Minimally Invasive Surgical Therapy
For Benign Prostatic Hyperplasia (BPH)
I find myself always having to go to the toilet to pass urine. When I do, it takes some time before urine starts flowing out, and when I am done, I have to go to the toilet again very soon after.
Is there anything that I can do about this?
What is Benign Prostatic Hyperplasia (BPH)?
Benign Prostatic Hyperplasia is a condition in men where the prostate gland becomes enlarged. It is neither life threatening nor cancerous.
What are risk factors for BPH? This condition is usually related to age. BPH is found to affect:
• 50% of men at the age of 50 years old
• Up to 90% of men above the age of 801
How do I know if I have BPH?
Most men with BPH usually present with Lower Urinary Tract Symptoms (LUTS). These symptoms include:
• Increase in frequency of urination (both day and night)
• Difficulty or delay when starting urination, sometimes requiring to strain/force urine out
• Slow/weak stream when passing urine
• Urgent feeling to urinate
• Waking up at night to urinate
• A sense that you are unable to completely empty your bladder
• Dribbling at the end of urination/ urinary stream that stops and starts
What options do I have?
Options to managing BPH include:
• Medication
• Minimally Invasive Surgical Therapy
• Surgery (Transurethral Resection of Prostate – TURP)
What is Minimally Invasive Surgical Therapy (MIST)?
BPH can be managed with either medication or surgery (TURP).
Additionally, MIST has emerged in the last decade as a viable surgical management for BPH.
Advantages of MIST over Major Surgery (TURP):
• Shorter operative time
• Day surgery
• Reduced anaesthetic risk
• Reduced side effects, especially sexual side effects
What does MIST include?
The last decade has seen the advancement of MIST for BPH. These include:
• Rezum
• Urolift
• iTind
Approach your Doctor to discuss which technique would be appropriate for your condition.
Who is eligible for MIST? MIST can be appropriate for you if you:
• Have pre-existing conditions that make you unfit for major surgery/general anaesthesia
• Want to avoid long-term medical therapy
• Are worried and want to avoid sexual side effects associated with medical therapy/major surgery
Who should not have MIST?
You should not have MIST if you have:
• Bladder stone
• Recurrent blood in the urine
• Obstructive uropathy
• Recurrent urinary retention
• Prostate cancer
• Other underlying conditions causing your urinary symptoms (ie: diabetes, urethral stricture, neurogenic bladder)
Rezum
What is the Rezum
System?
Rezum is a minimally invasive procedure that uses thermal energy in the form of water vapour to induce instantaneous cell death when injected into the prostatic tissue.
Advantages of the Rezum System
• Lower risk profile and short procedure duration (around 30 minutes)
• Sexual function is preserved2
• This procedure can be done as a Day Surgery Procedure under Local Anaesthesia/Periprostatic Block
How does the Rezum work?
This procedure involves the use of radiofrequency to create thermal energy in the form of water vapour, which is injected into excess prostatic tissue and causes cell death.
How is it done?
1. A cystoscope is connected to a camera and a light source and fitted through the shaft of the delivery device
2. A roller pump is connected which provides irrigation of saline fluid for continuous irrigation
3. Sterile water is subjected to radio frequency treatment to create water vapour and injected into excess prostatic tissue via a needle tip
4. After the procedure, an indwelling urinary catheter may be left for around 1 week to facilitate recovery
Enlarged Prostate
A n enlarged prostate can squeeze the uretha, making it difficult to p as s
Reduced Prostate
Following treatment with Rezum Therapy, your body heals and the extra tissue is gone, the urethra opens and urine can flow freely.
UroLift
What is the UroLift System?
• UroLift, Prostatic Urethral Lift (PUL), is a proven approach to treating BPH that lifts and holds the enlarged prostate tissue out of the way, so it no longer blocks the urethra
• A minimally invasive procedure to treat BPH and a good alternative to medical or major surgery
• Does not require heating, cutting or destruction of prostate tissue3-7
Advantages of the UroLift System
• Lower risk profile compared to major surgery and equally effective procedure
• Rapid Symptom Relief 8
• Shown to preserve sexual function and not cause new and lasting sexual dysfunction*9-10
• Low catheterisation rate of the leading BPH procedures10
• No instances of new, sustained erectile or ejaculatory dysfunction in the L.I.F.T. pivotal study11
How does the UroLift System work?
• This procedure involves lifting the prostatic urethra with nitinol implants to mechanically pull excess prostatic tissue away from the urethra to relieve lateral lobe obstruction
• Typically 4 implants are used per procedure
How is it done?
It is done via 3 easy steps:
Step 1
The UroLift Delivery Device is placed through the obstructed urethra to access the enlarged prostate.
Step 2
The UroLift implants are placed to lift and hold the enlarge prostate tissue out of the way and increase the opening of the urethra. The permanent implants are delivered through a small needle that comes out of the UroLift Delivery Device and into the prostate.
Step 3
The UroLift System treatment provides quick symptom relief by opening the obstructed urethra.
What is iTind?
• The iTind System is a minimally invasive procedure that involves the insertion of the iTind device into the prostatic urethra, that is subsequently removed after 5 - 7 days, providing relief for urinary symptoms due to BPH12
• It does not involve any cutting or burning of prostate tissue, and does not leave behind permanent implants
• It is suitable for a subset of patients with a specific urinary tract morphology, which needs to be assessed with a flexible scope of the urinary system prior to surgery.
How does the iTind System work?
The iTind device reshapes the prostatic urethra to create a wider channel for improved urinary flow
Advantages of the iTind System
No permanent implants required: temporary implant is removed after 5 - 7 days
• Sexual function is preserved
• Rapid relief of symptoms in majority of patients
• Outpatient procedure with minimal downtime
• No need for urinary catheter postoperatively
• Clinically proven durability of results out to 3 years12
How is it done?
1. The iTind device is inserted in its folded configuration using a cystoscope
2. The device expands over 5 - 7 days, exerting gentle pressure in the prostatic urethra at three precise points to widen its calibre.
3. The device is then completely removed in the clinic after 5 - 7 days using a flexible silicone catheter. Most patients experience symptom improvement directly after implant removal, typically with further improvement over the following 6 - 12 weeks in most patients.
What do these procedures involve?
• Rezum and Urolift are typically done in operating theatre under general anesthesia, but sedation and local anesthesia can be considered for patients with general anesthesia risks
• iTind is done in Urology specialist outpatient clinic under local anesthesia
Before the procedure
• You would be required to not eat or drink for up to 6 to 8 hours prior to your procedure
• Depending on the type of procedure you are planned for, you may be required to take medications to empty your bowels 1 day before treatment
• Do inform your doctor if you are taking any blood thinner medications (i.e. Aspirin, Warfarin, Anti-coagulants e.g. Apixaban, Rivaroxaban, Dabigatran, etc.)
After the procedure
You will be closely monitored for a few hours after your procedure. If no complications are noted, you may be discharged on the same day to rest at home.
Depending on which procedure you have undergone and if you are able to urinate, you may or may not be sent home with a urinary catheter with plans to remove the catheter after 1-2 weeks. If you are discharged with a urinary catheter, you will realise that you do not need to strain for urination as urine will flow out of your bladder via the catheter.
You will be allowed to eat and drink on the same day after the surgery.
We strongly encourage you to drink at least 1.5 liters of fluids a day, if your medical condition allows it. This will allow continuous flushing of your bladder.
It is common to see bleeding in the urine - lasting up to a few days - after your procedure. This is due to instrumentation done during the procedure. Normally, this bleeding gets better over a few days and eventually resolves on it own.
Will my prostate continue to grow even after I get a MIST procedure? What if I need another procedure?
Your prostate may continue to grow after the MIST procedure. However, receiving MIST treatment does not preclude subsequent treatment or TURP procedure.
How quickly can I expect to have symptom relief?
Most patients experience minimal downtime post-treatment and symptom relief as soon as two weeks after.6
When can I resume my usual activities?
Many men experience rapid recovery in the days following the procedure.6 Your doctor will discuss any restrictions and your specific situation after your procedure.
Will I need to continue taking my BPH medications after the procedure?
The goal of the MIST procedures is to provide the relief you need to discontinue your BPH medications. Your doctor will decide if continued use of BPH medication is necessary.
Will my sexual function be affected by the MIST procedure? Studies have shown that MIST procedures preserve sexual function better than traditional surgery and does not cause instances of new sustained erectile or ejaculatory dysfunction.6
How much will my MIST procedure cost?
Your MIST procedures involve consumable items that cost between $2,000 and $6,000, which may not be fully covered by Medisave, Medishield Life or insurance reimbursements. The detailed cost will be discussed with you during the financial counselling session.
Is there one method “better” than the other?
All three techniques have their pros and cons. What is important is finding the appropriate technique to suit your needs and manage your condition.
Your doctor will discuss the appropriate technique for your condition.
I’m keen! What’s next?
If MIST is something that you think you might be interested in, follow these 5 easy steps!
1. Ask to take the International Prostate Symptom Score Questionnaire to determine the severity of your BPH symptoms
2. Make an appointment with your Doctor to see if you are a candidate for MIST and which would be the appropriate procedure for you
3. We may recommend a series of diagnostic tests to fully evaluate your condition
4. Check with your insurance if MIST is covered under your insurance coverage
5. Await the date for your MIST procedure!
References:
1. Enlargement P. National Institute of Diabetes and Digestive and Kidney Diseases. National Institutes of Health. US Department of Health and Human Services. Accessed. 2019 Apr;29.
2. McVary KT, Rogers T and Roehrborn CG: Rezūm water vapor thermal therapy for lower urinary tract symptoms associated with benign prostatic hyperplasia: 4-year results from randomized controlled study. Urology 2019; 126: 171
3. Lokeshwar SD, Harper BT, Webb E. Epidemiology and treatment modalities for the management of benign prostatic hyperplasia. Transl Androl Urol 8: 529–539.
4. Miano R, De Nunzio C, Asimakopoulos AD, Germani S, Tubaro A. Treatment options for benign prostatic hyperplasia in older men. Medical science monitor: international medical journal of experimental and clinical research. 2008 Jul 1;14(7):RA94-102.
5. Woo HH, Chin PT, McNicholas TA, Gill HS, Plante MK, Bruskewitz RC, Roehrborn CG. Safety and feasibility of the prostatic urethral lift: a novel, minimally invasive treatment for lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). BJU international. 2011 Jul;108(1):82-8.
6. Roehrborn CG, Rukstalis DB, Barkin J, Gange SN, Shore ND, Giddens JL, Bolton DM, Cowan BE, Cantwell AL, McVary KT, Te AE. Three year results of the prostatic urethral LIFT study. The Canadian journal of urology. 2015 Jun 1;22(3):7772-82.
7. Kadner G, Valerio M, Giannakis I, Manit A, Lumen N, Ho BS, Alonso S, Schulman C, Barber N, Amparore D, Porpiglia F. Second generation of temporary implantable nitinol device (iTind) in men with LUTS: 2 year results of the MT-02-study. World journal of urology. 2020 Dec;38(12):3235-44.
8. Sønksen J, Barber NJ, Speakman MJ, Berges R, Wetterauer U, Greene D, Sievert KD, Chapple CR, Montorsi F, Patterson JM, Fahrenkrug L. Prospective, randomized, multinational study of prostatic urethral lift versus transurethral resection of the prostate: 12-month results from the BPH6 study. European urology. 2015 Oct 1;68(4):643-52.
9. Montorsi F, Brock G, Lee J, Shapiro J, Van Poppel H, Graefen M, Stief C. Effect of nightly versus on-demand vardenafil on recovery of erectile function in men following bilateral nerve-sparing radical prostatectomy. European urology. 2008 Oct 1;54(4):924-31.
10. McVary KT, Gange SN, Shore ND, Bolton DM, Cowan BE, Brown BT, Te AE, Chin PT, Rukstalis DB, Roehrborn CG. Treatment of LUTS secondary to BPH while preserving sexual function: randomized controlled study of prostatic urethral lift. The journal of sexual medicine. 2014 Jan 1;11(1):279-87.
11. Cantwell AL, Bogache WK, Richardson SF, Tutrone RF, Barkin J, Fagelson JE, Chin PT, Woo HH. Multicentre prospective crossover study of the ‘prostatic urethral lift’ for the treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia. BJU Int. 2014 Apr;113(4):615-22
12. Porpiglia F, Fiori C, Bertolo R, Giordano A, Checcucci E, Garrou D, Cattaneo G, De Luca S, Amparore D. 3-Year follow-up of temporary implantable nitinol device implantation for the treatment of benign prostatic obstruction. BJU Int. 2018 Jul;122(1):106-112
Khoo Teck Puat Hospital • (65) 6555 8000 • www.ktph.com.sg
Yishun Community Hospital • (65) 6807 8800 • www.yishuncommunityhospital.com.sg
The information is correct at the time of printing and subject to revision without further notice.