Pharmacologic treatment

In current clinical practice, most patients with Benign Prostatic Hyperplasia (BPH) do not present with obvious surgical indications; they often have milder lower urinary tract symptoms ( LUTS) which is initially managed with medical therapy.

Starting over 3 decades ago with the use of non-selective alpha-blockers such as phenoxybenzamine, the medical therapeutic options for BPH have since evolved significantly, giving rise to the receptor-specific alpha-blockers that comprise the first line of therapy.

All agents currently used in the treatment of BPH are given in Table 1. The alpha-1-receptor blockers provide rapid relief, while the 5-alpha-reductase inhibitors target the underlying disease process, providing a rationale for a combination therapy.

Table 1: Agents used in the treatment of benign prostatic hyperplasia¹

Surgery

- Transurethral resection of the prostate (TURP) – Long been accepted as criterion standard for relieving BOO secondary to BPH.

- Open prostatectomy – Reserved for patients with very large prostates (>75 g), patients with concomitant bladder stones or bladder diverticula, and patients who cannot be positioned for transurethral surgery.

Minimally invasive treatment

Most minimally invasive therapies rely on heat to destroy prostatic tissue. Their objective is to decrease the amount of obstructing prostate tissue while avoiding the adverse effects associated with TURP. Heat may be delivered in the form of laser energy, microwaves, radio waves, high-intensity ultrasound waves, and high-voltage electrical energy. Many of these minimally invasive therapies are undergoing constant improvements and refinements, resulting in increased efficacy and safety.

Recent updates

• The role of TURP in patients with benign prostate obstruction (BPO) was re-examined during the EAU Annual Congress Milan 2013 against the use of new technologies such as laser ablation techniques. In spite of issues such as post-operative retention, blood transfusion and mortality, experts pointed out that TURP has low morbidity and provides an effective and durable solution. It was concluded that, while TURP is not a ‘gold standard’ for treating BPO due to issues such as bleeding, it still is the ‘reference standard’ to be met by all alternative treatment options – which have to be proved non-inferior, cost-effective, and involve equipment that is readily available.²

• A new study involving 200 patients evaluated the safety, efficacy, and short-term outcomes of the new GreenLight (GL) XPS 180W laser system in comparison to the former generation GL-HPS 120W system for the treatment of benign prostatic hyperplasia (BPH). Both GreenLight systems were found to provide safe, effective, tissue vaporisation with significant clinical relief of BPH obstruction. The new GL-XPS 180W system was however associated with less operative time and fibre use, and greater reduction of prostate-specific antigen (PSA), suggesting more cost-effective and efficient tissue removal.³

References

1- Levi A. Benign Prostatic Hypertrophy. Medscape reference. Available at http://emedicine.medscape.com/article/437359-overview. Updated April 23, 2013.

2- Vega J. Re-examining TUR-P: gold standard for benign prostate obstruction? (EAU Annual Congress Milan 2013) 2013-03-18

3- Ben-Zvi T et al. GreenLight XPS 180W vs HPS 120W laser therapy for benign prostate hyperplasia: a prospective comparative analysis after 200 cases in a single-center study. Urology. 2013 Apr;81(4):853-8. MIMS Ireland Copyright®