Combined prostatic urethral lift and remodeling of the prostate and bladder neck - Beyond the Abstract

In this study we take a closer look at the feasibility and safety of combining prostatic urethral lift (PUL) and a limited resection of the prostatic middle lobe or bladder neck incision in the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH).

In 2012 we started our PUL at the University of Freiburg Medical Centre Department of Urology. As suggested by the device’s design we excluded patients with a significant prostatic middle lobe from PUL treatment. However, it soon became evident that many younger patients with small prostates and LUTS (ie., the target population for PUL) had either an additional obstructive middle lobe or primary obstructive bladder neck. 

For several decades, the resection of the smooth sphincter of the bladder neck has been considered the main reason for a loss of antegrade ejaculatory function after TURP. This theory on the mechanisms of ejaculation has been challenged by recent video-urodynamic findings suggesting that antegrade ejaculation operates independently of a preserved bladder neck. The current theory locates an ejaculation-related smooth muscle (musculus ejaculatorius) in the paracollicular tissue about 1 cm proximal to the verumontanum [1]. Recently, Alloussi et al. described an ejaculation preserving resection technique (subsequently termed epTURP) leaving this particular tissue (and some dorsal tissue at the apex flanking the plate of musculus ejaculatorius) unresected in an otherwise complete radical TURP [2]. 

In the combined approach as described in our manuscript, transurethral resection is limited to the prostatic middle lobe and/ or high bladder neck, preserving the paracollicular region around the verumontanum—i.e., the musculus ejaculatorius plate.

We believe that the combination of PUL and surgical remodeling of the bladder neck/middle lobe offers a true alternative for patients with LUTS secondary to BPH. In appropriate patients (medium size prostates, moderate symptoms and functional impairment), it not only provides improved functional results and symptom relief (as compared to drugs or PUL alone), but at the same time preserves sexual function and continence.


Written by: Martin Schoenthaler, MD, University Medical Center Freiburg · Department of Urology

References:

1. Hermabessiere J, Guy L, Boiteux JP (1999) Human ejaculation: physiology, surgical conservation of ejaculation. Prog En Urol J Assoc Fr Urol Société Fr Urol 9:305–309
2. Alloussi SH, Lang C, Eichel R, Alloussi S (2014) Ejaculation-preserving transurethral resection of prostate and bladder neck: shortand long-term results of a new innovative resection technique. J Endourol 28:84–89.


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