Update on minimally invasive therapies for benign prostatic hyperplasia.

Benign prostatic hyperplasia (BPH) is, and will remain, increasingly common with aging. Histologically it has been identified in 50% of patients by age 50, and in 80% of 80 year olds. The excessive growth of prostatic stromal and epithelial cells causes benign prostatic enlargement (BPE). With continued growth, however, BPE can evolve into benign prostatic obstruction (BPO), a condition often associated with bothersome lower urinary tract symptoms (LUTS) that worsen an individual’s quality of life. Transurethral resection of the prostate (TURP) has been considered the gold standard for treating patients with significant urinary symptoms related to BPH. Unfortunately, along with this technique come the risks of undergoing an invasive surgical procedure necessitating general anesthesia. To this end, new and more minimally invasive techniques (MIT) have been developed. This review examines some of the minimally invasive options available for treating BPH and the criteria used to determine which are used. In general, minimally invasive therapies for BPH produce symptomatic and objective results more slowly compared to surgical procedures. Whereas surgery can definitively eliminate obstructing tissue as a source of the problem, MIT require a longer process wherein prostatic tissue damaged by energy breaks down and reabsorbs naturally over time. Often, such a compromise in recovery speed is acceptable to men with mild LUTS as an alternative to hospitalization and/or more serious complications related to surgery. In addition to this figurative “refractory” period in which therapeutic results are not immediately apparent, MIT generally share similar side-effect profiles including: urgency, irritation, and post-procedural swelling. Retention secondary to swelling can be avoided with catheterization or alpha-blocker therapy. Occasionally, volume of ejaculate may be decreased following MIT, particularly when the bladder neck is intruded upon during the intervention. WATCHFUL WAITING Many men elect not to pursue medical or surgical therapy for their BPH, instead opting for a strategy termed “watchful waiting.” This is the least invasive management strategy available for this condition and a reasonable approach in patients with minimal prostatic enlargement and mild LUTS. It has been suggested that “active surveillance” is a more accurate phrase for this option than “watchful waiting” because the latter connotes a passive absence of intervention. In reality, patients are evaluated each year with a digital rectal examination (DRE), assessment of symptoms, and a PSA level. Uroflow and PVR volumes may be beneficial as well. Additionally, behavioral modifications such as timed-voiding and limiting intake of caffeinated and alcoholic beverages have been shown to reduce the effects of LUTS in patients with BPH. Watchful waiting has emerged as a recommended therapeutic option for patients with minimal impairment in quality of life secondary to their symptoms.