Beyond enucleation and vaporization, a spectrum of other surgical and minimally invasive options exists for the management of benign prostatic hyperplasia. This chapter covers the traditional standard of transurethral resection of the prostate (TURP), the growing field of Minimally Invasive Surgical Therapies (MIST), and the role of prostatic stents.
Transurethral Resection of the Prostate (TURP)
For many years, TURP was considered the gold standard for the surgical treatment of BPH. The procedure involves the endoscopic removal of prostatic tissue in small fragments, or "chips," using an electrocautery loop. While still a widely performed and effective procedure, its role has been challenged by the advent of newer, less invasive techniques.
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Monopolar TURP: The traditional form of TURP, which uses a monopolar electrode. It requires the use of a non-conductive irrigating fluid (such as glycine) to prevent the dispersion of electrical current. This carries a risk of transurethral resection (TUR) syndrome, a rare but serious complication caused by the systemic absorption of the irrigating fluid, leading to dilutional hyponatremia.
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Bipolar TURP: A newer modification of TURP that utilizes bipolar energy. This allows the procedure to be performed in a saline environment, which is isotonic and eliminates the risk of TUR syndrome. Bipolar TURP has been shown to have a better safety profile than monopolar TURP, with a lower risk of bleeding and hyponatremia.
Minimally Invasive Surgical Therapies (MIST)
MIST represents a diverse group of office-based or outpatient procedures that aim to relieve bladder outlet obstruction with less morbidity than traditional surgery. These therapies are generally best suited for patients with smaller prostates and those who wish to preserve ejaculatory function.
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Prostatic Urethral Lift (UroLift): This procedure involves the placement of small, permanent implants to retract the obstructing lateral lobes of the prostate, thereby opening the urethral channel. It is a purely mechanical approach that does not involve cutting or heating of prostatic tissue.
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Convective Water Vapor Thermal Therapy (Rezum): This technique utilizes the thermal energy of steam to ablate prostatic tissue. A small needle is inserted into the prostate, and a controlled dose of steam is injected, causing cell death and subsequent tissue resorption.
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Prostatic Artery Embolization (PAE): An interventional radiology procedure that involves the selective embolization of the prostatic arteries. By reducing blood flow to the prostate, PAE induces ischemia and shrinkage of the gland, thereby relieving obstruction.
Prostatic Stents
Prostatic stents are devices placed within the prostatic urethra to maintain its patency. They can be temporary or permanent and are typically reserved for patients who are not candidates for more invasive surgery due to significant comorbidities. While effective in relieving obstruction, stents can be associated with complications such as migration, encrustation, and irritative voiding symptoms.