Men with hard-to-treat benign prostatic hyperplasia (BPH) usually respond well to surgery, but conventional procedures carry certain risks.
That’s largely because surgical techniques for treating an enlarged prostate require the destruction of tissue, which can lead to complications.
But a minimally invasive surgical procedure for treating BPH that leaves the prostate intact is now available. Instead of destroying tissue, the prostatic urethral lift (PUL) procedure uses implants to prevent the prostate gland from encroaching on the urethra and blocking the flow of urine.
But is this new method as effective as transurethral resection of the prostate (TURP) and other techniques? And what are the chances that it will disrupt sexual function or cause other long-term complications?
The TURP standard
When medication and lifestyle changes fail to relieve lower urinary tract symptoms caused by BPH, surgery is the next option. The “gold standard” surgical procedure for treating BPH is TURP, which entails using small instruments to trim away excess prostate tissue that is pushing against the urethra and interfering with urine flow.
Most men who undergo TURP enjoy a significant improvement in symptoms, but like any surgical procedure it carries some risks. Bleeding and urinary tract infectionsurinary tract infections
after the operation are a concern. Moreover, some TURP patients experience long-term complications.
Roughly 10 percent of patients end up with erectile dysfunction (ED), for instance. About two-thirds of men develop retrograde ejaculation, meaning they release little or no semen when they ejaculate, which can cause infertility or just be bothersome to some men.
TURP can backfire in a small number of cases and worsen urinary problems. For instance, about 3 percent of men develop urinary incontinence, while 7 percent are left with scarring in the urethra, which can further block urine flow.
Over the years, doctors and scientists have developed other surgical methods for removing excess prostate tissue; instead of cutting, they use lasers and other treatments to shrink prostates. But those approaches can cause long-term complications, too.
The new alternative
In 2013 the U.S. Food and Drug Administration approved the UroLift system, a permanent implant used during the PUL procedure to relieve low or blocked urine flow in men age 50 years and older with BPH. It works by holding in place overgrown prostate tissue that has been moved away from the urethra during the PUL procedure.
A patient undergoing a PUL typically remains awake and requires only local anesthesia to prevent pain and discomfort. (General anesthesia is often used in TURP and related procedures.) After the anesthesia takes effect, the doctor inserts a slender sheath, which contains a thin needle that houses the implant, into the patient’s urethra through the opening at the tip of the penis.
The doctor gently advances the sheath through the urethra to the point where it passes through the enlarged prostate. The sheath pushes against one prostate lobe, causing it to compress.
After the sheath is properly positioned, the needle is inserted into the prostate tissue, crosswise, through the lobe’s outer edge, or capsule. The needle holds the implant, a slim peg about a third of an inch (8 mm) in length and made of nitinol (nickel titanium). The peg is connected to a fine polyester thread, or monofilament. The doctor withdraws the needle, with the monofilament attached, which pulls the peg flat against the capsule.
When the needle is fully retracted, the doctor attaches a stainless steel end piece to the monofilament on the side of the prostate lobe that abuts the urethra. Initially, tension on the monofilament keeps the lobe in its new compressed shape, but as the tissue heals, a permanent unobstructed channel is created.
The surgeon repeats the procedure on the other lobe, opposite the first implant and, depending on the degree of obstruction, adds more implants to ensure the enlarged prostate is fully compressed and the urethra is open; the average man gets four implants.
Men typically go home the same day after a PUL, while TURP and other operations usually require a night or two in the hospital. Some men experience symptoms such as painful urination, blood in the urine, or a sudden need to urinate, but the aftereffects are usually mild to moderate and fade after a few weeks.
Success and PUL
Several studies have found that the PUL procedure can effectively relieve BPH symptoms with a low risk for long-term complications. The longest published follow-up to date has been for two years, but that study, which was published in 2012, involved only 64 men.
A larger trial, known as the LIFT (Luminal Improvement Following prostatic Tissue approximation for the treatment of LUTS secondary to BPH) study, was conducted at 19 medical centers in the United States, Canada, and Australia. The study included 206 men over age 50 years who had an enlarged prostate and lower urinary tract symptoms, such as a weak urine stream and difficulty emptying the bladder.
The researchers randomly chose 140 of the men to undergo a PUL. The remaining 66 men underwent a “sham” procedure, which included a standard cystoscopy, and did not receive implants.
The study results, which were published in 2013 in The Journal of Urology, showed that men who underwent a PUL noticed improvement in their LUTS right away. On average, they experienced an overall 50 percent improvement in their symptoms after three months, as measured by the American Urological Association (AUA) Symptom Index, a standard questionnaire used to evaluate BPH.
Results were comparable to earlier studies, which found that men with BPH who underwent a PUL could expect about a 40 percent improvement in symptoms.
Interestingly, men who received the sham treatment improved, too. But symptom relief was far greater in men who had undergone the PUL procedure. The investigators believe the improvement reported by men who underwent the sham procedure may have been caused by the placebo effect or by some aspect of the sham treatment that relieved their symptoms.
Long-term (one-year) follow-up of the men in the LIFT trial who underwent a PUL demonstrated that their symptom improvement persisted. Also, none of the men who received the implants developed sustained sexual problems, such as erectile dysfunction or retrograde ejaculation. Other studies have reported similar findings.
The bottom line
The research on the PUL may seem promising, but it’s important to keep some caveats in mind. It’s not yet entirely clear how a PUL compares with TURP. Research to date has shown that TURP offers somewhat greater symptom relief.
Also, you may not be a candidate for the PUL procedure if you have a very large prostate or your BPH is causing serious complications, such as urinary retention or failing kidney function. For now, the older method remains the gold standard.
However, a PUL may be appealing to some men, particularly those who can’t tolerate medical therapy and want to have greater assurance of preserving their erectile function. Although it’s early and data are limited, results from the LIFT study and others, showing no new sustained cases of ED or ejaculatory dysfunction up to two years out, are encouraging.
Keep in mind that surgical skill and expertise with the PUL procedure are important. If the implant is not placed properly, it can be exposed to bladder urine and may become encrusted.
Read more about surgery and other treatment options for BPH.