Surgical Treatment Options for Benign Prostatic Obstruction

Beyond Prostate Volume

Claudia Deyirmendjian; Dean Elterman; Bilal Chughtai; Kevin C. Zorn; Naeem Bhojani


Curr Opin Urol. 2022;32(1):102-108. 

In This Article

Sexual Function Preservation

Sexual dysfunction, particularly ejaculatory dysfunction, is among the most common adverse events associated with surgical management for BPO. For example, post-TURP patients have reported worsening of ejaculatory function (65%) and erectile dysfunction (10%).[13] Sexual health is an important preoperative consideration for BPO patients, regardless of age.[14,15] Therefore, when selecting a treatment option for BPO in sexually active men a few options are of particular interest.

Transurethral incision of the prostate (TUIP) is a technique first introduced in the 1970s that may be a good option for men with smaller prostate glands.[16] Rather than removing prostatic tissue, a deep incision in the bladder neck is performed to liberate the urethra. In one meta-analysis comparing 7 TUIP studies, 28% of patients undergoing TUIP experienced ejaculatory dysfunction, which was about half the incidence of this event in TURP patients. Still, in the majority of the studies a higher Qmax and better symptom relief were achieved with TURP, whereas the other studies reported no difference.[17] One prospective study of 80 patients with prostates <30cc demonstrated TUIP outperformed TURP for retrograde ejaculation (22.5% vs 52.5%; P < 0.001) and erectile dysfunction (7.5% vs 20%, P = 0.036) at 4 years postop.[18]

Water vapor convective thermal therapy or Rezūm has been effectively used to treat BPO while preserving sexual function. A randomized trial comparing Rezūm to a sham procedure in men with prostate glands less than 80cc reported that no patient developed de novo erectile dysfunction, and the postoperative anejaculation rate decreased from 2.9% to 0% after 3 months.[19] The long-term results of the trial did not reveal any difference in sexual function up to 2 years after surgery, measured by IIEF-15 and MSHQ-EjD scores. At 4 years postop, both scores had significantly decreased.[20]

In 2013, water jet ablation of prostatic tissue known as Aquablation was introduced.[21] This promising technology decreases operative time while preserving erectile and ejaculatory function, in part due to the precision of real time ultrasound guided imaging intra-operatively.[22] In the WATER clinical trial (prostate glands sized between 30–80cc) MSHQ-EjD or IIEF-5 scores decreased more in TURP patients compared to the patients who underwent Aquablation (56% vs 33%, P = 0.0268). MSHQ-EjD scores were stable following Aquablation but worsened after TURP (P = 0.0254).[23] Bach et al. corroborated the superiority of ejaculatory function rates with Aquablation and reported that among the subjects with antegrade ejaculation, 73% maintained ejaculatory function over the 3-month follow-up period.[24] In WATERII, Aquablation was used to treat large prostates between 80 and 150cc. IIEF-5 did not change from baseline after one year, whereas MSHQ-EjD decreased slightly. Among 77 sexually active subjects, 81% maintained antegrade ejaculation, and no men developed de novo erectile dysfunction.[25]

UroLift, also known as prostatic urethral lift, involves the placement of permanent mechanical implants, to rapidly expand the urethral lumen and alleviate lower urinary tract symptoms (LUTS). The LIFT study is a randomized control trial comparing 140 UroLift patients to 66 patients undergoing a sham procedure for men with prostates less than 80cc. There was no difference in 3-month postoperative sexual function according to changes in IIEF-5 and MSHQ-EjD scores.[26] The BPO6 trial also demonstrated at 2 years postoperatively that there was no difference between UroLift and TURP in erectile function however, ejaculatory function measured by MSHQ-EjD score favored UroLift. In the same study, IPSS and Qmax change were superior with TURP, as was retreatment rate (6% vs 11%).[27] In another study with 86 patients undergoing UroLift independent of prostate size, no procedure-related erectile or ejaculatory dysfunction developed. Although UroLift improved functional outcomes 2 years after surgery, retreatment rate was 12.8% over 2 years.[28]

The novel temporary implantable nitinol device, or iTind, received FDA approval in 2020. The second-generation device uses three struts to gradually expand tissue through ischemic necrosis over 5–7 days of placement prior to device removal.[29–31] Six months following the procedure in the MT-06 study, the 70 patients who underwent iTind did not experience any change in erectile or ejaculatory function and even reported improvements in MSHQ-EjD scores (9.2–11.2; P < 0.01). The short-term outcomes demonstrated improved IPSS, quality of life (QoL), Qmax but no change in PVR.[32] Long-term outcomes after iTind were analyzed in the MT-02 study and also demonstrated improvements in IPSS, QoL and Qmax, without deterioration of PVR at 2 years. No patient reported a decrease of sexual or ejaculatory function; however, this assessment used a yes/no (nonvalidated) questionnaire thus lacking the specificity of accepted questionnaires.[33]