Minimally invasive BPH management and sexual dysfunction
Benign prostatic hyperplasia (BPH) and resulting lower urinary tract symptoms (LUTS) are one of the major health problems, affecting 50% of men over 60 years and 80% of men over 80 years. BPH is a completely benign disease and not associated with any cancerous behavior (prostate is a completely unrelated condition). The benign prostatic hyperplasia consists of the proliferation of epithelial and smooth muscle cells within the transitional zone of the prostate that causes formation of benign lesion, called prostatic adenoma. As a result of it the flow resistance through the prostatic urethra increases, leading to irritative (nocturia, urgency, frequency) and obstructive (hesitancy, dribbling, weak stream) symptoms. Historically symptomatic BPH was managed for years with Transurethral resection of prostatic adenoma that became widely available in 1967 and underwent a lot of technological modifications since. In 1990s medical therapy with alpha blockers and later on with Proscar took off and still remains very popular. The main reason of cut back on surgical management was its inherent risks, with one of its major adverse effects being the increased risk of sexual dysfunction.
As sexual activity remains an essential component of overall QoL (quality of life) in most men regardless of age, the benefits of more invasive interventions to increase the efficacy of relieving obstructive urinary symptoms must be weighed against the cost and risks of developing sexual dysfunction. As such, newer technologies attempting to strike the balance of achieving improved efficacy and decreased sexual dysfunction is constantly underway.
It is well known that the main sexual side effects after any kind of transurethral or open BPH surgery are different types of ejaculatory dysfunction that exceed 30 % 0f cases. The postoperative problems with obtaining erection are also encountered in 10-15%, particularly, considering that baseline erectile function is not perfect in aging males with BPH.
The prostatic urethral lift (PUL), performed with the UroLift® system (NeoTract, Pleasanton, CA, USA), is a considerably novel yet minimally invasive technique that utilizes permanent nitinol and stainless steel implants placed under cystoscopic guidance. It works by retracting the obstructing lateral lobes of the prostate and creating a proper channel for urinary flow. It has demonstrated considerable safety and efficacy in the improvement of LUTS in patients with small- to medium-sized prostates (< 80 g) but is not ideal in patients with obstructing median lobes. The main advantage of prostatic urethral Lift (PUL) in comparison with another invasive and minimally invasive BPH management options is the low incidence of sexual side effects. Moreover, PUL is known to preserve sexual function with no evidence to date reporting any incidence of ED or EjD. The largest prospectively collected PUL data from the LIFT study by Roehrborn et al. demonstrated no significant changes in IIEF scores, assessing Erectile Function when compared to baseline during annual follow-ups. Symptomatic relief from LUTS was achieved within 2 weeks of PUL while erectile and ejaculatory functions were preserved up to 5 years after PUL. It also had minimal adverse urinary symptoms and most were seen only in the first 3 months postoperatively, e.g., dysuria (9%) and urge incontinence (3%). The rate of dysuria decreased to 1% after 3 months, while the rate of urge incontinence dropped to 1% after 2 years The majority of recent studies demonstrated the superiority of PUL to TURP with regard to quality of recovery and preservation of ejaculatory function as measured by special Sexual Dysfunction score system.
Thus, the current literature unanimously supports the claim that this tissue-sparing approach or Urolift provides modest and rapid relief of LUTS while simultaneously preserving sexual function and should be considered in patients with prostate sizes smaller than 80 g.