Overview of Prostatic Urethral Lift
The Prostatic Urethral Lift (PUL) is a type of surgery that is a less invasive yet effective method for treating symptoms of benign prostatic hyperplasia (BPH), a condition wherein the prostate grows larger than normal. The PUL procedure involves using tiny medical devices to gently push back the enlarged tissue of the prostate. This allows the urethra (the tube through which urine leaves the body) to become clear, helping urine flow more easily. The great thing about this treatment is that it doesn’t harm or remove any tissue, and it can frequently be done in one go with the patient under local anesthesia. This means that it might provide quick relief from BPH symptoms, even reducing the need to take ongoing BPH medication.
Typically, BPH results from an increase in the number of certain cells in the prostate. This increase causes the prostate to broaden, which in turn narrows the urethra, leading to a series of annoying symptoms. These can include feeling a frequent or urgent need to urinate, needing to urinate many times during the night, difficulty beginning to urinate, having a urine flow that stops and starts, and having a weaker urine flow.
Research shows that BPH negatively affects up to three-quarters of men over 50, and this rate increases to as high as 90% for those over 70. While BPH can decrease one’s quality of life, it can also lead to other health problems like repeated urinary tract infections, sudden inability to urinate, bladder stones, and blood in the urine. Traditionally, treatments for BPH usually involve surgery or ongoing medication. However, the PUL offers another, less invasive option in the range of available treatments.
Anatomy and Physiology of Prostatic Urethral Lift
The prostate gland is a sturdy, cone-shaped structure found in males. It sits under the bladder, surrounding the tube through which urine leaves the body, known as the urethra. The prostate is found in front of the pubic bone, and a layer of fascia (connective tissue) separates it from the rectum. Muscles that play significant roles in urination and the release of sperm are found beneath and alongside the prostate.
Speaking about its structure, the prostate is divided into 5 different sections: anterior, posterior, 2 sides, and a middle section. The prostate’s central area is made up of the largest section, the peripheral zone, and the central zone, which surrounds the tubes that release sperm. Another zone, called the transition zone, is smaller and surrounds the urethra. A fibrous capsule covers the prostate and acts as a boundary.
BPH, or benign prostatic hyperplasia, is a condition where the prostate gland becomes enlarged. This enlargement is usually due to an overgrowth of cells (hyperplasia) in the prostate’s transition and central zones. This growth commonly forms multiple nodules, or lumps, in the prostate. The urinary problems associated with BPH are generally due to changes in the structure of the urethra, rather than direct pressure on the bladder outlet.
Why do People Need Prostatic Urethral Lift
BPH, or an enlarged prostate, is usually managed with medication that strictly works on alpha-adrenergic receptors – a type of protein found in the body’s cells. These medications can be used alone or in combination with another type of drugs called 5 alpha-reductase inhibitors. However, sometimes the symptoms persist despite medication, or the patient can’t tolerate the side effects. In such cases, different treatments that are more effective or durable may be necessary.
BPH usually causes nodular growths (called hyperplasia) mainly in the intermediate and central sections of the prostate, known as the lateral and median lobes. These growths can, in turn, cause enlargement of the said lobes, potentially obstructing urine flow. But this obstruction is due to altered shape of the urethra (a tube carrying urine from the bladder to the outside of the body), not just outright squeezing of the bladder’s exit point. The enlargement of the lateral lobes is a common cause behind lower urinary tract symptoms (LUTS), which helps identify who needs treatment.
A few of the minimally invasive procedures to treat persistent LUTS include methods that remove or vaporize parts of the prostate like those using transurethral resection (TURP), GreenLight laser (GLL-PVP), and holmium laser (HoLEP). Other treatments involve open surgery such as a simple-prostatectomy, and artery-blocking methods like prostatic artery embolization (PAE). Alternatively, UroLift procedure (PUL) offers treatments like water vapor thermal ablation (heating the prostate to remove its tissue), drug-coated catheters specific to BPH, and temporary nitinol devices.
To choose the best treatment method, it’s important to consider individual patient’s preferences, present health conditions, prostate size and structure, and a detailed risk-benefit analysis for each surgical option.
PUL treatment is often chosen for patients with severe LUTS that are significantly affecting their quality of life. Ideal candidates for PUL should have a normal neck of the bladder and only minor enlargement of the median lobe of the prostate. While the enlargement of this lobe used to exclude a patient from having the treatment, recent research shows it can be safely addressed using PUL, yielding similar results.
Even at 2 years after surgery, PUL remains effective regardless of prostate size or extent of protrusion into the bladder, with most of the patients (86%) experiencing significant symptom relief within a month. It is also a good option for men whose prostate measures between 20 to 100 cubic cm in volume. An affected sexual function, commonly a concern especially for younger men, hasn’t been observed in studies of patients undergoing PUL.
For someone to qualify for PUL, they need to be over 50 years old, have a prostate volume of 20 to 100 cubic cm, an IPSS (a scoring system used to measure the severity of their LUTS) over 12, a maximum urinary flow rate under 15 mL/s, and a PVR (amount of urine left in the bladder after urination) less than 350 mL.
Once considered a contraindication for PUL, obstructive median lobes can now be effectively managed if the right surgical techniques are used, especially as the treatment does not affect erectile and ejaculatory functions. The mild reported side effects are generally short-term in nature. Symptom relief can even start as early as 2 weeks post-procedure, lasting up to 5 years. Of those who required retreatment, about half underwent traditional methods such as TURP or laser-based removal of the prostate, one-third had a second PUL, and the rest had a PUL device removal.
Additionally, there is focus on research comparing PUL and TURP for patients who also have prostate cancer and require pre-radiotherapy intervention. The fast relief and minimal treatment delay from PUL have suggested its efficacy in such cases.
When a Person Should Avoid Prostatic Urethral Lift
There are certain situations and health conditions that make the use of Prostatic Urethral Lift (PUL) inappropriate or too risky. PUL is a type of treatment used to alleviate symptoms due to an enlarged prostate. This could include people who have had an infection of the prostate (prostatitis) in the last year, or those with an active urinary tract infection. These infections could worsen because of the procedure.
Those who have had issues with not being able to urinate, or have had prior surgeries for benign prostate hyperplasia (BPH), which is a non-cancerous enlargement of the prostate, may not be ideal for PUL. Past surgeries could have changed the structure or created scar tissue that could complicate the procedure. This also applies to individuals who have had surgery or radiation treatment to the pelvic area, as these may change the structure of the area or weaken tissue, and thus increase the risk of complications.
Furthermore, if a man has a prostate-specific antigen (PSA) level greater than 10 ng/mL, this could be an indicator of prostate cancer, and so PUL would not be advisable unless a biopsy has ruled out the presence of cancer.
Apart from these factors, there are also technical limitations of the PUL system. For example, it might be more challenging to use in patients with a high bladder neck. It’s also not suitable for those with a significantly enlarged prostate, if it’s more than 100 mL. Furthermore, the lack of long-term studies and research on patients with multiple health problems (comorbidities) makes its use more restricted. Potential patients should be advised that there is a high possibility of needing further treatment in the long term and the cost per implant might affect their decision to go ahead with PUL.
The main reasons why PUL might not be right for some people include:
- Active urinary tract infection
- PSA level greater than 10 ng/mL (unless cancer has been ruled out by biopsy)
- Having had prostatitis within the past year
- Past issues with urinary retention
- Previous treatment for BPH
- Past pelvic surgery or radiation treatment
Interestingly, it was previously believed that PUL should not be used in cases where the patient was unable to urinate due to a sudden issue (acute urinary retention). However, newer research has shown that 73% of patients were able to stop using a catheter (a tube inserted into the body to help with urinating) and avoid further surgical intervention within 12 months. Those with lower baseline PSA levels, lower post-void residual urine amounts (PVR, which measures the amount of urine left in the bladder after urinating), and shorter pre-PUL catheter use benefited most from being catheter-free.
Equipment used for Prostatic Urethral Lift
Here’s the list of essential tools the doctor uses when doing a procedure called PUL (Prostatic Urethral Lift):
- A 2.9 mm 0° scope, a kind of small camera used to view the area
- A 20F sheath, a tube to protect the scope
- A visual obturator, a device to help insert the scope
- A camera and monitor for cystoscopy, which allows the doctor to see inside your bladder
- A system to irrigate, or rinse with fluid
- Standard endoscopic grasper kit, tools used to hold onto and manipulate things inside the body
- Lubrication that has an anesthetic called lidocaine in it. This helps to lessen any discomfort
- Prostatic urethral device, a specific tool used for this treatment (you can see an image of this device)
The doctor might also have a special tool ready for grabbing and extracting, or taking out, things inside the body. This can be used in case it becomes necessary to remove a piece of the PUL implant during surgery.
There are also a few optional tools that might be used:
- Two-way Foley catheter and drainage bag, a tube and bag to collect urine
- Transrectal ultrasound for local prostatic anesthesia, a device that uses sound waves to guide the doctor and numb just the prostate area
- Local anesthetic (a medication to numb a small area) and a needle to inject it. It’s common to use a mix of short-acting and long-acting anesthetics to help keep you comfortable. An example is a 50:50 mix of 1% lidocaine and 0.5% bupivacaine.
Who is needed to perform Prostatic Urethral Lift?
To carry out a procedure known as PUL, you’ll be in the care of a specialized team:
The first is the surgeon, a doctor specifically trained to perform operations.
Next, there’s the scrub nurse who assists the surgeon during the operation, providing the necessary surgical instruments and supplies.
The circulating nurse plays a vital role too. This person makes sure the surgical environment is safe and everything runs smoothly. They also coordinate the surgical team’s activities.
Finally, the anesthesia team is responsible for your comfort and safety during the operation. They’ll give you medications that make you sleep or numb particular areas, so you don’t feel pain. They also monitor your vital signs (like heart rate and oxygen level) throughout the procedure.
Everyone on this team works together to ensure your surgery goes as smoothly and successfully as possible.
Preparing for Prostatic Urethral Lift
Before any treatment for lower urinary tract symptoms (LUTS), such as difficult urination, or the frequent need to urinate, particularly at night, doctors need a complete background of your health. This includes any current symptoms you’re experiencing, previous medical treatments you’ve had for these symptoms, and your medical and surgical history. The doctor will use various tools to evaluate your symptoms, including a questionnaire known as the International Prostate Symptom Score or American Urological Association (AUA) BPH symptom score. It consists of a set of questions aimed at understanding the severity of your symptoms and how they are affecting your general life quality. The score then helps to categorize your symptoms as mild, moderate, or severe.
In addition to this questionnaire, the doctor will also assess other aspects of your health. These include any risk factors such as smoking, exposure to certain occupational materials, or a family history of prostate conditions. It’s also important for the doctor to understand how you see your symptoms and what you expect from the treatment.
Along with the detailed health history, a physical examination is conducted. This involves examining the prostate and external genitalia to check for any other conditions. Pre-surgery tests are also done to assess infections or abnormalities including urine tests, and scanning the prostate structure and size.
If you’re due to have a prostatic urethral lift (PUL), a procedure that helps to ease LUTS, a flexible cystoscopy can be performed. This procedure uses a thin tube with a camera and light at the end to examine the urinary tract for a more detailed evaluation.
If you’re taking blood thinners, it’s usually advised to stop these a few days before the procedure to reduce the risk of excessive bleeding. The specific timing depends on what type of blood thinner you’re using. However, in some cases, aspirin use can continue even during the procedure.
How is Prostatic Urethral Lift performed
The Prostatic Urethral Lift (PUL) system is a tool used by doctors to help treat certain prostate problems. It has a design that’s a bit like a gun and is used to insert a prostatic implant – a small device made up of two linkages tied together by a strong, everlasting suture (a type of thread used in surgery).
During the operation, your doctor pushes this delivery tool through the urethra – the tube that carries urine from your bladder out of your body – until it reaches the prostatic part. The implant is then released into position by a tiny needle at the end of the device, which pierces into the prostate tissue. This needle holds the first linkage externally to the prostatic capsule. When the needle is pulled back, tension is applied to the suture, causing the second linkage to be fixed within the urethral passage. You typically need around 3.5 implants for the treatment to work, and the great thing is that both local or general anesthesia can be used. And you may not have to stay in the hospital for this; it can also be done on an outpatient basis.
The main goal of the PUL procedure is to create some relief by forming specific channels in the prostate. During the treatment, a cystoscopy is performed for the doctor to get a better picture of the bladder neck and configuration of the prostate. The procedure starts by compressing the part of the prostate where the implant will be placed. The implant needle is then fired into the prostate tissue and its covering. From there, the first linkage and part of the suture get deployed into the prostatic covering. Next, the needle is pulled back, and tension is applied to the suture. The procedure gets repeated until you have the correct number of implants in place. The right amount of implants ensures that your urethra is dilated appropriately, which can assist your urinary flow.
Most of the time, you wouldn’t need a catheter after this procedure. This method is chosen as it affects the urinary flow positively while being as less invasive as possible and preserving erectile and ejaculation functions.
There’s also an updated PUL procedure to tackle the obstructive median lobes. This approach is pretty much like the normal technique. The key difference comes in when deploying the implant on the middle lobe. According to a study carried out, some tissue can be pulled into the prostate region and fixed on either side of the urethra, depending on the person’s prostate structure. What’s important is to deploy the implant away from the nerves and blood vessels.
In case any complications arise, removing the implant promptly is possible. Doctors can use graspers to remove the suture if it can still be seen in the prostate region, use an electric current, or use laser enucleation (a method of removing prostate tissue). However, it’s essential to be careful while using laser enucleation as there have been instances where the instruments jammed with the implant.
Possible Complications of Prostatic Urethral Lift
Having a Prostatic Urethral Lift (PUL) surgery can sometimes lead to complications. These might range from minor issues to severe problems. Thus, it’s important for patients to be closely watched after the surgery so any issues can be quickly dealt with if they occur.
Minor complications are usually not severe, occur quickly, and resolve easily. These might include painful urination, feeling the need to urinate urgently, blood in urine, general discomfort or pelvic pain, or urinary tract infections.
Major complications, while rare, can be quite serious. These might include blood clot retention, which is when clots form in the bladder and block urine flow. Other complications can include difficulty urinating, inability to control urination, inflammation of the prostate, inflammation of the testicles, stones in the prostatic fossa, and even breakage of the implant – although this last one is exceedingly rare, happening in only 0.004% of cases.
There can also be complications if the PUL device is not correctly placed. Ideally, it should be positioned at least 1 to 1.5 cm below the bladder neck. If it’s placed too close, it may lead to severe irritative symptoms, stone formation, and frequent urinary tract infections. But again, the chances of stone formation are very low, at 0.006%.
If you’re having an MRI scan, it’s important to note that the PUL implant is MRI-safe under certain conditions. The magnetic field has to be 3 Tesla or lower, the spatial field gradient shouldn’t exceed 1500 Gauss/cm, and the specific absorption rate of the MRI system must not exceed 4 W/kg for 15 minutes of continuous scanning. If these conditions are met, at most the PUL implant might cause the body temperature to increase by no more than 2.4 °C during a 15-minute scan.
However, the PUL implant might affect the quality of the MRI images in certain parts of the prostate. This could make it harder to identify any potential prostate cancer. So, if you’re considering PUL procedure, you should be aware of how the implant may affect MRI scans.
What Else Should I Know About Prostatic Urethral Lift?
Prostatic Urethral Lift (PUL), a less invasive surgery, is making a major difference in treating Lower Urinary Tract Symptoms (LUTS) that are due to Benign Prostatic Hyperplasia (BPH). BPH is a condition where the prostate gland grows larger and can cause problems with urination.
Research has shown that PUL can quickly improve these urinary issues and enhance the patient’s life quality. In a review involving around 600 patients, PUL was found to boost the functioning of the urinary system and contributed to an increase in the flow of urine. While the results were not as substantial as those seen with traditional surgical treatments, most patients reported improvements within the first month of their PUL surgery.
PUL has a low impact on sexual health, with minimal changes to sexual and ejaculatory functions after surgery. Comparatively, other kinds of BPH treatments, including a technique called ‘Aquablation’ and traditional surgeries, are seen to cause more considerable sexual dysfunction.
Another major benefit of the PUL procedure is the quick recovery time. Due to its less-invasive nature, patients can get back to their regular activities faster than with traditional surgeries. Many patients who undergo PUL will only need to use a catheter for up to 24 hours after surgery, and typically spend just one day in the hospital, as opposed to the two-day stay usually needed following traditional procedures.
The safety profile of PUL is quite good, and it involves a low risk of severe complications. This makes it a suitable choice for patients who may not be eligible for more invasive procedures due to complex health conditions.
PUL is flexible from an anesthesia perspective; it can be performed under local, spinal, or general anesthesia depending on patient’s preference and overall health. Furthermore, the procedure can reduce or even remove the need for ongoing BPH medications, which often have side effects.
PUL is usually an outpatient procedure, which means that patients typically don’t need to stay in the hospital overnight. This contributes to both patient convenience and cost-effectiveness for healthcare providers.
