What are the alternatives to Transurethral Resection of the Prostate (TURP)?

Alternatives to Transurethral Resection of the Prostate (TURP)

There are multiple effective surgical alternatives to TURP for treating benign prostatic hyperplasia (BPH), with laser enucleation procedures like HoLEP now considered the gold standard for all prostate sizes according to current guidelines. 1, 2

Surgical Alternatives to TURP

Enucleation Procedures

• Holmium Laser Enucleation of the Prostate (HoLEP)

  • Strongly recommended by European Association of Urology (EAU) guidelines as an alternative to TURP or open prostatectomy 1
  • Suitable for all prostate sizes, including large prostates (>80ml)
  • Advantages: reduced bleeding risk, shorter catheterization time, shorter hospital stay
  • Can be performed in patients on anticoagulant therapy

• Thulium Laser Enucleation (ThuLEP/ThuVEP)

  • Recommended as an alternative to TURP, HoLEP, or bipolar enucleation 1
  • Particularly beneficial for patients on anticoagulant therapy
  • Similar efficacy to other enucleation techniques

• Bipolar Transurethral Enucleation (B-TUEP)

  • Recommended as an alternative to TURP 1
  • Comparable efficacy with potentially better safety profile than monopolar TURP

Vaporization Procedures

• Laser Vaporization

  • 80-W KTP, 120-W or 180-W LBO laser vaporization strongly recommended as alternatives to TURP 1
  • Suitable for prostate volumes of 30-80ml
  • Particularly beneficial for patients on antiplatelet or anticoagulant therapy

• Bipolar Transurethral Vaporization (B-TUVP)

  • Alternative to TURP for prostates 30-80ml in size 1
  • Offers similar efficacy with potentially reduced bleeding risk

Alternative Ablative Techniques

• Aquablation

  • Robot-assisted water jet ablation technique
  • Recommended for prostates 30-80ml in size 1
  • Caution: higher risk of bleeding and limited long-term data

• Prostatic Artery Embolization (PAE)

  • Minimally invasive option performed by interventional radiologists
  • Less effective than TURP but offers shorter catheterization and hospitalization time 1
  • Should be performed in specialized centers with urologist and radiologist collaboration

Non-Ablative Techniques

• Prostatic Urethral Lift (UroLift)
  • Strongly recommended for men interested in preserving ejaculatory function 1
  • Suitable for prostates <70ml without middle lobe
  • Less effective than TURP but with fewer sexual side effects

For Small Prostates (<30ml)

• Transurethral Incision of the Prostate (TUIP)
  • Strongly recommended for prostates <30ml without middle lobe 1
  • Shorter operation time and lower retrograde ejaculation rate than TURP
  • Higher reoperation rate compared to TURP

Medical Therapy Before Surgery

For patients not ready for surgery, medical options include:

• Alpha-blockers (first-line therapy) - improve symptoms within 4 weeks 3
• 5-alpha reductase inhibitors (finasteride, dutasteride) - for prostates >30ml 3, 4
• Combination therapy - alpha-blocker plus 5-alpha reductase inhibitor for prostates >40ml 1, 4

Decision-Making Algorithm

1. Assess prostate size:

   • <30ml: Consider TUIP (if no middle lobe) or TURP
   • 30-80ml: Consider TURP, laser vaporization, or enucleation procedures

   • 80ml: Consider HoLEP, ThuLEP, or open prostatectomy

2. Consider patient factors:

   • On anticoagulants/antiplatelets: Prefer laser procedures (HoLEP, ThuLEP, laser vaporization)
   • Desire to preserve ejaculatory function: Consider UroLift
   • High surgical risk: Consider PAE or minimally invasive options

3. Consider surgeon expertise:

   • Procedures like HoLEP require specific training and experience
   • Availability of equipment may influence options

Important Considerations

• The trend in BPH surgery is moving toward laser-based procedures, with HoLEP now considered by many to be the new gold standard 2
• Despite newer technologies, TURP remains the benchmark against which other surgical therapies are compared 1, 5
• Cost-effectiveness analysis suggests that surgical intervention as initial therapy may be more cost-effective than starting with pharmacotherapy in moderate-to-severe BPH 6
• The number of TURPs performed has declined significantly over the past decades due to pharmaceutical therapy 7

Remember that while TURP has been the historical gold standard, newer technologies offer comparable efficacy with potentially better safety profiles, particularly for specific patient populations.