The Role of Laparoscopy in Prostatic Hyperplasia: An Underused Option?

Editorial

Benign Prostatic Hyperplasia (BPH) is very commoninmen after age 40 and may causes important Lower Urinary Tract Symptoms (LUTS) that compromise the quality of life of these patients [1].

The treatment of symptomatic BPH ranges from active surveillance, drug therapies with alpha blockers, inhibitors of 5-alpha reductase, anti-muscarinics, inhibitors of phosphodiesterase-5 and herbal remedies along with combined therapies, but, in several cases a surgical approach may be necessary [1].

According to the latest guidelines from the American Urological Association (AUA), the surgical treatment of prostatic hyperplasia is reserved for patients with moderate to severe symptoms and for patients with acute urinary retention or complications of disease progression, such as recurrent urinary tract infection, recurrent hematuria refractory to medical therapy, renal failure due to prostatic hyperplasia and bladder stones [2].

The role of minimally invasive surgery in the management of BPH is evolving. Since the report of an open retro pubic simple prostatectomy performed by Terence Millin in 1945 [3], several other surgical methods have been proposed with diverse outcomes [1].

Minimally invasive surgery modalities are associated with decreased morbidity when compared with open reconstructive techniques. Now adays, the gold standard surgical therapy for patients with prostates between 30 and 80cc remains Trans Urethral Resection of the Prostate (TURP) [4,5].

In the presence of large prostates, above 80 cc, open prostatectomy appears to be a better option than TURP. But in recent reports Holimum laser has emerged as an alternative to open surgery. Transurethral enucleation (HoLRP), transurethral ablation (HoLEP) and photo selective vaporization (PVP) applying the laser technology are, nowadays, considered as alternatives to TURP and open surgery for patients withmoderate or severe LUTS in the presence of large prostates [4,5].

However, according to the European consensus, open prostatectomy would still play a major role in the surgical management of BPH patients, especially in the presence of prostates greater than 80 to 100 cc, when Holmium laser is not readily available [4,5].

In the modern era, in a quest for minimally invasive alternatives, several authors have described alternative approaches to open prostatectomy and since the first description of simple laparoscopic prostatectomy by Mirandolino et al. [6], other groups have also reported their techniques using a laparoscopic approach in the management of BPH in the presence of large prostates, aiming to replicate the traditional open approach [7].

Although reproducible and with good results when compared to their open counterpart [8] the laparoscopic approach still appears to be an underused option in the management of BPH.

The laparoscopic technique according to the current literature for removing large prostatic adenomas can be performed with efficacy and safety when compared with traditional open procedures. Recently, In a systematic review published about a year ago Asimakopoulos AD, et al. published a systematic review about this subject including 14 studies and 626 patients.

When compared with open simple prostatectomy the laparoscopic approach is associated with a less blood loss and a reduced irrigation requirement, a shorter postoperative catheterization period, and a shorter hospital stay, at the expense of an extended operative time.

Laparoscopic simple prostatectomy seems feasible and safeand in laparoscopic centers where the holmium laser is not readily available it could be a less invasive option and an alternative to the open approach. Nevertheless, randomized clinical trials are still necessary in order to compare this technique with other minimally invasive procedures aiming to confirm the benefits of this technique.

References

1. Lee NG, Xue H, Lerner LB. Trends and attitudes in surgical management of benign prostatic hyperplasia. Can J Urol. 2012;19; 6170-6175.
2. McVary KT, Roehrborn CG, Avins AL, Barry MJ, Bruskewitz RC, Donnell RF, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol. 2011;18;1793-1803.
3. Millin T. Retropubic prostatectomy; a new extravesical technique; report of 20 cases. Lancet. 1945; 2; 693-696.
4. Madersbacher S, Alivizatos G, Nordling J, Sanz CR, Emberton M, de la Rosette JJ. EAU 2004 guidelines on assessment, therapy and follow-up of men with lower urinary tract symptoms suggestive of benign prostatic obstruction (BPH guidelines). Eur Urol. 2004; (5); 547-554.
5. Oelke M, Bachmann A, Descazeaud A, Emberton M, Gravas S, Michel MC, et al. EAU Guidelines on the Treatment and Follow-up of Non-neurogenic Male Lower Urinary Tract Symptoms Including Benign Prostatic Obstruction. Eur Urol. 2013.
6. Mariano MB, Graziottin TM, Tefilli MV. Laparoscopic prostatectomy with vascular control for benign prostatic hyperplasia. J Urol. 2002; 167; 2528-2529.
7. Asimakopoulos AD, Mugnier C, Hoepffner JL, Lopez L, Rey D, Gaston R, et al. Laparoscopic treatment of benign prostatic hyperplasia (BPH): overview of the current techniques. BJU Int. 2012; 107; 1168-1182.
8. Sotelo R, Spaliviero M, Garcia-Segui A, Hasan W, Novoa J, Desai MM, et al. Laparoscopic retropubic simple prostatectomy. J Urol. 2005;173(3):757-60.