Manual Alternate Methods in the Treatment of Benign Prostatic Hyperplasia

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Technologies to Treat Benign Prostatic Hyperplasia - #UCLAMDChat Webinar

PUL is a new procedure to relieve urinary symptoms such as having to urinate often, having to strain or not being able to empty the bladder completely. Unwanted side effects of treatment may be problems with erections, ejaculation or needing to be treated again.

PUL works by placing little hooks that compress the tissue of the prostate to open up the urinary stream without the need to cut or remove any tissue. We did this review to compare PUL to other surgical treatments in men with an enlarged prostate and bothersome urinary symptoms. We included two randomized controlled studies clinical trials where people are randomly put into one of two or more treatment groups with men comparing PUL to sham surgery participants are made to believe they received treatment, while in reality they did not or transurethral resection of prostate TURP: removing the excess prostate growth using a camera and an electrically activated resecting loop inserted via the penis.

The average age of the participants was Compared to sham surgery up to three months, PUL may improve urinary symptoms and likely improves quality of life without additional unwanted side effects after surgery. In the short term, there were no additional surgeries because PUL did not work. PUL likely does not make erections or ejaculation worse. However, we are either very uncertain or have no evidence about serious unwanted side effects or the need for additional treatment after surgery.

Findings of this review are up-to-date until 31 January, The certainty of evidence for most outcomes was low. This means that the true effect may be substantially different from what this review shows. PUL appears less effective than TURP in improving urological symptoms both short-term and long term, while quality of life outcomes may be similar. The effect on erectile function appears similar but ejaculatory function may be better.

We are uncertain about major adverse events short-term and found no long-term information.

We are very uncertain about retreatment rates both short-term and long-term. We were unable to assess the effects of PUL in subgroups based on age, prostate size, or symptom severity and also could not assess how PUL compared to other surgical management approaches. Given the large numbers of alternative treatment modalities to treat men with LUTS secondary to BPH, this represents important information that should be shared with men considering surgical treatment.

A variety of minimally invasive surgical approaches are available as an alternative to transurethral resection of prostate TURP for the management of lower urinary tract symptoms LUTS in men with benign prostatic hyperplasia BPH. A recent addition to these is prostatic urethral lift PUL. We included parallel group randomized controlled trials RCTs. Two review authors independently screened the literature, extracted data , and assessed risk of bias. We performed statistical analyses using a random-effects model and interpreted them according to the Cochrane Handbook for Systematic Reviews of Interventions.

We planned subgroup analyses by age, prostate volume, and severity of baseline symptoms.

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Benign prostatic hyperplasia

The mean age was Mean prostate volume was We considered review outcomes measured up to and including 12 months after randomization as short-term and later than 12 months as long-term. For patient-reported outcomes, lower scores indicate more urological symptom improvement and higher quality of life. In Sotelo et al. After these initial presentations, laparoscopic simple prostatectomy has spread However, it is a challenging operation, even for a laparoscopic expert.

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Finger assistance may be used for a quicker enucleation of large adenomas. The aim of the present study is to describe the surgical steps of the laparoscopic, extraperitoneal transcapsular adenomectomy Millin. We also briefly describe the extraperitoneal transvesical approach and discuss the possible disadvantages of the intraperitoneal approach. A , The patient is placed in dorsal lithotomy position with legs only slightly raised to allow intraoperative DRE. The placement of the needle at this level avoids important vascular injuries.

Once the preperitoneal space is created, the trocars are inserted under digital guidance on the index finger of the left hand, which also lifts the anterior abdominal wall upwards. A, We use four trocars. The fascial opening of the suprapubic incision is temporarily closed we do not tie the suture but we keep the extremities together with a large Crile clamp to avoid CO 2 leakage during the procedure. B, Finally, the patient is placed in Trendelenburg position.

Clearing of anterior preprostatic fat, coagulation of the superficial dorsal penile vein and opening of the prostatic capsule. This prevents tearing of the veins, which would occur if the fat was removed side to side. Once the fat has been removed, the superficial dorsal vein of the penis can be easily evidenced, coagulated by bipolar coagulation on both sides of the future line of transversal capsular incision and transected far away from the puboprostatic ligaments to avoid bleeds from the dorsal vascular plexus.

The catheter balloon aids in the identification of the bladder neck. The opening of the capsule should be proportional to the volume of the adenoma. During this time, gentle pressure should be applied with the tip of the suction device manoeuvred by the assistant to reduce bleeding from capsular vessels.

Bipolar diathermy is usually enough to control these bleeds.


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After developing the anterior plane, the dissection moves laterally and then posteriorly. Adhesions between the adenoma and the capsule must be cut with monopolar scissors under direct vision. The bladder neck and the urethra are transected under direct vision Figures 8 and 9, respectively and the adenoma is removed and placed in the left lateral iliac space.

The prostate fossa is inspected for any remaining nodules of adenoma. Bleeding points are controlled with bipolar coagulation for small vessels and sutures for larger capsular arteries. The enucleation of the adenoma may be quicker if performed with finger assistance. The adenoma is then digitally enucleated. The specimen is removed through this incision. Insufflation is restarted after the suprapubic incision is closed with a size zero polyglactin running suture.

Enlarged prostate treatment options and lifestyle changes

In this case, a transverse cystotomy incision is made proximally to the junction of the bladder and prostate: in this manner the anterior bladder neck is incised and entry is gained into the bladder lumen. A circular incision is made on the vesical mucosa overlying the prostate lobes in the vicinity of the bladder neck area, which is deepened until the prostate adenoma is identified.


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  7. Careful blunt and electrocautery dissection is performed to reach the proper subcapsular plane outside the prostate adenoma. Laparoscopic simple prostatectomy can be useful in cases in which the prostate is too voluminous to be removed by TURP in a short time with the exception of bipolar TURP instruments that make use of saline solution avoiding the TUR syndrome , in which BPH is accompanied by bladder diverticula or bladder stones, or if it is difficult to insert the urethroscope because of a serious urethral stricture, and where the patient has difficulty in assuming the lithotomy position.

    Less morbidity and pain with respect to OP because of smaller incisions and absence of retractor use. This could lead to smaller surgical incisions, better cosmesis, less risk of wound infections, less use of analgesics and consequently a shorter hospital stay and earlier return to normal activities. A transperitoneal transvesical approach could be also used for laparoscopic treatment of BPH. With the extraperitoneal approach, the risk of bladder rupture in case of bladder tamponade by clots is avoided as well as the additional anaesthesiology risks determined by the steep Trendelenburg position required by the transperitoneal approach.

    In the hands of an experienced laparoscopist, it appears safe, feasible, reproducible and a minimally invasive alternative to open surgery for patients with large prostate adenomas. Volume , Issue 7.

    6 Natural Remedies for Enlarged Prostate (BPH)

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