What are the treatment options for a lobular prostate?

Treatment Options for Lobular Prostate

For patients with lobular prostate, treatment options include watchful waiting, medical therapy (alpha blockers, 5-alpha reductase inhibitors), and surgical interventions (TURP, simple prostatectomy, or minimally invasive therapies) based on symptom severity, prostate size, and anatomical configuration. 1

Understanding Lobular Prostate

Lobular prostate refers to a prostate with a specific anatomical configuration, particularly the presence of middle or lateral lobes that may contribute to lower urinary tract symptoms (LUTS). This anatomical variation is important when selecting appropriate treatment options.

• Lobular configuration of the prostate, especially the presence of a middle lobe, may predict response or lack thereof to certain minimally invasive or medical therapies 1
• The shape of the prostate as assessed by cystoscopy (lateral versus middle lobes) can forecast the response to minimally invasive and surgical therapies 1
• Rodents have a naturally lobular prostate with lobes radiating away from the urethra, while the human prostate has a compact zonal anatomy, making anatomical variations clinically significant 2

Treatment Algorithm Based on Symptom Severity

For Mild Symptoms:

• Watchful waiting is the preferred management strategy for patients with mild symptoms 1
• Annual re-examination with repeat of initial evaluation is recommended 1
• Simple measures such as decreasing fluid intake at bedtime and reducing caffeine and alcohol intake may reduce symptom distress 1

For Moderate to Severe Symptoms:

Medical Therapy Options:

• Alpha-adrenergic blockers (alfuzosin, doxazosin, tamsulosin, terazosin) are appropriate first-line options 1
• 5-alpha reductase inhibitors (finasteride, dutasteride) should be offered to patients with demonstrable prostatic enlargement (prostate volume >30cc, PSA >1.5ng/mL, or palpable enlargement) 1
• Combination therapy (alpha blocker + 5-ARI) is effective for patients with larger prostates and can reduce clinical progression 1
• Finasteride has been shown to reduce prostate volume by 17.9% and decrease the risk of acute urinary retention by 57% compared to placebo 3

Surgical Therapy Options:

• Transurethral resection of the prostate (TURP) remains the benchmark therapy for BPH and should be offered as a treatment option 1
• Simple prostatectomy (open, laparoscopic, or robotic-assisted) should be considered for patients with large prostates 1
• Transurethral incision of the prostate (TUIP) should be offered for patients with prostates ≤30g 1
• Minimally invasive therapies such as transurethral microwave heat treatments, water vapor thermal therapy, or prostatic urethral lift may be appropriate for selected patients 1

Treatment Selection Based on Prostate Anatomy

The presence of lobular anatomy, particularly middle lobes, affects treatment selection:

• Middle lobe presence: May contraindicate certain minimally invasive therapies such as prostatic urethral lift (PUL) 1
• Lateral lobes: May respond better to certain surgical approaches 1
• Intravesical lobes: May impact the choice of therapy and should be evaluated before selecting treatment 1

Special Considerations

• Prostate size assessment is crucial before selecting therapy, as it predicts natural history and response to 5-alpha reductase inhibitors 1
• Urodynamic studies may be considered optional prior to invasive therapy, particularly when the outcome may impact choice of intervention 1
• Sexual function preservation: Water vapor thermal therapy may be offered to eligible patients who desire preservation of erectile and ejaculatory function 1
• Adverse effects: 5-ARI therapy may cause sexual side effects including impotence (8.1%), decreased libido (6.4%), and decreased ejaculate volume (3.7%) 3

Common Pitfalls and Caveats

• Failure to correct PSA values in patients taking 5-ARIs (by doubling the PSA value) may lead to delayed diagnosis of prostate cancer 1
• Not considering the presence of middle lobes before selecting minimally invasive therapies can lead to treatment failure 1
• Underestimating the impact of treatment on sexual function - patients should be informed about potential side effects before selecting therapy 3
• Prolonged resection times should be avoided with monopolar TURP approaches due to increased risk of complications 1

Remember that treatment selection should be guided by prostate size, anatomical configuration, symptom severity, and patient preferences regarding side effects and quality of life outcomes.