Lesser Surgical Options for Prostate Issues
Yes, multiple minimally invasive surgical therapies (MIST) are available as alternatives to traditional transurethral resection of the prostate (TURP), offering reduced morbidity while maintaining effectiveness for benign prostatic hyperplasia (BPH). 1
Treatment Selection Algorithm
The choice of surgical intervention depends on prostate size, symptom severity, and patient priorities regarding sexual function preservation:
For Small Prostates (<30g)
- Transurethral incision of the prostate (TUIP) is the preferred lesser surgery, offering effective symptom relief with minimal adverse effects compared to TURP 2
- This approach avoids the tissue resection required in TURP while addressing bladder outlet obstruction 3
For Moderate to Large Prostates (>30g)
Multiple minimally invasive options exist as alternatives to TURP:
Laser-Based Therapies:
- Holmium laser enucleation of the prostate (HoLEP) provides outcomes comparable to TURP with reduced bleeding risk and shorter catheterization time 1
- Photoselective vaporization of the prostate (PVP) using laser energy offers effective tissue ablation with less perioperative morbidity 1
- Thulium laser enucleation (ThuLEP) represents another laser option with similar efficacy profiles 1
Ablative Water-Based Technologies:
- Aquablation therapy uses robot-executed waterjet ablation with sustained 5-year functional outcomes and preservation of sexual function 4
- Convective water vapor therapy (Rezum) is an office-based procedure delivering thermal energy to ablate obstructing tissue while preserving ejaculatory function 4
Other Minimally Invasive Options:
- Prostatic urethral lift (PUL) mechanically opens the prostatic urethra without tissue destruction 1
- Transperineal laser prostate ablation (TPLA) provides office-based thermoablation with preservation of sexual function 4
- Transurethral microwave therapy delivers heat energy to reduce prostatic tissue 1
- Transurethral needle ablation (TUNA) uses radiofrequency energy for tissue ablation 1
Key Advantages of Lesser Surgeries
Reduced Perioperative Morbidity:
- Many procedures can be performed as outpatient or office-based interventions, eliminating hospitalization 4, 2
- Shorter catheterization periods and faster recovery compared to TURP 5
- Suitable for high-risk patients who cannot tolerate traditional surgery 2
Sexual Function Preservation:
- Aquablation, Rezum, and TPLA demonstrate excellent preservation of erectile and ejaculatory function 4
- This represents a critical advantage over TURP, which carries significant risk of ejaculatory dysfunction 1
Efficacy Profile:
- These minimally invasive procedures provide efficacy between medical therapy and TURP 1, 2
- While not as effective as TURP for symptom reduction, they offer meaningful improvement with substantially less morbidity 1, 5
Critical Counseling Points
Patients must understand the trade-offs:
- Lesser surgeries generally provide less symptom improvement than TURP but with reduced complications 1, 2
- Sexual side effects vary by procedure, with newer ablative technologies offering better preservation 4
- Some procedures may require retreatment more frequently than TURP 1
Shared decision-making is essential:
- The American Urological Association emphasizes providing risk/benefit profiles for all treatment options to allow informed patient choice 1
- Patients may prefer less effective therapy if it carries less risk or better preserves quality of life 1
Common Pitfalls to Avoid
- Failing to assess prostate size before selecting a procedure—TUIP is only appropriate for prostates <30g 3, 2
- Not discussing sexual function priorities with patients before surgery—this significantly impacts treatment selection 1, 4
- Overlooking office-based options like Rezum and TPLA for appropriate candidates who want to avoid hospitalization 4
- Assuming all minimally invasive procedures are equivalent—efficacy, durability, and side effect profiles differ substantially between technologies 1, 4