Choices for treating the symptoms of benign prostatic hyperplasia (BPH) have never been so great and, with the needs of BPH patients as varied as the treatments available, there is no “one-size-fits-all” solution to BPH management, according to a review, “Recent advances in treatment for Benign Prostatic Hyperplasia,“ published in the journal F1000Research.
Researchers from Guy’s and St. Thomas NHS Trust, U.K., and Tauranga Hospital, New Zealand, who authored the review, said two themes frame the ongoing advances in BPH treatment: personalized medicine and what they call a medical technology revolution. While treatment options for BPH have traditionally been divided into medical and surgical, the authors argued that the line between the two is now rather blurred.
Current drug treatment options are centered around alpha-blockers, 5-alpha reductase inhibitors, and PDE5 inhibitors. Alpha-blockers reduce symptoms by relaxing the smooth muscle in the prostate. They are currently considered first-line treatment, although they do not slow the progression of BPH or alter the likelihood of avoiding surgery. 5-alpha reductase inhibitors, while effective in reducing symptoms, have been associated with a small increase in cancer risk, and are plagued by frequent reports of worsening sexual function. The latest contribution to the medical options – PDE5 inhibitors – do not suffer this side effect profile, but the exact benefits, as well as the mechanism of action, of this drug class are still not clear. The authors argued that the improved sexual function often experienced on PDE5 inhibitors might contribute more to men’s perceived health than any actual effect on BPH.
Attempts have been made to inject drugs directly into the prostate. Initial trials suggested that Botox injections could be beneficial, but later studies found no support for the effectivity of the treatment. So-called office procedures are also making their way into the field. These methods, often involving energy sources such as heat and water to reduce prostate size, make it possible to reduce prostate tissue volume without general anaesthesia and hospitalization.
There are far more advances on the technological side of the therapeutic coin. The most promising new technique so far has been the prostatic urethral lift, called UroLift. The technology involves a mechanical implant that lifts the lobes of the prostate out of the way of the urinary duct to ease flow.
Most traditional surgical procedures cause retrograde ejaculation, a condition that affects both fertility and perceived sexual performance and satisfaction. The urethral lift causes ejaculation problems to a minimal extent, and when recently compared to traditional surgery — transurethral resection of the prostate (TURP) — it had similar outcomes and a minimal rate of complications. Since there is no long-term data on the new techniques introduced, time will have to tell whether the UroLift is beneficial in the long run.
Prostatic artery embolisation is a new method with only recently published data to support it. The procedure involves the puncture of a groin artery with embolisation of the arteries supplying the prostate with blood. This is said to shrink the prostate, but the studies of the technique have been criticized for poor design and a lack of randomized controlled trials comparing the method to a well-established technique. Major BPH societies, therefore, caution against this method until more convincing data are available.
Today, there are also numerous options for BPH surgery. Lasers have been around for the last two decades and, recently, trials comparing laser surgery with traditional methods have found laser surgery to be as good as traditional TURP and associated with low levels of complications.
Holmium laser enucleation of the prostate (HOLEP) is the most well-studied of the laser techniques, and is suitable for men with very large prostates. Recently published 10-year follow-up data also show good long-term outcomes. While many newer laser techniques exist on the market, they are not as well documented as HOLEP and few comparison trials exist. The authors, therefore, did not issue any comments about which laser technique might be the best, as it is likely dependent on the clinical characteristics of the patient as well as technique and surgeon specifics.
The popularity of robotic surgery for BPH is on the rise, but it has not yet been directly compared to established laser techniques, so any potential benefits are yet to be documented. Robotic surgery is also far more expensive than laser-based surgery.
The authors argued that the future of BPH treatments likely lies in the combination of drugs targeting the complex interactions between bladder receptors, neural pathways, and structural changes. On the technological front, many novel and current techniques have yet to prove their superiority over traditional techniques. But a personalized approach to treatment is undoubtedly the way to go. It is a step away from recommendations of first- and second-lines of treatment toward personal choices made by the treating physician, in discussion with the patient, to determine an optimal and individual treatment plan.