Bloodless management of benign prostatic hyperplasia: medical and minimally invasive treatment options

Figures & data

Table

	Main advantages	Main disadvantages
Medical
α-Blockers	Rapid onset of action	Risk of orthostatic hypotension, no effect on clinical progression
5α-Reductase inhibitors	Effective against clinical progression	Late onset of action, sexual function disorders
Combination treatment	Acute onset of action/effective against clinical progression	High long-term cost, complications related to both treatments
Non-laser minimally invasive
TURP	Worldwide experience/Gold standard BPH treatment	Significant morbidity
TUEVP	Lower morbidity than TURP	Higher rates of urinary retention/need for re-intervention than TURP
TURIS	Decreased risk of dilutional hyponatremia	Significant morbidity
TUIP	Limited rates of retrograde ejaculation, minimum morbidity	Indicated only for small volume prostatic glands, not effective when a prominent median lobe is present
HIFU	Well tolerated	Prolonged urinary retention, high rate of symptom recurrence
TUNA	Office based procedure, few anesthetic requirements	High cost, results are declining in the long-term
TUMT	Office based procedure, no requirements for anesthesia, minimum morbidity	High cost, inferior efficacy than TURP
PS	Indicated for patients with severe comorbidities due to minimum anesthetic requirements	More than half of cases are expected to need re-intervention in the long-term.
Laser minimally invasive
TLC	Minimum morbidity	Prolonged post-operative urinary catheterisation, inferior durability than TURP
LVP	The most cost-effective compared with all other treatment options. Reduced length of hospital stay, duration of postoperative catheterisation and adverse effect rate. Durable results	Not well suited for large (>70 cc) prostatic volumes. Rarely, urethral stricture and bladder neck contracture in small (<40 cc) prostatic volumes
HoLRP/HoLEP	Suited for large prostate glands. Reduced length of hospital stay, duration of postoperative catheterization and adverse effect rate. Durable results	Time consuming
LTIP	Minimum rate of postoperative catheterisation	Indicated only for small volume prostatic glands
ILC	Office based procedure, few anesthetic requirements	Prolonged post-operative catheterisation, relative high rates of re-intervention

Figure 1. Treatment decision making flowchart. TURP: transurethral prostatectomy, TUEVP: transurethral electovaporisation, TURIS: trasurethral resection in saline, TUIP: transurethral incision of the prostate, HIFU: transrectal high intensity focused ultrasound, TUNA: transurethral needle ablation, TUMT: transurethral microwave thermotherapy, PS: prostatic stenting, TLC: transurethral laser coagulation, LVP: laser vaporization of the prostate, HoLPR/HoLEP: Holmium laser resection of the prostate/Holmium laser enucleation of the prostate, LTIP: laser transurethral incision of the prostate, ILC: interstitial laser coagulation.