Benign prostatic hyperplasia (BPH) is remarkable in its prevalence. The disease is almost synonymous with aging, its incidence increasing as people get older to affect about 10-20% of men in their thirties and forties, 50-60% in their sixties, and 80-90% in their seventies and eighties.1 These numbers make BPH the fifth most common non-cancerous disorder facing men 50 and older.2
BPH also ranks seventh in annual medical costs for men,2 a significant healthcare burden that is growing as the population ages. The number of doctor’s visits for BPH have increased, and that trend is expected to continue.2 Total healthcare expenditures related to this progressive disease are extensive, including presentation to primary care for examinations, long-term medications, and surgical procedures, as well as treatment for such complications as bladder or kidney stones, infections, renal failure, and acute urinary tension.
My practice is a destination for patients with BPH who seek out or are referred to a specialist. Our goals in combating the disease include maintaining a high quality of life for our patients, reducing the risk for complications, and treating acute problems as they arise. Because BPH is a progressive disease and an expensive disease process, we approach treatment with a view toward reducing necessary interventions over time.
Customized Treatment
There are many treatments for BPH, ranging from medication to surgery, but first men have to seek help for the problem. Unfortunately, most men think that BPH symptoms are “just part of getting older,” so they ignore them until the disease progresses. Outreach efforts to raise awareness of the disease may help patients understand that they need help and it is available.
There is a common misconception that BPH is just bladder outlet obstruction. BPH is a histologic diagnosis based on tissue, but the symptom complex known as lower urinary tract symptoms (LUTS) that encompases BPH also includes bladder outlet obstruction and other symptoms affecting the prostate itself, the lower urinary tract and the bladder. These symptoms typically escalate over time. We must look at the entire urinary system and consider other etiologies when treating patients and fit interventions to individual needs. To do that, we create a treatment algorithm based on symptoms, prostate morphology, other conditions such as diabetes, and anticoagulants or other mediations that affect treatment.
Patients with mild BPH can start with behavior modification and limited fluids, followed by graduation to medications. These include alpha-blockers such as tamsulosin (Flomax, Boehringer Ingelheim), 5-alpha reductase inhibitors like dutasteride (Avodart, GSK) or finasteride (Proscar, Merck), or a combination of the two. Phosphodiesterase-5 (PDE-5) inhibitors such as tadalafil (Cialis, Eli Lilly) can help, as well as antimuscarinics and new beta 3 agonists.
As BPH progresses, the prostate’s volume increases and symptoms exacerbate, and patients may require surgery. Traditional surgeries for BPH are open prostatectomy (removal of the prostate through an open incision) and transurethral resection of the prostate (TURP), which removes enough of the prostate to open the urethra. Both have risks, require hospital stays, and have recovery period of several weeks.
Because BPH is so prevalent, a host of treatment advances have emerged in the past decade. Just about every surgical energy modality we know has been applied to the prostate, including stents to maintain an open urethra and radiofrequency treatment procedures that reduce urinary symptoms. Definitive procedures that reduce prostate volume, including holmium laser vaporization of the prostate, termed HolVap, and holmium laser enucleation of the prostate (HoLEP), are less invasive than traditional surgeries, offering alternatives for advanced cases.
Help for Advanced Cases
Because patients come to my practice in search of a BPH specialist, I often see advanced, complex cases. Patients have large prostate volumes, as well as other health problems while taking anticoagulation medications. A big part of my practice is HoLEP performed with the Pulse 120H holmium laser system by Lumenis because it is a unique, definitive, minimally invasive solution.
HoLEP is minimally invasive, with a very small risk of transfusion or need for retreatment.3-8 The majority of patients leave the hospital the same day or the next day with no catheter. This is a contrast to open prostatectomy, which is a very effective procedure but has a high morbidity, or robotic-assisted simple prostatectomy. Patients may require blood transfusions, long hospitalization, prolonged recovery or convalescence, and catheterization. Ablative procedures have not been shown to have the same benefits as HoLEP for advanced patients over the long term.
HoLEP is indicated for larger prostates, and there is no size limit. It could be performed on smaller glands, but there tends to be a higher rate of bladder neck contracture or stricture, albeit still low at around 5%.9 Patients who show the greatest benefit from the procedure have prostates of 80g or larger, as well as other considerations such as compromised bladder function or concomitant use of blood thinners. HoLEP is even effective for catheter-dependent patients whose bladder have poor squeeze (hypocontractile) or patients with previous treatments, including ablation or TURP. Because of the ability to control bleeding, HoLEP can be used to treat patients who take certain anticoagulation drugs or refuse to accept the risk of a blood transfusion.
In long-term follow-up data, HoLEP patients do well over 6 years.3 They return quickly to normal activities. Lifelong medication is not necessary, and patients do not need to see an urologist regularly.
I have been performing HoLEP since 2006, so we have over 2,000 procedures in our database that we have followed. It is my first choice for good candidates – men with large prostates and various comorbidities and complications, making them higher risk to undergo open or robot-assisted surgery. The HoLEP procedure offers them relief from symptoms and complications and an end to ineffective long-term treatments that can cause discomfort and embarrassment, as well as incur significant costs.
Economics of Treating BPH
Another big-picture advantage I see in utilizing HoLEP is the opportunity to decrease the burden of BPH on the healthcare system. It is a permanent solution like open prostatectomy, without the hospitalization, recovery, and potential complications. Patients do not face a future of repeated, escalating treatments or costly prescriptions.
One challenge I see right now is that not enough surgeons know how to perform the procedure. I teach courses at meetings and in professional education to facilitate adoption, but it is a difficult procedure to pick up from a class or videos. It requires advanced training. Surgeons who do not encounter it in a residency program have a difficult time getting hands-on experience. For enucleation to reduce the healthcare burden of BPH, it must be widely understood and performed.
References
1. Claus G Roehrborn CG. Benign Prostatic Hyperplasia: An Overview. Rev Urol. 2005; 7(Suppl 9): S3–S14. (Accessed online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1477638/#B1)
2. Hollingsworth JM, Wei JT. Economic Impact of Surgical Intervention in the Treatment of Benign Prostatic Hyperplasia. Rev Urol. 2006; 8(Suppl 3): S9–S15. (Accessed online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1686802/)
3. Gilling PJ, Aho TF, Frampton CM, King CJ, Fraundorfer MR. Holmium laser enucleation of the prostate: results at 6 years. Eur Urol. 2008;53(4):744–749.
4. Kuntz RM, Lehrich K, Ahyai SA. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100 grams: 5-year follow-up results of a randomised clinical trial. Eur Urol. 2008;53(1):160–166.
5. Tan AH, Gilling PJ, Kennett KM, Frampton C, Westenberg AM, Fraundorfer MR. A randomized trial comparing holmium laser enucleation of the prostate with transurethral resection of the prostate for the treatment of bladder outlet obstruction secondary to benign prostatic hyperplasia in large glands (40 to 200 grams) J Urol. 2003;170(4 Pt 1):1270–1274.
6. Mottet N, Anidjar M, Bourdon O, et al. Randomized comparison of transurethral electroresection and holmium: YAG laser vaporization for symptomatic benign prostatic hyperplasia. J Endourol. 1999 Mar;13(2):127-30.
7. Matlaga BR, Kim SC, Kuo RL, Watkins SL, Lingeman JE. Holmium laser enucleation of the prostate for prostates of >125 mL. BJU Int. 2006;97(1):81–84.
8. Aho TF, Gilling PJ, Kennett KM, Westenberg AM, Fraundorfer MR, Frampton CM. Holmium laser bladder neck incision versus holmium enucleation of the prostate as outpatient procedures for prostates less than 40 grams: a randomized trial. J Urol. 2005 Jul;174(1):210-4.
9. Naspro R, Suardi N, Salonia A, et al. Holmium laser enucleation of the prostate versus open prostatectomy for prostates >70 g: 24-month follow-up. Eur Urol. 2006 Sep;50(3):563-8.
Mitchell R. Humphreys, MD, is Dean of the Mayo Clinic School of Continuous Professional Development, Professor of Urology, and Endourology Fellowship Director at Mayo College of Medicine, Phoenix, Ariz.
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