Evaluation of treatments for benign prostatic enlargement

Research published by the National Institute for Health Research Health Technology Assessment (NIHR HTA) programme has found that transurethral resection, the most common operation for benign prostatic enlargement (BPE), remains a clinically and cost-effective treatment. BPE commonly causes older men to have difficulty passing urine and may require surgery to alleviate the problem.

Researchers at the University of Aberdeen, led by Professor James N'Dow, examined existing data to determine the risk factors and clinical and cost-effectiveness of less minimally invasive treatments for BPE compared to the current standard of transurethral resection. These included ‘tissue ablative’ treatments such as holmium laser enucleation of prostate (HoLEP); transurethral vaporisation; and ‘minimally invasive’ techniques such as laser coagulation, microwave therapy and transurethral needle ablation. They also looked at the overall long term benefits to patients.

Methods similar to transurethral resection require an anaesthetic, stay in hospital, and can sometimes lead to unwanted side effects such as bleeding. However, some patients do not require general anaesthetic and treatment can be performed within an out patient department using alternative procedures. Newer procedures have been developed but there is uncertainty about their clinical and cost-effectiveness.

The research team concluded that transurethral resection provides a consistent, high level of long-term symptom improvement. Improvements in quality of life and urinary flow were also observed. The risks associated with the minimally invasive interventions were generally lower than transurethral resection, with fewer adverse events, such as the need for a blood transfusion. However, the need for repeat surgery was more common with the newer technologies, especially the minimally invasive interventions. The evidence also suggests that HoLEP could offer some advantage over transurethral resection (such as equally good urine flow but shorter hospital stay and reduced bleeding) although long-term follow-up data is needed.

Professor James N’Dow said, “Overall our findings do not support a change in surgical treatment of BPE and suggests that TURP should remain the standard approach. Which minimally invasive intervention is most promising is unclear and good quality randomised controlled trials are needed to prove whether they are superior. Until then personal preference will influence choice of procedure with some patients choosing minimally invasive treatment options for their decreased morbidity.

To view full details about the project visit www.hta.ac.uk/1468 and the report is also published in the BMJ.