What are the surgical approaches to the prostate lobes for various conditions?

Surgical Approaches to Prostate Lobes for Various Conditions

Transurethral resection of the prostate (TURP) remains the benchmark surgical therapy for benign prostatic hyperplasia (BPH) with the strongest evidence for efficacy, but specific surgical approaches should be selected based on prostate size, anatomical configuration, and surgeon expertise. 1

Anatomical Considerations for Surgical Approaches

The prostate is surgically approached based on its anatomical zones:

• Inner/Transition Zone: Primary target for BPH surgeries as this is where adenomatous growth occurs
• Peripheral Zone: More commonly involved in prostate cancer
• Central Zone: Less commonly targeted in surgical interventions
• Anterior Fibromuscular Stroma: Non-glandular tissue

Surgical Options Based on Prostate Size

Small Prostates (≤30g)

• Transurethral Incision of the Prostate (TUIP)
  • First-line surgical approach for small prostates
  • Advantages: Lower rate of retrograde ejaculation (18.2% vs 65.4% with TURP) and reduced need for blood transfusion (0.4% vs 8.6%) 1
  • Technique: Incisions made at 5 and 7 o'clock positions from bladder neck to verumontanum

Medium-Sized Prostates (30-80g)

• Transurethral Resection of the Prostate (TURP)

  • Gold standard against which other interventions are measured
  • Options include:
    • Monopolar TURP: Traditional approach but with risk of TUR syndrome
    • Bipolar TURP: Reduced risk of hyponatremia and TUR syndrome, allowing longer resection times 1
  • Technique: Endoscopic removal of prostatic tissue via urethra using an electrified loop

• Transurethral Vaporization of the Prostate (TUVP)

  • Electrosurgical modification of standard TURP
  • Bipolar TUVP offers improved visualization, reduced blood loss, and faster resection 1

• Photoselective Vaporization of the Prostate (PVP)

  • Using 120W or 180W laser platforms
  • Similar outcomes to TURP regarding symptomatic improvement 1

• Holmium Laser Procedures

  • HoLEP (Holmium Laser Enucleation of the Prostate): Emerging as new gold standard 2
  • Advantages: Can be performed on patients with high risk for postoperative bleeding

Large Prostates (>80g)

• Open Prostatectomy

  • Surgical removal of inner portion via suprapubic or retropubic incision 1
  • Typically for prostates >80-100ml

• Laparoscopic or Robotic-Assisted Prostatectomy

  • Modern alternatives to open approach for large glands 1

• HoLEP

  • Size-independent procedure endorsed by guidelines 2
  • Can be used for all prostate sizes, including very large glands

Surgical Approaches for Specific Clinical Scenarios

For Patients with Urinary Retention

• Surgical intervention is the appropriate treatment for patients who have developed acute urinary retention or other BPH-related complications 1
• Prostatic stents may be considered only in high-risk patients with urinary retention who cannot undergo other procedures 1

For Patients on Anticoagulation

• Laser therapies (HoLEP, PVP) are preferred due to reduced bleeding risk 3

For Patients with Coexisting Prostate Cancer

• BPH surgeries can relieve LUTS in selected prostate cancer patients on active surveillance or in advanced stages 4
• Caution with pre-radiotherapy BPH surgery due to potential increased radiotoxicity 4

Minimally Invasive Options

• Transurethral Microwave Thermotherapy (TUMT)

  • Uses microwave energy to heat and destroy excess prostate tissue
  • Less invasive alternative to TURP

• Transurethral Needle Ablation (TUNA)

  • Uses radiofrequency energy through needles inserted into the prostate
  • More effective than medical therapy but less effective than TURP 1
  • Higher requirement for analgesia/sedation compared to TUMT

Surgical Decision-Making Algorithm

1. Assess prostate size via ultrasound or estimated by PSA/DRE

2. Evaluate symptom severity using AUA Symptom Index

3. Consider anatomical features (presence of middle lobe, intravesical protrusion)

4. Review patient factors:

   • Anticoagulation status
   • Comorbidities
   • Presence of urinary retention
   • Coexisting prostate cancer

5. Select appropriate surgical approach:

   • Small prostate (≤30g): TUIP
   • Medium prostate (30-80g): TURP (monopolar or bipolar), PVP, or HoLEP
   • Large prostate (>80g): Open/laparoscopic/robotic prostatectomy or HoLEP

Common Pitfalls and Caveats

• TUR syndrome risk with monopolar TURP: Avoid prolonged resection times
• Prostate size estimation errors: Ultrasound assessment recommended before minimally invasive or surgical therapies
• Middle lobe enlargement: May impact choice of therapy and predict response to treatment
• Post-procedure irritative symptoms: Common with TUNA and can persist for weeks
• Retrograde ejaculation: High risk with TURP (65.4%) compared to TUIP (18.2%) 1
• Bleeding risk: Consider laser therapies for patients on anticoagulation

The surgical management of BPH has evolved significantly with newer techniques emerging, but TURP and open prostatectomy remain widely utilized procedures 3. HoLEP is increasingly recognized as a new gold standard that can be used regardless of prostate size 2.