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ATLANTA -- The gold standard surgical treatment for benign prostatic hyperplasia (BPH) led to a few more complications, but reduced the reoperation rate by 50% or more compared with newer minimally invasive procedures, a review of more than 600,000 cases showed.

The two most common complications, urethral stricture and bladder neck contracture, occurred more often with transurethral resection of the prostate (TURP) than with transurethral microwave therapy (TUMT), transurethral needle ablation (TUNA), or two laser procedures.

However, 8.3% of TURP patients subsequently required reoperation, whereas as many as 26% of patients treated with the other procedures needed another BPH-related operation at some point.

"In most cases, the reoperation was a TURP, so many of the patients might have avoided reoperation if they had a TURP as the initial procedures," Sean Elliott, MD, of the University of Minnesota in Minneapolis, reported here at the American Urological Association meeting.

For years, TURP's status as the standard for BPH surgery went largely unchallenged. Over the past decade or so, several new procedures have emerged, and a growing number of patients have been treated with newer techniques, resulting in a corresponding decrease in the number of TURPs.

Few randomized controlled trials have directly compared the newer procedures with TURP or with one another. Consequently, limited information has accumulated regarding the relative effectiveness of the procedures, particularly how they stack up against TURP.

To examine the relative effectiveness and safety of the BPH procedures, Elliott and colleagues reviewed Medicare claims data to identify all men who had treatment of BPH during 2001 to 2007 by five different procedures: TURP, TUMT, TUNA, laser coagulation, and laser vaporization.

The primary outcome of interest was repeat surgery. The key secondary outcome was the frequency of surgical complications with each procedure. Both outcomes were assessed through 2008. Median follow-up was 3.6 years.

The results showed that 624,319 men underwent BPH procedures during the study period. TURP accounted for 51.8% (319,233) of all the procedures, although its share of the surgical volume had begun to decline toward the end of the review, Elliott said.

Analysis of procedures by year showed that 19% of TURP procedures were performed in 2001 and 9.2% in 2007. TUMT was the second most common procedure, accounting for 131,892 (21.4%) of all BPH surgeries over the 7-year period, followed by laser vaporization (75,262, 12.2%), laser coagulation (47,038, 7.6%), and TUNA (43,310, 7.0%).

With the exception of laser coagulation, the volume of the minimally invasive alternatives to TURP increased each year of the study period. The proportion of TUMT procedures performed in 2001 was 5.4%, increasing to more than 19% in 2005 and 2006 and declining slightly to 17.1% in 2007.

Fewer than 8% of all laser vaporization procedures were performed during the first 3 years, jumping to 30% in each of the last 2 years. The distribution of TUNA procedures ranged from 7.3% in 2001 to a maximum of 17% to 18% in 2004 and 2005, before declining to 15% in each of the last 2 years.

The 5-year estimated rate of reoperation was:

• 8.3% with TURP
• 15.8% with laser vaporization
• 22.4% with laser coagulation
• 21.2% with TUNA
• 25.8% with TUMT

"The likelihood of repeat surgery after laser or thermotherapy was 2.1 to 3.5 times higher than after TURP," said Elliott. "The type of primary surgery was the only variable with any clinically significant influence on the risk of repeat surgery."

"The observed risk continued to climb through the end of our observation period," he added.

Urethral stricture occurred in 4.4% of all BPH surgeries. The rate was 5.7% with TURP and was least common after TUMT (2.3%) or TUNA (2.6%, P<0.001). Bladder neck contracture occurred in 2% of patients, including 2.6% of those treated with TURP, 2.3% after laser coagulation, 1.6% after laser vaporization, and <1% after TUMT or TUNA (P<0.001).

In response to a question, Elliott said the investigators did not have access to information about medication use among patients.

"It would be interesting to know," he said. "If almost 30% of patients are having repeat surgery after TUMT, it could be that 50% or more are being treated with medication."

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