Tailored treatment key to managing enlarged prostate, expert says

Recently, new treatment methods for benign prostatic hyperplasia (BPH) have been introduced, attracting significant attention.

In addition to conventional treatments, such as medication and surgery, minimally invasive treatments with shorter recovery periods and lower risks of complications are emerging as promising alternatives.

One of the typical minimally invasive procedures is “iTind,” newly introduced by Olympus Korea this year. iTind is a treatment that involves temporarily inserting a device into the prostate urethra to alleviate urinary symptoms. It has been recognized by the Ministry of Health and Welfare as a new medical technology with proven safety and efficacy.

Korea Biomedical Review recently met with Professor Kim Si-hyun of the Department of Urology at Soon Chun Hyang University Hospital Cheonan, who introduced this treatment to expand patient-tailored treatment options. The discussion focused on the latest trends in BPH treatment, the clinical applications of iTind, and the changes it will bring to patients.

Question: What is the recent trend in BPH patients?

Answer: The number of young patients visiting hospitals due to urinary discomfort is on the rise. As prostate diseases are frequently covered in the media, including TV, public awareness of the disease has increased, and many people visit hospitals when they experience early symptoms, such as frequent urination or nocturia, suspecting prostate problems. In the past, patients would only visit the hospital when symptoms were severe, but nowadays, even mild discomfort prompts them to seek medical attention, resulting in a wider range of patient ages. In the past, most patients were in their 60s and 70s; however, the number of patients in their 40s and 50s has been steadily increasing recently.

Q: Does the approach to treating BPH vary depending on age?

A: Age is a key factor in determining treatment guidelines. The younger the patient, the greater the importance of preserving sexual function. In patients in their 50s with large prostates who are difficult to treat with medication, traditional surgery may cause side effects, including sexual dysfunction. In such cases, minimally invasive procedures that reduce these side effects may be a suitable alternative.

Q: Is BPH treated in order of severity, starting with medication, then procedures, and finally surgery?

A: First, various tests, including a questionnaire using the IPSS (International Prostate Symptom Score), are conducted to assess the patient's subjective level of discomfort. If the patient's discomfort exceeds the test results, active treatment is considered. Conversely, if the test results are poor but the patient's discomfort is minimal, treatment focused on monitoring the condition is selected.

Benign prostatic hyperplasia is a benign condition, not a malignant disease, so resection is not performed simply because the prostate is enlarged.

If the prostate is slightly enlarged but urinary discomfort is not severe, medication is administered and the condition is monitored. At this time, objective indicators, including urine flow rate, are also taken into consideration. The maximum urine flow rate, amount of urine excreted, and residual urine volume after urination are comprehensively evaluated to determine the treatment direction. However, even if the test results are abnormal, surgery or other procedures are not necessarily performed. The treatment method is decided after sufficient explanation and discussion with the patient.

Unlike diseases like cancer, where the doctor decides the treatment direction based on the stage of the disease, BPH is a disease where the treatment direction is determined based on the patient's quality of life and subjective symptoms. Recently, it has become common for doctors to design a treatment plan in collaboration with the patient, rather than making decisions alone.

Q: What are some minimally invasive procedures?

A: Representative minimally invasive procedures include “iTind,” “prostate ligation (UroLift),” and “Rezum.” UroLift utilizes special ligation threads to tie the prostate tissue and expand the urethra, whereas Rezum employs steam to contract the prostate tissue. These minimally invasive procedures are performed without the need for general anesthesia, and most patients can return to their daily activities immediately after the procedure. Therefore, they are suitable for older adults who have difficulty with general anesthesia, patients who are concerned about sexual dysfunction, and patients who want a quick recovery.

The goal of BPH treatment is to ensure smooth urine flow. The most common surgical procedure is transurethral resection of the prostate, which involves inserting an endoscope into the urethra and removing prostate tissue with an electric knife. This procedure has long been considered the standard treatment due to its safety and effectiveness. Various surgical and procedural methods that have emerged since then have been developed to demonstrate that they are as effective as, or at least as effective as, transurethral resection.

These minimally invasive treatments have advantages over conventional surgery because they do not require general anesthesia and have a high likelihood of preserving sexual function. The Korean Urological Association (through guidelines) recommends transurethral resection, “HoLEP,” and open simple resection depending on the size of the prostate. These surgeries are still considered the most effective treatments.

However, these procedures require general anesthesia and have a long recovery time, which can be burdensome for older adults with weak cardiopulmonary function, limiting their applicability.

Minimally invasive procedures are highly satisfying to patients because they are less burdensome and have a faster recovery time than conventional surgery without significantly reducing efficacy. However, they are not covered by insurance, which makes it hard for some patients to choose it.

Q: Earlier, you mentioned three types of minimally invasive procedures. What are the criteria for selecting each procedure?

A: The choice of procedure depends on the size and shape of the prostate. Generally, minimally invasive procedures are not recommended for prostates weighing 80g or more. However, exceptions include treatments using steam or surgery that removes tissue using high-pressure water jets, which can be attempted even for prostates weighing 80g or more. The shape is also an important variable. The prostate consists of the left lobe, right lobe, and middle lobe. If the middle lobe is excessively protruding, traditional resection is generally performed. However, some patients strongly desire minimally invasive procedures despite these limitations. In such cases, the procedure may be performed after thoroughly explaining the limited effectiveness beforehand.

Approximately 5–10 percent of patients are reported to have developed a middle lobe, and this type also exists among Korean patients. There are cases where the overall prostate size is small but the middle lobe is large, and morphological peculiarities, such as primary bladder neck obstruction, also influence the choice of procedure. As the appropriate treatment varies depending on the shape of the prostate, the treatment direction is determined after accurately identifying the structure through ultrasound and endoscopic examinations.

Q: What are the characteristics of iTind, the most recently introduced minimally invasive procedure?

A: The biggest advantage of iTind is that it has almost no learning curve, making it easy for medical professionals to learn the procedure. Proficiency can be achieved with about five procedures. From the patient's perspective, this means there is little variation in the procedure across medical institutions. Additionally, the procedure takes only about 10 minutes and does not require general anesthesia. However, since iTind involves inserting a nitinol-based medical device into the prostate to expand the urethra, the device must remain inside the body for about a week. Nevertheless, this does not significantly interfere with daily activities.

Q: What is the difference in effectiveness between minimally invasive procedures and traditional surgical methods (transurethral prostate resection)?

A: The surgical method used as a benchmark for evaluating the effectiveness of minimally invasive procedures is transurethral resection of the prostate (TURP). Comparisons are made using indicators, including the IPSS (International Prostate Symptom Score), uroflowmetry, and the IIEF (International Index of Erectile Function). The three procedures—iTind, Rezum, and UroLift—are known to yield better results than TURP in terms of IIEF scores, and they are evaluated as not inferior to TURP in terms of IPSS and uroflowmetry results.

Q: Do patients sometimes request a specific procedure first?

A: Recently, more patients are visiting hospitals after learning about procedures through various channels in advance. However, as mentioned earlier, minimally invasive procedures are most effective when the prostate size is around 60g. For sizes exceeding 80g, HoLEP is recommended, and for sizes greater than 100g, robotic surgery or open surgery is advised. The appropriate treatment option varies depending on the patient's condition, so it is essential to consult with a urologist to determine the optimal treatment method.

Q: We heard that the Urology Department at Soon Chun Hyang University Hospital Cheonan offers various patient-tailored procedures.

A: The Prostate Clinic at Soon Chun Hyang University Hospital Cheonan has a comprehensive treatment system capable of addressing a wide range of conditions, from malignant diseases such as prostate cancer to benign conditions like benign prostatic hyperplasia. Based on a system equipped with various treatment technologies, the clinic selects the most appropriate procedures and surgeries according to each patient's condition. Additionally, during the initial visit, the clinic conducts precise examinations and provides thorough consultations to present the most suitable customized treatment options for each patient.

Q: Is there any message you would like to convey to patients?

A: Our medical staff considers the health and quality of life of each individual patient as their top priority when deciding on a treatment method. Therefore, we ask that patients trust the judgment of our medical staff during the treatment decision process and participate in the consultation process to find the optimal treatment method for their condition. Please understand that the examination and treatment process may take some time, as it is necessary to determine the most appropriate treatment direction. We would appreciate it if you could communicate with our medical staff with an open mind.