madman
Super Moderator
ABSTRACT
This article reviews the prostatic urethral lift (PUL) and its potential benefits and risks compared with transurethral resection of the prostate (TURP). TURP is the traditional procedure for benign prostatic hyperplasia (BPH) and is associated with ejaculatory and erectile dysfunction. PUL is a minimally invasive option, but its efficacy has not been well studied. A literature review indicates that both procedures should be afforded equal consideration, and both have limitations. Further long-term research is needed to establish if PUL is superior to TURP.
Learning objectives
● Define PUL and how the procedure compares with TURP.
● Identify negative outcomes to both PUL and TURP.
● Identify candidates for PUL.
Benign prostatic hypertrophy (BPH) is associated with aging, and in most men, the prostate increases in size without noticeable symptoms.1 In 30% of men over age 50 years, BPH can lead to lower urinary tract symptoms (LUTS), including benign but irritating symptoms such as a weakened urinary stream, increased nocturia, and urinary urgency.1,2 Other complications of BPH include urinary retention, urinary tract infections, and prostatic bleeding.2 Treatments for LUTS secondary to BPH depend on the severity of symptoms and patient preference. Options range from medications such as tamsulosin, which relaxes and opens the prostatic urethra, to surgical prostatectomy.1 Medication used for BPH typically are alpha-blockers (such as tamsulosin), 5-alpha reductase inhibitors (such as finasteride, which cause involution of prostate cells), and more recently phosphodiesterase inhibitors (PDE inhibitors, such as tadalafil, traditionally used for erectile dysfunction but which have been found to improve LUTS when taken on a daily basis).3 Alpha-blockers typically cause adverse reactions such as dizziness and retrograde ejaculation; finasteride can lead to decreased libido and breast tenderness.3 Efforts have been made to create medications with a higher affinity for alpha-1A receptors, which are found predominantly in the male bladder outflow tract.4 Other alpha-receptors found in the brain and periphery are not targeted, thus reducing unwanted adverse reactions such as dizziness or hypotension, which are common reactions to nonselective alpha-blockers such as tamsulosin.4,5 Despite this effort, two such medications, naftopidil, and silodosin, have been found in meta-analyses to yield no significant improvement in urologic symptom scores when compared with tamsulosin.4
Although medications are the first-line treatment for BPH, studies have found that they have long-term negative effects.2 Alpha-1 receptors in the brain play an important role in cognition and long-term use of alpha-blockers poses an increased risk for poor cognition and eventual dementia.6 Because of this concern, urologists have been moving toward procedures rather than medications.2,6
When medication fails, the next step is to consider procedures. Transurethral resection of the prostate (TURP) consists of resection of prostatic tissue that encroaches into the prostatic urethra.7 TURP has been the gold standard procedure for LUTS associated with BPH for decades but is associated with ejaculatory and erectile dysfunction, and 20% of patients need to restart medication within 3 years of the procedure.8 Other complications associated with TURP include urethral stricture, infection, bleeding requiring transfusion, and urinary incontinence.8
Prostatic urethral lift (PUL), created in 2004, is a minimally invasive option for men with LUTS as a result of BPH and does not involve blunt resection.9 The procedure consists of permanent implants placed transurethrally into both prostatic lobes, causing compression of lobes and widening of the prostatic urethra (Figure 1).10 PUL is relatively new to the urologic community, with the first data published on the procedure in 2011.10 The literature provides little evidence about the efficacy of the procedure and if outcomes are superior to those of traditional TURP.11 This article reviews the long-term outcomes and risks associated with PUL and TURP.
CONCLUSION
As with any new procedure, PUL faces questions about its safety, efficacy, and whether it is an improvement over the current options. Early data note a minimal to moderate improvement in IPSS scores and quality of life as well as reduced ejaculatory dysfunction. Compared with patients undergoing TURP, those undergoing PUL have an increased likelihood of needing a repeat procedure within 2 years.15 Comparing PUL with TURP is important in order to identify appropriate patients for both procedures and increase clinicians’ ability to help patients make an educated treatment decision. If more research on PUL was conducted, urology clinicians might be more likely to consider the procedure. JAAPA
This article reviews the prostatic urethral lift (PUL) and its potential benefits and risks compared with transurethral resection of the prostate (TURP). TURP is the traditional procedure for benign prostatic hyperplasia (BPH) and is associated with ejaculatory and erectile dysfunction. PUL is a minimally invasive option, but its efficacy has not been well studied. A literature review indicates that both procedures should be afforded equal consideration, and both have limitations. Further long-term research is needed to establish if PUL is superior to TURP.
Learning objectives
● Define PUL and how the procedure compares with TURP.
● Identify negative outcomes to both PUL and TURP.
● Identify candidates for PUL.
Benign prostatic hypertrophy (BPH) is associated with aging, and in most men, the prostate increases in size without noticeable symptoms.1 In 30% of men over age 50 years, BPH can lead to lower urinary tract symptoms (LUTS), including benign but irritating symptoms such as a weakened urinary stream, increased nocturia, and urinary urgency.1,2 Other complications of BPH include urinary retention, urinary tract infections, and prostatic bleeding.2 Treatments for LUTS secondary to BPH depend on the severity of symptoms and patient preference. Options range from medications such as tamsulosin, which relaxes and opens the prostatic urethra, to surgical prostatectomy.1 Medication used for BPH typically are alpha-blockers (such as tamsulosin), 5-alpha reductase inhibitors (such as finasteride, which cause involution of prostate cells), and more recently phosphodiesterase inhibitors (PDE inhibitors, such as tadalafil, traditionally used for erectile dysfunction but which have been found to improve LUTS when taken on a daily basis).3 Alpha-blockers typically cause adverse reactions such as dizziness and retrograde ejaculation; finasteride can lead to decreased libido and breast tenderness.3 Efforts have been made to create medications with a higher affinity for alpha-1A receptors, which are found predominantly in the male bladder outflow tract.4 Other alpha-receptors found in the brain and periphery are not targeted, thus reducing unwanted adverse reactions such as dizziness or hypotension, which are common reactions to nonselective alpha-blockers such as tamsulosin.4,5 Despite this effort, two such medications, naftopidil, and silodosin, have been found in meta-analyses to yield no significant improvement in urologic symptom scores when compared with tamsulosin.4
Although medications are the first-line treatment for BPH, studies have found that they have long-term negative effects.2 Alpha-1 receptors in the brain play an important role in cognition and long-term use of alpha-blockers poses an increased risk for poor cognition and eventual dementia.6 Because of this concern, urologists have been moving toward procedures rather than medications.2,6
When medication fails, the next step is to consider procedures. Transurethral resection of the prostate (TURP) consists of resection of prostatic tissue that encroaches into the prostatic urethra.7 TURP has been the gold standard procedure for LUTS associated with BPH for decades but is associated with ejaculatory and erectile dysfunction, and 20% of patients need to restart medication within 3 years of the procedure.8 Other complications associated with TURP include urethral stricture, infection, bleeding requiring transfusion, and urinary incontinence.8
Prostatic urethral lift (PUL), created in 2004, is a minimally invasive option for men with LUTS as a result of BPH and does not involve blunt resection.9 The procedure consists of permanent implants placed transurethrally into both prostatic lobes, causing compression of lobes and widening of the prostatic urethra (Figure 1).10 PUL is relatively new to the urologic community, with the first data published on the procedure in 2011.10 The literature provides little evidence about the efficacy of the procedure and if outcomes are superior to those of traditional TURP.11 This article reviews the long-term outcomes and risks associated with PUL and TURP.
CONCLUSION
As with any new procedure, PUL faces questions about its safety, efficacy, and whether it is an improvement over the current options. Early data note a minimal to moderate improvement in IPSS scores and quality of life as well as reduced ejaculatory dysfunction. Compared with patients undergoing TURP, those undergoing PUL have an increased likelihood of needing a repeat procedure within 2 years.15 Comparing PUL with TURP is important in order to identify appropriate patients for both procedures and increase clinicians’ ability to help patients make an educated treatment decision. If more research on PUL was conducted, urology clinicians might be more likely to consider the procedure. JAAPA
