BPH is a progressive disease, and some patients eventually need surgical treatment to relieve the lower urinary tract symptoms and their impact on quality of life and complications.
1. Indications for surgical treatment
Patients with moderate/severe BPH whose lower urinary tract symptoms have significantly affected the patient’s quality of life can choose surgical treatment, especially for patients who have poor drug treatment or who refuse to receive drug treatment, may consider surgery.
When the following complications occur in patients with BPH, surgery is recommended:
Repeated urinary retention (inability to urinate after at least one extubation or two urinary retention)
Repeated hematuria, 5-α reductase inhibitor treatment is ineffective
Repeated urinary tract infections
Secondary upper urinary tract hydrops (with or without renal impairment)
For BPH patients with large diverticulum of the bladder, inguinal hernia, severe hemorrhoids or prolapse of the anus, surgical treatment should be considered if the clinical judgment is not to relieve the lower urinary tract obstruction.
The determination of residual urine volume and maximum urine flow rate has a certain reference value for the degree of lower urinary tract obstruction caused by BPH, but due to the instability of repeated measurement, individual differences, and the inability to distinguish lower urinary tract obstruction and bladder contraction weakness At present, it is considered that it cannot be used as an indication for surgical treatment alone.
What kind of treatment the doctor chooses will respect the wishes of the patient. The choice of surgical method should take into account the doctor's treatment experience, the patient's opinion, the size of the prostate, and the patient's concomitant diseases and general condition.
2. Surgical treatment
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) Routine surgery
The standard surgical treatments include transurethral resection of the prostate (TURP), transurethral incision of the prostate (TUIP), and open prostatectomy. TURP is still the best way to treat BPH. 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 electrovaporization of the prostate (TUVP) or plasma bipolar resection (PKVP) is currently also used in surgical treatment. All the above-mentioned various treatments can improve more than 70% of lower urinary tract symptoms in patients with BPH.
It is mainly suitable for the treatment of BPH patients whose prostate volume is below 80ml. The restriction on prostate volume is appropriately relaxed according to the doctor's technical proficiency. The incidence of blood volume expansion and dilutional hyponatremia (transurethral resection syndrome) caused by excessive absorption of washing fluid is about 2%. The risk factors of transurethral resection syndrome include excessive intraoperative bleeding, long operation time and large prostate volume. TURP operation time is prolonged, and the risk of transurethral resection syndrome is significantly increased. The chance of needing a blood transfusion is about 2-5%. The incidence of various complications after surgery: urinary incontinence 1-2.2%, retrograde ejaculation 65-70%, bladder neck contracture about 4%, urethral stricture about 3.8%.
It is suitable for patients with prostate volume less than 30ml and no mid-lobe hyperplasia. The improvement of lower urinary tract symptoms after TUIP treatment is similar to that of TURP. 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. But the long-term recurrence rate is higher than TURP.
③ Open prostatectomy
It is mainly suitable for patients with prostate volume greater than 80ml, especially those with bladder stones or bladder diverticulum that require simultaneous surgery. Commonly used surgical methods include suprapubic prostatectomy and retropubic prostatectomy. The chance of needing blood transfusion is higher than TURP. The incidence of various complications after surgery: about 1% of urinary incontinence, about 80% of retrograde ejaculation, about 1.8% of bladder neck contracture, and about 2.6% of urethral stricture.
It is suitable for BPH patients with poor coagulation function and small prostate volume. It is another choice of TUIP or TURP. Long-term complications are similar to TURP.
Using a bipolar plasma resection system, transurethral resection of the prostate is performed in a similar manner to monopolar resection. Due to the use of normal saline as the intraoperative irrigation fluid, the incidence of intraoperative bleeding and transurethral resection syndrome is reduced.