was at least 75 g, acute urinary retention repeatedly occurred or maximal flow rate (Qmax) was at most 10 ml/s, and International Prostate Symptom Score (IPSS) was at least 12. The surgery was performed by the laparoscopic extraperitoneal approach with a transcapsular route. Feasibility was assessed by objective operative parameters (reconversion, operating time, and blood loss) and perioperative complications. Data on short-term follow-up were also available.

Results

The mean age of the patients was 70.6 years. Mean preoperative prostate-specific antigen and prostate volume were 6.1 ng/ml and 109.3 cc, respectively. Mean operation time was 191.9 minutes and estimated blood loss was 390.9 cc. The resected adenoma weighed on average 72.4 g. No conversion to open surgery was required. Mean preoperative IPSS and quality of life (QoL) scores were 26.86 and 4.86. Mean Qmax, measured before the surgery, was 4.5 ml/s and residual urine was 106 ml. Mean postoperative IPSS and QoL scores were 4.2 and 1.5. After the surgery, mean Qmax was 15.5 ml/s and residual urine was 24.1 ml.

Conclusions

In the case of voluminous BPH, laparoscopic retropubic simple prostatectomy is expected to be a useful treatment on the condition that the learning curve can be overcome with clinical experience.