British doctor says he would have TURP.

Question from a reader in today's Daily Mail Health section.

  For a long time I’ve suffered from an enlarged prostate, but I cope quite well so I’ve managed to avoid surgery. Nevertheless, when I heard about UroLift I thought I’d finally found the answer. Now I’ve read about yet another procedure, PAE (prostate artery embolisation). If you were in my shoes, which procedure would you choose?

Answer: After four decades in medical practice I have learned to be cautious of any new drug or treatment, medical or surgical, especially before making recommendations, because experience tells me that new quite often isn’t better and can sometimes end up being worse.  An enlarged prostate, known medically as benign prostatic hyperplasia, is increasingly common in men with age.  Over the years, male hormones cause the gland — which sits around the urethra and underneath the bladder — to become slowly enlarged. This can obstruct the urethra, leading to a poor stream, hesitancy (an intermittent stream), urgency (needing to go in a hurry) and nocturia (going more than once at night).  Medications can be very effective — alpha-blockers work by relaxing the muscle of the prostate tissue, while alpha-reductase inhibitors block the effects of male hormones — but a significant number of men do still require surgery. 

Since the Eighties, the most popular option has been transurethral resection of the prostate (TURP), a keyhole procedure where a wire, guided by a camera, is inserted into the urethra then heated to burn away some of the enlarged gland. TURP remains the gold standard because it’s the only procedure that long-term studies have shown is safe and effective.  However, some men fear TURP as it involves a general anaesthetic and two or three days in hospital. Some are also anxious about the potential risks, as TURP can damage a sphincter (or valve) at the entrance of the bladder, causing retrograde ejaculation — where semen is sent backwards into the bladder. Erectile function is not harmed, but patients are no longer fertile.  The UroLift System is a new option that can be done under local anaesthetic. Two to four pairs of what are effectively treasury tags are used to pull back the enlarged tissue, improving flow.  The procedure seems to be effective, but no more so than TURP, and there are questions about how long the effects might last as we don’t yet have enough long-term studies to know. 

Also the treasury tags are, in part, metallic, which may distort the signal in MRI imaging should that be needed in the future, for example to diagnose prostate cancer. 

PAE is another new procedure (first used in the UK in 2012) that must be regarded as experimental until we see the results of large studies — and the National Institute for Health and Care Excellence approves it. Here, the prostate is shrunk by using microscopic particles to block the blood vessels supplying it. It’s done by feeding a catheter up through the main artery in the groin under local anaesthetic.  

I think you will guess the option I’d prefer if I were in your shoes.

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