Education And Debate

Controversies in Management: Alternatives are still unproved

BMJ 1994; 309 doi: http://dx.doi.org/10.1136/bmj.309.6956.717 (Published 17 September 1994) Cite this as: BMJ 1994;309:717
  1. M C Bishop
  1. City Hospital, Nottingham NG5 1PB.

    For many years transurethral resection of prostate has been established as the optimum treatment for benign prostatic hyperplasia. This viewpoint is now being challenged because of criticism of the operation itself and by the availability of a bewildering variety of alternative treatments (box). Most are recent innovations, and results of long term follow up studies are not yet available. Unfortunately, claims for their superiority have sometimes been exaggerated by their enthusiastic proponents.

    Treatments for benign prostatic hyperplasia

    Physical

    Balloon dilatation

    Intraurethral implants - Spirals, stents

    Microwave thermotherapy - Transrectal, transurethral

    Laser - “Side fire” ablation, contact incision, transurethral needle ablation

    Ultrasonic tissue - External source

    Disintegration - Transurethral probe

    Cryosurgery Transurethral resection or incision of prostate

    Pharmacotherapy

    (alpha) Adrenergic antagonists - for example, prazosin, indoramin, terazosin, doxazosin

    Antiandrogen treatment - Surgical castration, medical castration (luteinising hormone releasing hormone analogues, cyproterone, flutamide

    Specific prostatic androgen inhibitor - 5(alpha) reductase inhibitor (finasteride)

    Mortality and morbidity

    Recent reports of an unexpectedly high incidence of complications after transurethral resection of prostate need to be taken seriously, but few would agree that the early and late mortality figures published by Roos et al are typical of modern practice.1 Mortality is influenced by many factors that have not necessarily been evaluated or reported but could bias results. More obviously these include the skill and continuing experience of the surgeon, the size of the prostate resected (which in turn influences duration of resection and hence blood loss and irrigant absorption), and cardiovascular …

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