Benign prostatic hyperplasia (BPH) or prostate adenoma refers to the increase in natural volume of the prostate. Although the precise causes of this hypertrophy are still not known precisely, this is probably the result of disorders of hormonal balance and should not be confused with a cancerous tumor (this is the reason why the term “Benign”). It is a phenomenon observed in most men from the fifties, to more or less advanced degrees. If simple monitoring and / or drug therapies fail to achieve satisfactory outcomes, the physician and patient should consider the use of surgery.
However, at present there are many techniques available, each offering its own advantages and having its own disadvantages. Schematically, most techniques involve removing the excess prostatic tissue in order to clear the urethra (excretory duct of the bladder also having a role in reproductive functions); They are differentiated by the methods / technologies used to remove excess prostate tissue.
A good comparison to understand what prostate adenoma and what its treatment should be is to imagine an egg in an egg cup.
Treatment involves removing the egg – the adenoma – leaving in place the egg cup that corresponds to the prostatic shell. It is not therefore a question of removing all the prostate. This complete ablation is performed only in the case of cancer and is not adapted to the treatment of a benign pathology such as the adenoma.
The oldest technique to remove this benign prostatic hypertrophy is the classic open surgical adenomectomy.
The same procedure can be performed with minimal incisions by conventional or robot-assisted laparoscopy.
Mono-polar trans urethral resection of the prostate (RTUP or transurethral resection of prostate) began to develop in the 1970s and has rapidly established itself as the gold standard of surgical treatment Of the adenoma of the prostate. It is also by comparison with its results that the most recent techniques compare theirs.
It allows the adenoma to be removed by dividing it into small chips by accessing it by natural routes, without open incision of the abdomen
Thus for many years, it was the volume of the adenoma that conditioned the choice between these two types of interventions. From a certain volume of adenoma, which the clinician urologists appreciate by the rectal examination and ultimately by ultrasound, the use of the “open” highway was indispensable because it is not desirable to Have excessively long surgical durations in conventional urethral resection, on pain of exposing the patient to severe complications such as TURP SYNDROME.
These techniques, both the highway and the RTUP have other pitfalls.
The prostate is richly vascularized and this surgery has a certain hemorrhagic potential especially in patients with cardiovascular diseases treated with drugs that fluidize the blood.
Finally, open-celled adenomectomy as well as RTUP are “ablative” techniques. As the comparison with egg and egg cup suggests, their goal is to achieve a complete removal of the prostate adenoma. The consequence of this complete ablation is the occurrence of a definite retrograde ejaculation which rejects many patients. It also affects fertility but at the usual ages when prostate adenoma results in discomfort as it warrants a surgical indication, this rarely poses a problem.
New techniques have therefore appeared in recent years to try to improve the treatments and alleviate some or all of these disadvantages.
These new techniques often reduce the duration of postoperative bladder sampling and are more suited to the current surgical outpatient outpouring.
Some of them use the same energy as the RTUP: electricity. The most interesting and promising of these is the bipolar trans urethral resection that performs the same procedure as the TURP but takes place in saline fluid medium, which avoids the risk of the appearance of the TURP syndrome.
Applications of the LASER ray to prostate surgery have grown considerably over the past twenty years.
Two types of interventions are currently required:
- The photo vaporization of the KTP laser adenoma (Greenlight),
- The enucleation of the Holmium laser adenoma (HOLEP) which reproduces by the natural pathways the same procedure for complete ablation of the adenoma of the prostate that open surgery.
Finally, there are also treatments which are proposed to improve by non-medicinal means the discomfort associated with prostate adenoma without claiming to remove it.
With all these new treatments there is a major problem is the risk of overestimating the effect of the technique by a placebo effect, known to be very pronounced with regard to urinary symptoms. Hence the importance of carrying out controlled studies. Indeed, so far, all the so-called mini-invasive techniques evaluated in the past (microwave, radiofrequency, Botox, ethanol …) have not kept their promises.
It is important to emphasize the importance of a retreat on the technique, because the objective is to obtain a lasting effect and not a transient subjective improvement.