Update on minimally invasive surgery and benign prostatic hyperplasia

Abstract

Transurethral resection of the prostate (TURP) became the gold standard surgical treatment for benign prostatic obstruction without undergoing randomized controlled trials against the predecessor standard in open suprapubic prostatectomy. TURP has historically been associated with significant morbidity and this has fuelled the development of minimally invasive surgical treatment options. Improvements in perioperative morbidity for TURP has been creating an ever increasing standard that must be met by any new technologies that are to be compared to this gold standard. Over recent years, there has been the emergence of novel minimally invasive treatments such as the prostatic urethral lift (PUL; UroLift System), convective WAter Vapor Energy (WAVE; Rezum System), Aquablation (AQUABEAM System), Histotripsy (Vortx Rx System) and temporary implantable nitinol device (TIND). Intraprostatic injections (NX-1207, PRX-302, botulinum toxin A, ethanol) have mostly been used with limited efficacy, but may be suitable for selected patients. This review evaluates these novel minimally invasive surgical options with special reference to the literature published in the past 5 years.

Transperineal intraprostatic injection of botulinum neurotoxin A vs transurethral resection of prostate for management of lower urinary tract symptoms secondary to benign prostate hyperplasia: A prospective randomised study

“…TURP as previously documented became the 'gold standard' surgical treatment for BPH [10,11,[26][27][28], thus the present study evaluated the outcome of patients with LUTS secondary to BPH (LUTS/BPH) using transperineal intraprostatic BoNT-A injection in comparison to TURP. Patients in the BoNT-A group received 200 U BoNT-A, the choice of the injection dose was dependent on previous findings; Crawford et al [29] found that BoNT-A injection of 100 or 300 U BoNT-A is effective and safe, but the 100 U dose may be preferable due to similar efficacy with reduced costs and adverse effects.…”

An Update on Minimally Invasive Surgery for Benign Prostatic Hyperplasia: Techniques, Risks, and Efficacy

“…A nickel-titanium alloy, or nitinol, device aims to relieve LUTS due to BPH by using expanded struts that exert a radial force [21]. The radial force compresses obstructive prostatic lobes causing local ischemic necrosis of the urethral mucosa [22].…”

“…The least studied technique thus far, histotripsy uses high intensity ultrasound technology to vaporize fluid in prostatic tissues and release gaseous microbubbles which cause tissue destruction [7,21,41]. In animal studies with canines by Darnell et al [42] in 2015 found that histotripsy caused 31% decrease in prostate volume with limited inflammation and fibrosis.…”

“…A robotic-assisted novel technique, Aquablation utilizes high-pressure saline to dissect prostatic tissue under transrectal ultrasound guidance [7,21,43]. Once resection is complete, cauterization can be used to initiate hemostasis.…”

“…The primary advantages of Aquablation include a resection time of under 10 minutes, preservation of sexual function and urinary continence, and avoidance of thermal damage (which seems to be the reason for the reduction in urinary symptoms) [21,43,44]. With only one double blind RCT to date, lack of consistent Level 1 evidence and long-term follow-up pose the biggest disadvantages to this procedure [45].…”