Surgery for benign prostatic hyperplasia

Prostate laser surgery is used to relieve moderate to severe urinary symptoms caused by prostate enlargement. The surgeon inserts a scope through the penis tip into the urethra. A laser passed through the scope delivers energy to shrink or remove excess tissue that is preventing urine flow.[7]

Different types of prostate laser surgery include:

• Visual laser ablation of the prostate (VLAP) technique involving the Nd:YAG laser with contact on the prostatic tissue.
• Photoselective Vaporisation of the Prostate (PVP). A laser is used to melt away (vaporize) excess prostate tissue and enlarge the urinary channel.[7] A high-power 180-watt 532 nm wavelength laser with a 650-micrometre laser fiber is used. This fiber has an internal reflection with a 70-degree deflecting angle. It is used to vaporize the tissue to the prostatic capsule. GreenLight 532 nm lasers target haemoglobin as the chromophore and typically have a penetration depth of 0.8 mm (twice as deep as holmium).
• Holmium Laser Ablation of the Prostate (HoLAP) is similar to PVP but uses a different type of laser.[7] HoLAP uses a 550 um disposable side-firing fiber that directs the beam from a high-power 100-watt laser at a 70-degree angle from the fiber axis. The holmium wavelength is 2,140 nm, which falls within the infrared portion of the spectrum and is invisible to the naked eye. Whereas GreenLight relies on haemoglobin as a chromophore, water within the target tissue is the chromophore for Holmium lasers. The penetration depth of Holmium lasers is <0.4 mm, avoiding complications associated with tissue necrosis often found with the deeper penetration and lower peak powers of Nd:YAG lasers used in the 1990s.[5]
• Holmium Laser Enucleation of the Prostate (HoLEP) is used to cut and remove the excess tissue that is blocking the urethra. Another instrument is then used to cut the prostate tissue into small pieces that are easily removed. HoLEP can be an option for men who have a severely enlarged prostate and is the only prostate size-independent treatment option approved by the American Urologic Association.[8] HoLEP is largely similar to the HoLAP procedure; the main difference is that instead of ablating the tissue, the laser cuts a portion of the prostate, which is then cut into smaller pieces and flushed with irrigation fluid. As with the HoLAP procedure, there is little bleeding during or after the procedure. Three 2015 reviews found that HoLEP is superior to TURP in some respects and for some patients.[5][9][10]

Both wavelengths, GreenLight and Holmium, ablate approximately one to two grams of tissue per minute.

Post-surgical care often involves placement of a Foley catheter or a temporary prostatic stent to permit healing and allow urine to drain from the bladder.

These procedures are typically performed with local anesthesia, and the patient returns home the same day. Some urologists have studied and published long-term data on the outcomes of these procedures, with data out to five years.

Transurethral microwave thermotherapy (TUMT) was originally approved by the United States Food and Drug Administration (FDA) in 1996, with the first generation system by EDAP Technomed. Since 1996, other companies have received FDA approval for TUMT devices, including Urologix, Dornier, Thermatrix, Celsion, and Prostalund. Multiple clinical studies have been published on TUMT. The general principle underlying all the devices is that a microwave antenna that resides in a urethral catheter is placed in the intraprostatic area of the urethra. The catheter is connected to a control box outside of the patient's body and is energized to emit microwave radiation into the prostate to heat the tissue and cause necrosis. It is a one-time treatment that takes approximately 30 minutes to 1 hour, depending on the system used. It takes approximately 4 to 6 weeks for the damaged tissue to be reabsorbed into the patient's body. Some of the devices incorporate circulating coolant through the treatment area with the intent of preserving the urethra while the microwave energy heats the prostatic tissue surrounding the urethra.

Transurethral needle ablation (TUNA) operates with a different type of energy, radio frequency (RF) energy, but is designed along the same premise as TUMT devices, that the heat the device generates will cause necrosis of the prostatic tissue and shrink the prostate. The TUNA device is inserted into the urethra using a rigid scope much like a cystoscope. The energy is delivered into the prostate using two needles that emerge from the sides of the device, through the urethral wall and into the prostate. The needle-based ablation devices are very effective at heating a localized area to a high enough temperature to cause necrosis. The treatment is typically performed in one session, but may require multiple sticks of the needles depending on the size of the prostate. The most recent American Urological Association (AUA) Guidelines for the Treatment of BPH from 2018 stated that "TUNA is not recommended for the treatment of LUTS/BPH".[11]

Water vapour thermal therapy (marketed as Rezum) is a newer office procedure for removing prostate tissue using steam. Several studies including a four-year follow-up provided evidence for improvement of BPH symptoms, preserved sexual function, and low surgical retreatment rates.[12][13]

Prostatic urethral lift (marketed as Urolift) is a procedure for men with urinary symptoms caused by prostate enlargement. It consists of placing small hooks that compress the prostate tissue to open the urinary stream without cutting or removing tissue. This procedure likely improves quality of life without additional negative side effects when compared with a sham surgery.[14]

Compared with transurethral resection of the prostate, the standard surgery for treating benign prostatic hyperplasia, this procedure may be less effective in reducing urinary symptoms but may preserve ejaculation and have fewer unwanted effects on erections.[14]

Temporary implantable nitinol device (marketed as TIND and iTIND) is a device that is placed in the urethra that, when released, is expanded, reshaping the urethra and the bladder neck.

The American Urological Association (AUA) guidelines for the treatment of BPH from 2018 list minimally invasive therapies including TUMT - but not TUNA - as acceptable alternatives for certain patients with BPH.[11] However, the European Association of Urology (EAU) has - as of 2019 - removed both TUMT and TUNA from its guidelines.[15]