Sizing up the evidence: Treatment options for Benign Prostatic Hypertrophy (BPH)

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Around this time of year we start to hear a lot about one specific area of men’s bodies: the prostate (and yes – the moustache). And much of the conversation seems to focus on PSA – prostate-specific antigen testing – and prostate cancer. But whether or not to screen for prostate cancer with PSA testing isn’t the only question facing health care providers and patients when it comes to the prostate and men’s health.

Benign prostatic hypertrophy or BPH, a non-cancerous enlargement of the prostate, affects many men as they age. Around 25 per cent of men in Canada over the age of 50 have BPH, and that increases to 90 per cent for men in their 80s. BPH can lead to pressure on the bladder and urethra (the tube carrying urine from the bladder) and can obstruct urine flow. A number of treatment options exist, and it isn’t always clear which alternative is best for each patient.

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CADTH — an independent agency that finds and summarizes the research on drugs, medical devices, and procedures — was asked to look at the evidence on BPH treatment options to help guide health care decisions. CADTH’s Rapid Response service provides summaries and critical appraisal of the evidence in as little as 30 days and has two recent evidence reviews on treatment options for BPH.

The first review looked at the use of GreenLight laser for BPH. This involves the use of a high-powered laser to remove prostate tissue by vaporizing it and is sometimes referred to as photoselective vaporization of the prostate or “PVP”. GreenLight laser was developed as a less-invasive alternative to transurethral resection of the prostate (TURP) – a surgical procedure in which an instrument is inserted into the urethra and a heated electrode is used to trim away excess prostate tissue. Although TURP is effective in reducing urinary symptoms caused by BPH, its complication rate may be as high as 20 per cent, and up to 15 per cent of patients require retreatment within 10 years.

After searching the recent medical literature, six reports were included in the GreenLight laser evidence review – one being a systematic review covering nine different trials, and two were economic studies. Based on these, the review found that although TURP takes less time to perform than GreenLight laser procedures, catheterization time is longer with TURP. The length of stay in hospital is also longer and TURP patients require more blood transfusions and have more blood clot retention than GreenLight laser patients. However, GreenLight laser patients have higher rates of dysuria (painful urination) compared with TURP patients. Importantly, there are no long-term differences in outcomes such as urinary and erectile function between the two treatments. Because the difference in cost between GreenLight laser and TURP procedures is unclear, the cost-effectiveness of GreenLight laser for BPH is also unclear.

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A second alternative to TURP for the treatment of BPH also reviewed by CADTH is bipolar plasma vaporization of the prostate – sometimes referred to as “BPVP”. This procedure is similar to TURP, but the irrigation fluid used inside the urethra with the instrument is turned into a vapour. This causes a thin layer of gas, or “plasma”, to form around the electrode and protects surrounding tissue from potentially damaging excess heat. When CADTH searched the medical literature from the last five years for evidence on BPVP, seven studies met the necessary criteria to be included in the review. The evidence shows that BPVP results in better outcomes than TURP for up to 18 months following surgery and its safety is satisfactory. In the longer term, BPVP reduces the symptoms of BPH and results in fewer repeat procedures than does TURP. However its cost-effectiveness is unclear.

Knowing what the evidence says on GreenLight laser and BPVP is helpful to physicians, decision-makers, and patients faced with tough treatment decisions for BPH. But there are some limitations to the evidence CADTH has reviewed. All three BPH treatment options continue to advance which can make the relevance of evidence reviews time-limited. And although GreenLight laser and BPVP were both compared to the more traditional TURP procedure, they were not compared with each other. Future reviews of the evidence on BPH treatment options will likely be required and may contribute further information to help with this important decision for patients with BPH and their health care providers.

If you’d like more information about the CADTH Rapid Response reports on GreenLight laser and Plasma Vaporization of the Prostate – or on a variety of other drugs, devices, or procedures – they are all freely available on the CADTH website: www.cadth.ca/RapidResponse. Here you’ll find the reports listed chronologically as they are completed, or to find what you are looking for, you can use the search function at the top right of your screen.

To learn more about CADTH, visit www.cadth.ca, follow us on Twitter: @CADTH_ACMTS, or talk to our Liaison Officer in your region: http://www.cadth.ca/en/services/liaison-officer.