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Surgical intervention for benign prostatic hyperplasia (BPH)

Surgical intervention for benign prostatic hyperplasia (BPH)

Best Practice Guidance

Guidance under review

This guidance is clinically safe but is being updated to reflect the latest evidence identified during a recent review of all published EBI guidance.

Content will be updated and finalised by the end of September 2024.

Summary

Transurethral resection of prostate (TURP) is a therapeutic procedure involving removal of tissue from the inner aspect of the prostate using diathermy, via an endoscopic approach. It is commonly undertaken for voiding lower urinary tract symptoms (LUTS) presumed secondary to benign prostatic hyperplasia (BPH).

TURP is undertaken on an in-patient basis, with a catheter left in-situ for 24-48 hours post-op for the purpose of irrigation. TURP may be undertaken under either general or spinal anaesthesia.

TURP causes temporary discomfort, occasionally pain, haematuria and is associated with small risks of infection and acute urinary retention after removal of the catheter. There is also a risk of sexual dysfunction following TURP. There are small but significant risks of significant harm, including severe fluid and electrolyte imbalances associated with absorption of large volumes of irrigating fluid (TUR syndrome). TUR syndrome can be avoided by using bipolar diathermy, a variant of the standard technology.

TURP is the longest established of a range of endoscopic surgical procedures for benign enlargement of the prostate, with varying indications and potential complications. These include, among others:

 

  • Transurethral incision of the prostate (TUIP) or Bladder Neck Incision (BNI)
  • Holmium LASER enucleation of the prostate
  • 532 nm (‘Greenlight’) laser vaporisation of the prostate
  • UroLift
  • Transurethral needle ablation of the prostate (TUNA)
  • Transurethral vaporisation of the prostate (TUVP)
  • Transurethral water vapour therapy (Rezum).

Open simple/benign prostatectomy is uncommonly undertaken in men with very large prostates and problematic symptoms. Newer ablative therapies are currently under evaluation and non-surgical procedures such as prostatic artery embolisation (PAE).

 

This guidance applies to male adults aged 19 years and over.

Recommendation

Only men with severe voiding symptoms, or in whom conservative management options and drug treatment have been unsuccessful, should be offered surgical intervention. Surgery is indicated (in healthy men) in complicated BPH i.e. chronic retention with renal impairment as evidenced by hydronephrosis and impaired GFR, and in most cases of acute retention secondary to BPH.

As such, a staged approach to managing voiding LUTS is recommended:

  1. Conservative, or lifestyle interventions should be discussed.
  2. Drug therapy should then be considered, in the context of more bothersome LUTS, or LUTS not responding to simple lifestyle interventions.
  3. Where bothersome LUTS persist alongside high, or unchanged International Prostate Symptom Scores, or in the context of urinary tract infections, bladder stones or urinary retention, surgical intervention should be considered using a shared decision-making approach.

Men considering surgical intervention should be counselled thoroughly regarding alternatives to and outcomes from surgery. The quality of this counselling is deemed to be of major importance with respect to men’s future experience and outcomes.

Following a discussion about whether to intervene surgically, men should be counselled about their preferred and most suitable surgical modality, incorporating reference to available evidence. Practical concerns, including the distance required to travel to pursue a given modality of surgical treatment are also important. Appropriate support shoulder be provided to make shared decisions pertinent to physical, emotional, psychological and sexual health. If appropriate, carers should be informed and involved. With respect to surgical modality:

  • The UroLift system relieves lower urinary tract symptoms while avoiding the risk to sexual function and should be considered as an alternative to current surgical procedures for use in a day‑case setting in men who are aged 50 years and older and who have a prostate of less than 100 ml without an obstructing middle lobe
  • TURP, TUVP (including laser prostatic vaporisation) or HoLEP should be offered to men with voiding LUTS presumed secondary to BPH
  • HoLEP should be performed within centres specialising in the technique, or where mentorship arrangements are in place
  • TUIP should be offered to men with a prostate estimated to be smaller than 30ml
  • Open prostatectomy should only be offered as an alternative to endoscopic surgery, to men with prostates estimated to be larger than 80-100ml
  • Transurethral needle ablation, transurethral microwave thermotherapy, high‑intensity focused ultrasound, transurethral ethanol ablation of the prostate should not be offered as alternative surgical treatments for voiding LUTS presumed secondary to BPH.

Of note, some men with bothersome LUTS will have undergone multichannel cytometry, establishing clear evidence of bladder outlet obstruction. These men are the most likely to benefit from surgery, with guidance on when to undertake such assessment covered elsewhere in NICE and European guidelines.

 

 

Rationale for recommendation

NICE guidance provides clear evidence, in clinical and cost-effectiveness terms, that patients voiding LUTS presumed secondary to BPH, should be offered surgical intervention, only when those symptoms are severe, or when conservative management options have been unsuccessful.

TURP has long been the mainstay of surgical treatment for voiding LUTS presumed secondary to BPH. The newer surgical modalities outlined above have therefore been evaluated in comparison with TURP, as well as conservative management. NICE CG97 accordingly incorporated a comprehensive matrix of comparative studies between treatment modalities within its evidence review. This reflects increasing complexity in decision making around surgical intervention, increasingly involving ‘which’, as well as ‘when’ or ‘whether’ surgery should be offered.

The recommendation proposed here reflects the full breadth of comparative studies between surgical intervention and conservative management, as well as between different modalities of surgical intervention forming the basis of NICE CG97.

Patient information

Information for Patients

Benign prostatic hyperplasia (BPH) is a condition where, as people with a prostate grow older, the prostate gland becomes larger. It can cause urinary symptoms (affecting your pee). Some changes in lifestyle and some medicines may help relieve the symptoms. If these are not effective then in a small number of cases, surgery (an operation) may be appropriate.

About the condition

If you have found that lifestyle changes and medicines have not worked, then in some cases an operation on the prostate gland may help to improve symptoms. If the kidneys are not working well then an operation may be helpful.

BPH is a very common condition. It is not cancer. The increasing size of the prostate gland means that it is more difficult for urine to pass out from the bladder. This can lead to symptoms such as urgently needing to pass urine, difficulty starting urine flow, slow flow, and not completely emptying the bladder. In rare cases, there can be serious symptoms such as your kidneys not working well.

What are the BENEFITS of the surgery?

If you have found that lifestyle changes and medicines have not worked, then in some cases an operation on the prostate gland may help to improve symptoms. If the kidneys are not working well then an operation may be helpful.

What are the RISKS?

There are many sorts of operations that can be carried out. There are risks for all operations, including bleeding, infection, pain, and how an anaesthetic may affect you. There may also be a risk of developing sexual problems such as erectile dysfunction (unable to keep an erection).

What are the ALTERNATIVES?

Lifestyle changes such as avoiding caffeinated drinks, avoiding lots of fluid before bedtime and bladder training exercises are often helpful. There are also medicines to relax and shrink the prostate gland.

These changes and medicines should be tried before thinking about an operation. You can speak to a doctor or other clinician to help you decide what will work best for you.

What if you do NOTHING?

Without any lifestyle changes or treatments, symptoms of BPH may worsen over time.

Coding

Code Script

WHEN ( LEFT(der.Spell_Dominant_Procedure,4) like '%M61[123489]%’ 
OR LEFT(der.Spell_Dominant_Procedure,4) like '%M641%’ 
OR LEFT(der.Spell_Dominant_Procedure,4) like '%M65[12345689]%’ 
OR LEFT(der.Spell_Dominant_Procedure,4) like '%M66[12]%’ 
OR LEFT(der.Spell_Dominant_Procedure,4) like '%M68[13]%’
OR LEFT(der.Spell_Dominant_Procedure,4) like '%M704%’
OR LEFT(der.Spell_Dominant_Procedure,4) like '%M71[189]%’) 
AND der.Spell_Primary_Diagnosis like '%N40%’
AND not (apcs.der_diagnosis_all like '%C61%’ 
OR apcs.der_diagnosis_all like '%N13[0-9]%’ 
OR apcs.der_diagnosis_all like '%N17[01289]%’ 
OR apcs.der_diagnosis_all like '%N18[123459]%’
OR apcs.der_diagnosis_all like '%N19%’)
AND apcs.sex=1 
AND isnull(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 19 AND 120 
AND APCS.Admission_Method not like ('2%’) 
THEN '2I_BPH_surgery'

Code Definitions

Procedure codes (OPCS)

Main
M611 Total excision of prostate and capsule of prostate
M612 Retropubic prostatectomy
M613 Transvesical prostatectomy
M614 Perineal prostatectomy
M618 Other specified open excision of prostate
M619 Unspecified open excision of prostate
M641 Open resection of outlet of male bladder
M651 Endoscopic resection of prostate using electrotome
M652 Endoscopic resection of prostate using punch
M653 Endoscopic resection of prostate NEC
M654 Endoscopic resection of prostate using laser
M655 Endoscopic resection of prostate using vapotrode
M656 Endoscopic ablation of prostate using steam
M658 Other specified endoscopic resection of outlet of male bladder
M659 Unspecified endoscopic resection of outlet of male bladder
M661 Endoscopic sphincterotomy of external sphincter of male bladder
M662 Endoscopic incision of outlet of male bladder NEC
M681 Endoscopic insertion of prostatic stent
M683 Endoscopic insertion of prosthesis to compress lobe of prostate
M704 Balloon dilation of prostate
M711 High intensity focused ultrasound of prostate
M718 Other specified other operations on prostate
M719 Unspecified other operations on prostate

Diagnosis codes (ICD)

Inclusion
N40X Hyperplasia of prostate
Exclusion
C61X Malignant neoplasm of prostate
N130 Hydronephrosis with ureteropelvic junction obstruction (with N40X)
N131 Hydronephrosis with ureteral stricture, not elsewhere classified (with N40X)
N132 Hydronephrosis with renal and ureteral calculous obstruction (with N40X)
N133 Other and unspecified hydronephrosis (with N40X)
N134 Hydroureter (with N40X)
N135 Kinking and stricture of ureter without hydronephrosis (with N40X)
N136 Pyonephrosis (with N40X)
N137 Vesicoureteral-reflux-associated uropathy (with N40X)
N138 Other obstructive and reflux uropathy (with N40X)
N139 Obstructive and reflux uropathy, unspecified (with N40X)
N170 Acute renal failure with tubular necrosis
N171 Acute renal failure with acute cortical necrosis
N172 Acute renal failure with medullary necrosis
N178 Other acute renal failure
N179 Acute renal failure, unspecified
N181 Chronic kidney disease, stage 1
N182 Chronic kidney disease, stage 2
N183 Chronic kidney disease, stage 3
N184 Chronic kidney disease, stage 4
N185 Chronic kidney disease, stage 5
N189 Chronic kidney disease, unspecified
N19X Unspecified kidney failure

Additional Exclusions
apcs.der_diagnosis_all not like '%C[0-9][0-9]%' and 
apcs.der_diagnosis_all not like '%D0%' and 
apcs.der_diagnosis_all not like '%D3[789]%' and
apcs.der_diagnosis_all not like '%D4[012345678]%’

This code captures code in the ranges C00-C99, D00-D09 and D37-D48.
Age range: the codes use the following age ranges 0-18 for children and 19-120
for adults.
— Private Appointment Exclusion
AND apcs.Administrative_Category<>’02’

References

  1. NICE clinical guideline (2010) Lower urinary tract symptoms in men: management. [CG97].
  2. NICE Medical technologies guidance (2015) UroLift for treating lower urinary tract symptoms of benign prostatic hyperplasia [MTG 26].
  3. European Association of Urology guideline on the management of non-neurogenic male LUTS.
  4. Harrison S (2018) Urology, GIRFT Programme National Specialty Report. GIRFT.

How up to date is this information?

Last revised December 2023


Changes

December 2023 - Coding updated. August 2022 - Coding updated