Procedures for management of benign prostatic hyperplasia

Transurethral minimally invasive treatment options include transurethral needle ablation (TUNA) and transurethral microwave thermotherapy (TUMT). Both techniques involve using heat energy from either radiofrequency probes (TUNA) or a microwave probe (TUMT) to induce thermal necrosis of the adjacent prostate tissue. Criticisms of TUNA have centered around the lack of prospective randomized data on the technique and the apparently high lifetime retreatment rate (46% at 3 years in one study of 102 patients) [3]. Efficacy of TUMT has improved as technology has improved the ability of transurethral microwave probes to generate sufficient temperatures for prostate tissue ablation. It is estimated that around 80 000 TUMT cases are performed each year in the United States [2]. Similar to TUNA, concerns surrounding TUMT have focused on the lack of quality prospective data on the technique, especially given the technical differences in the devices available for the procedure over the years. Ultimately, the major benefits of TUNA and TUMT seem to be offering patients a lower rate of erectile dysfunction than conventional surgical management, with the major concern surrounding the treatments being the possible need for retreatment.

More recently, laser‐based transurethral options have become a popular option for BPH treatment. Treatments include holmium laser ablation of the prostate (HoLAP), enucleation of the prostate (HoLEP), and resection of the prostate (HoLRP), along with photoselective vaporization of the prostate (PVP). All therapies use a transurethral laser probe to heat the periurethral prostatic tissue, with or without an additional mechanical component of resection. Use of laser therapies for BPH has been associated with decreased catheterization time and lower complications rates. Data on the techniques are limited by short follow‐up and rapid evolution of device technology.

Surgical therapy for bladder outlet obstruction (BOO) related to BPH is defined as the mechanical debulking of tissue within the prostatic fossa. Techniques for debulking prostate tissues have evolved over the years, with options ranging from open prostatectomy to transurethral laser ablation and traditional TURP. Open (simple) prostatectomy represents the most invasive treatment option for BPH, and is generally reserved for patients with prostate volumes greater than 80–100 ml, bladder calculi, or bladder diverticula. It is associated with longer hospital stays and higher transfusion rates than TURP [4].

TURP remains the gold standard treatment option for LUTS related to BPH, and involves the use of a transurethral resectoscope to debulk the periurethral prostatic tissue. Short‐term complications of the procedure include hematuria, while long‐term complications can include urethral stricture, sexual dysfunction, and dilutional hyponatremia. The incidence of dilutional hyponatremia has decreased with the implementation of bipolar transurethral resection using normal saline as an irrigant compared to glycine. There has been only one reported randomized controlled trial comparing TURP and SAPE [5]. In the study, technical success rates for TURP and SAPE were comparable (100% and 94.7%, respectively). Patients were followed for 2 years. A compelling finding was the apparent trend toward greater improvement in IPSS, quality of life, peak urinary flow rate (Q_max), and postvoid residual bladder volume (PVR) after one and three months in the TURP group, with the SAPE group ultimately reaching similar values at six months with sustained results for the remainder of the study period. The authors discussed the logical nature of this outcome, given that SAPE is not an instantaneous ablative technique. One advantage of SAPE appeared to be the relative safety of the procedure; two TURP patients required transfusion and another required intensive care unit admission, versus 0 in the SAPE group. Patients undergoing prostate artery embolization have reported improvement in erectile function, possibly secondary to an increase in blood flow to the pudendal artery following embolization.

History of selective arterial prostate embolization

Embolization of prostate arteries has long been used to control serious bleeding after biopsy or prostatectomy. DeMeritt and colleagues described in their 2000 paper the first report of a patient experiencing decreased prostate volume following SAPE of the right inferior vesicle artery, which was used at the time for severe hematuria following prostate biopsy [6]. They discovered that prostate volume was reduced by 52% at 5 months and 62% at 12 months, suggesting that SAPE may be a clinically viable option for the treatment of BPH. SAPE has also been referred to as prostate artery embolization (PAE); this nomenclature is also used in uterine artery embolization (UAE). However, by using SAPE as an acronym we attempt to set it apart from UAE, which is technically less challenging.

Animal studies using triacrylic gelatin microspheres (Embosphere; Merit Medical, South Jordan, UT, USA) in dogs and pigs demonstrated the efficacy of embolization with spherical microparticles, resulting in decreased prostate volume with no apparent decrease in sexual function [7, 8]. Initial human implementation of SAPE for the treatment of BPH was described in 2010 by Carnevale et al. in two patients, both of whom experienced a steady decrease in prostate volumes up to six months [9]. A subsequent study by Pisco et al. demonstrated a mean improvement in IPSS of 6.5 points (P = 0.005) in a cohort of 15 patients treated with SAPE [10].

A single‐center prospective study of 72 patients evaluated for possible SAPE, of whom 20 underwent treatment, revealed 19 of 20 patients with improvement in symptoms at 1, 3, and 6 months. Similar improvements in quality of life and sexual function were noted [11]. There were no major or minor complications in the study. Findings suggested that SAPE is a safe and effective option for treatment of BPH. A more recent meta‐analysis examined the results of six studies of SAPE comprising a total of 481 patients revealed overall improvement in Q_max, PVR, IPSS, and quality of life endpoints at 12 months, with a low incidence of serious adverse events (0.3%) [12]. They report a relatively high rate of minor adverse events (32.93%), with the most common being transient acute urinary retention and dysuria.

Benign prostate hypertrophy workup and preoperative assessment

According to the 2010 AUA Guidelines for the Management of BPH, workup should follow an algorithmic approach as adapted from the 2009 article by Abrams et al. [13]. Assessment of LUTS may include a quality‐of‐life assessment using the IPSS, as well as quantitative measures such as PVR, prostate volume (either by ultrasound or MRI), urodynamic studies (generally Q_max and peak detrusor pressure (P_det) at Q_max), and a urinalysis.

At our institution, we consider patients for prostate artery embolization with:

• LUTS for >six months
  
• IPSS score >13
  
• Q_max < 12 ml/s and or urinary retention
  
• Prostate volume larger than 40 ml as assessed by MRI
  
• Negative screening prostate MRI (no lesions suspicious for cancer)
  
• Symptoms refractory to medical therapy or contraindications to medical therapy
  
• Baseline prostate specific antigen (PSA) <3.5 ng/ml.

In patients with baseline PSA >3.5 ng/ml, the patient must be counseled on risks and benefits of prostate cancer screening with their urologist. Furthermore, the subject must meet one of the following criteria:

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