New Surgical Options for BPH Must Measure Up

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From the Editorial Advisory Board

The past two decades have witnessed the introduction a dizzying array of minimally-invasive surgical alternatives to the gold standard treatments for BPH—transurethral resection of the prostate (TURP) and the open simple prostatectomy. TURP and open prostatectomy have established track records of durability, and their risks are well defined.

To outsiders, the evaluation and implementation of alternative BPH procedures look like a bandwagon approach to medical science. Unfortunately, all too often, short-term excitement and acceptance of a competing technology is followed by disappointment when the new procedure's durability proves to be less than ideal.

Innovators involved in developing new procedures that challenge the gold standards typically err by failing to reflect on the proven benefit of TURP and open simple prostatectomy: long-term relief of obstruction by creating a large prostatic defect with the complete removal of the obstructing prostatic tissue out to the surgical capsule. Of recently introduced alternatives, holmium laser enucleation of the prostate (HoLEP) is one of the few that incorporates, in a minimally invasive fashion, this principle.

Our current medical environment is faced with aggressive marketing by technology companies, resulting in near-immediate dissemination to the hospital nearest you. We continue to avoid critical evaluation of industry-supported studies reporting “promising” short-term results.

Playing the devil's advocate, who can blame the busy practitioner for giving in? These fast, outpatient or office-based procedures require minimal training (and often minimal technical skill) but at the same time carry all the financial rewards of an office-based procedure.

In contrast, the poor remuneration for TURP, open prostatectomy, or HoLEP within the hospital setting penalizes the practitioner who values long-term outcomes over any short-term and limited benefits of a minimally-invasive alternative.

The speed of introduction of new procedures into clinical practice does not allow us the luxury of awaiting longer-term follow-up studies prior to changing our recommendations for surgical intervention. For all new surgical approaches to BPH, we must demand that clinical studies document reduction in PSA post-procedure as a surrogate for the reduction in prostate volume.

Meeting this criterion would be our reassurance that the proponents of the new procedures are at least approaching the results urologists have come to expect from their gold standards.

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