1. Purpose of surgical treatment BPH is a progressive disease, and some patients eventually need surgical treatment to relieve the lower urinary tract symptoms and their impact on the quality of life and complications.
2. Indications for surgical treatment. Patients with severe BPH or lower urinary tract symptoms that have significantly affected the quality of life of the patient may choose surgical treatment[1,2], especially for patients who have poor drug treatment or who refuse to receive drug treatment, may consider surgical treatment .
When BPH causes the following complications, surgical treatment is recommended:
①Recurrent urinary retention (cannot urinate after extubation at least once or urinary retention twice);
②Recurrent hematuria, 5α-reductase inhibitor treatment is ineffective;
③Recurrent urinary tract infection;④
⑤Secondary hydrops in the upper urinary tract (with or without renal impairment)
For BPH patients with large bladder diverticulum, inguinal hernia, severe hemorrhoids, or prolapse of the anus, surgical treatment should be considered if the clinical judgment does not relieve the lower urinary tract obstruction.
The measurement of residual urine volume has a certain reference value for the degree of lower urinary tract obstruction caused by BPH. However, due to the instability of repeated measurements, individual differences, and the inability to distinguish lower urinary tract obstruction and bladder contraction weakness, it is currently considered The upper limit of residual urine volume that can be used as an indication for surgery cannot be determined. However, if the residual urine increases significantly so that BPH patients with overflow incontinence should consider surgical treatment.
Urologists should respect the wishes of patients in choosing which treatment methods. The choice of surgical treatment should take into account the doctor's personal experience, the patient's opinion, the size of the prostate, and the patient's concomitant disease and general condition.
3. Surgical treatment methods BPH surgical treatment includes general surgical treatment, laser treatment and other treatment methods. The effect of BPH treatment is mainly reflected in the changes in patients' subjective symptoms (such as I-PSS score) and objective indicators (such as maximum urine flow rate). The evaluation of treatment methods should consider comprehensive factors such as treatment effect, complications, and socioeconomic conditions.
(1) General surgery: The classic surgical methods include Transurethral Resection of the Pprostate (TURP), Transurethral iIncision of the Pprostate (TUIP), and Open Prostatectomy . Currently TURP is still the "gold standard" for BPH treatment [1,2]. The therapeutic effects of various surgical methods are close to or similar to TURP, but the scope of application and complications are different. As an alternative treatment to TURP or TUIP, transurethral Eelectrovaporization of the Pprostate (TUVP) and bipolar transurethral PplasmaKinetic Pprostatectomy (TUPKP) are also currently used in surgical treatment. All the above-mentioned various treatments can improve more than 70% of lower urinary tract symptoms in patients with BPH.
① 1) TURP: It is mainly suitable for the treatment of BPH patients whose prostate volume is below 80ml, and skilled surgeons can relax the restriction on prostate volume appropriately. The incidence of blood volume expansion and dilutional hyponatremia (transurethral resection syndrome, TUR-Ssyndrome) caused by excessive absorption of irrigation fluid is about 2%. Risk factors include excessive intraoperative bleeding, long operation time and prostate volume Great class [1,2]. TURP operation time is prolonged, and the risk of transurethral resection syndrome is significantly increased. The probability of a blood transfusion is about 2% to 5%. The incidence of various postoperative complications[1,2-6]: urinary incontinence is about 1%-～2.2%, retrograde ejaculation is about 65%-～70%, and bladder neck contracture is about 4%. Urethral stricture is about 3.8%.
② 2) TUIP: It is suitable for patients with prostate volume less than 30gml and no middle lobe hyperplasia. The improvement of lower urinary tract symptoms after TUIP treatment is similar to that of TURP[3,6]. Compared with TURP, it has fewer complications, lower risk of bleeding and need for blood transfusion, lower incidence of retrograde ejaculation, shorter operation time and shorter hospital stay. However, the long-term recurrence rate is higher than that of TURP .
③ 3) Open prostate enucleation: It is mainly suitable for patients with prostate volume greater than 80ml, especially those with bladder stones or bladder diverticula that require simultaneous surgery [4,5]. Commonly used surgical methods are suprapubic prostatectomy and retropubic prostatectomy. The probability of needing a blood transfusion is higher than that of TURP. The incidence of various postoperative complications[4,5]: urinary incontinence is about 1%, retrograde ejaculation is about 80%, bladder neck contracture is about 1.8%, and urethral stricture is about 2.6%. The effect on erectile function may not be related to surgery.
(2) Laser treatment: Prostate laser treatment is to relieve obstruction through delayed tissue shedding after tissue vaporization or tissue coagulation necrosis. The methods with definite curative effect include transurethral holmium laser enucleation of the prostate, transurethral laser vaporization of the prostate, and transurethral laser coagulation of the prostate.
① 1) Transurethral Hholmium Llaser Rresection/Eenucleation (HoLRP): The peak energy produced by Ho:YAG laser can lead to tissue vaporization and precise and effective resection of prostate tissue . The indwelling catheterization time after HoLRP is short. Difficulty urinating after surgery is the most common complication, with an incidence of about 10% . 75%-80% of patients have retrograde ejaculation, and there are no reports of postoperative erectile dysfunction .
② 2) Transurethral Llaser Vvaporization: Similar to prostate electrification, the prostate tissue is vaporized with laser energy to achieve the purpose of surgical treatment. The improvement of short-term I-PSS score, urinary flow rate, and QOL index is equivalent to that of TURP . The incidence of postoperative urinary retention requiring catheterization is higher than that of TURP. There was no pathological tissue after operation. The long-term efficacy remains to be further studied.
③ 3) Transurethral Llaser coagulation: It is an effective surgical method for the treatment of BPH [11,12]. Keep a distance of about 2mm between the tip of the fiber and the prostate tissue. The energy density is sufficient to coagulate the tissue, but it will not vaporize the tissue. The coagulated tissue will eventually die and fall off, thereby reducing the obstruction. The advantage lies in its simple operation, bleeding risk and low water absorption rate. Using mMeta analysis, it was found that the incidence of urinary retention and urinary irritation after transurethral laser coagulation of the prostate were 21% and 66%, which were significantly higher than the 5% and 15% of TURP.
(3) Other treatments
① 1) Transurethral Mmicrowave Ttherapy (TUMT): It can partially relieve the urinary flow rate and LUTS symptoms of BPH patients. It is suitable for patients who are ineffective in drug therapy (or unwilling to take long-term medication) but are unwilling to undergo surgery, and for high-risk patients with repeated urinary retention who cannot undergo surgery.
The principles of various microwave therapy devices are similar. Hyperthermia therapy is above 45°C. Low temperature treatment is not effective, so it is not recommended. The 5-year retreatment rate was as high as 84.4%; among them, the drug retreatment rate was 46.7%, and the surgical retreatment rate was 37.7% .
② 2) Transurethral Nneedle Aablation (TUNA): It is a simple and safe treatment method. It is suitable for high-risk patients who cannot accept surgery, and is not recommended as a first-line treatment for general patients. The postoperative lower urinary tract symptoms are improved by about 50% to 60%, the maximum urine flow rate is increased by about 40% to 70% on average, and TURP is about 20% required for 3 years . The long-term efficacy needs further observation.
③ 3) Prostatic stents (Sstents): Metal (or polyurethane) devices placed in the urethra of the prostate through an endoscope . Can relieve lower urinary tract symptoms caused by BPH. It is only suitable for high-risk patients with repeated urinary retention who cannot undergo surgery, as an alternative treatment for catheterization. Common complications include stent displacement, calcification, stent occlusion, infection, chronic pain, etc. .
Transurethral balloon expansion of the prostate still has a certain range of applications. At present, there is no clear evidence to support high-energy focused ultrasound and chemical ablation of prostate alcohol injection as an effective option for BPH treatment.