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This is a summary of the clinical commissioning policies for surgical procedures for the treatment of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH)
The routine commissioning of Holmium Laser Enucleation of the Prostate (HoLEP) is accepted in Devon for the treatment of patients with lower urinary tract symptoms caused by benign prostatic hyperplasia who have a large prostate that, due to its size, would only otherwise be suitable for treatment with an open prostatectomy.
The routine commissioning of Rezum and Aquablation (transurethral water jet ablation) is not accepted in Devon for the treatment of lower urinary tract symptoms caused by benign prostatic hyperplasia.
Prostatic artery embolisation (PAE) should be offered on an evaluation-in-service basis in Devon with data collection for 12 months.
Lower urinary tract symptoms (LUTS) comprise of storage, voiding and post‑micturition symptoms affecting the lower urinary tract. In men, the most common cause is benign prostate enlargement, which obstructs the bladder outlet. Benign prostate enlargement happens when the number of cells in the prostate increases, a condition called benign prostatic hyperplasia (BPH). LUTS are a major burden for the ageing male population. Age is an important risk factor for LUTS and the prevalence of LUTS increases as men get older. Bothersome LUTS can occur in up to 30% of men older than 65 years. The "gold standard" treatment option for men with LUTS caused by BPH is Transurethral Resection of the Prostate (TURP) however this is only suitable for patients with a prostate smaller than around 100 grams. Patients with prostates larger than 100 grams are commonly treated with an open prostatectomy (OP).
UroLift is an alternative to TURP to treat patients with LUTS caused by BPH. A prostatic urethral lift is performed using adjustable, permanent implants to pull excess prostatic tissue away from the urethra to stop it narrowing or blocking it.
UroLift has been found to be less effective than TURP in terms of international prostate symptom score and urinary flow, over a two year follow up. However, when assessing the improvements patients treated with UroLift achieved over 5 years in comparison to their baseline, pre-operative, symptoms a trial has demonstrated patients achieve a clinically significant improvement in international prostate symptom score and urinary flow. Patients treated with UroLift report better postoperative ejaculatory function than those treated with TURP.
The UroLift procedure can be conducted as a day case procedure and places less of a demand on inpatient bed availability and surgical theatre time. When four or fewer implants are used in the UroLift procedure it can incur a lower cost than a TURP.
GreenLight XPS is an alternative to TURP to treat patients with LUTS caused by BPH. The treatment uses a 180 watt GreenLight XPS laser which operates at a wavelength which is absorbed by oxyhaemoglobin in blood and tissue, causing tissue vaporisation. GreenLight has been demonstrated to be non-inferior to TURP, with improvements maintained over a 24 month follow up.
The GreenLight procedure requires a general operating theatre and can take longer than a TURP, but a majority of patients can be treated as a day case procedure and so places less of a demand on inpatient bed availability. The cost of consumables is such that this procedure can be delivered at a low cost per case compared to other procedures and it is considered good value for money.
Holmium Laser Enucleation of the Prostate (HoLEP) is an alternative to TURP to treat patients with LUTS caused by BPH. The treatment uses a laser to enucleate sections of the prostate which are passed into the bladder and then morcellated before removal via the urethra.
HoLEP can be performed on patients with large prostates that would otherwise have to be treated with an OP. A meta-analysis of randomised controlled trials has shown HoLEP to achieve comparable functional outcomes, including urinary flow, post void residual and international prostate symptom score, in comparison to open prostatectomy. The HoLEP procedure was found to take longer than an open prostatectomy but is associated with a shorter catheterisation time and hospital stay.
The commissioning of HoLEP provides a less invasive treatment option for patients with large prostates and has the potential to increase inpatient bed availability. The cost of treatment compares favourably with OP and is considered to represent good value for money.
Aquablation (transurethral water jet ablation) is an alternative to TURP to treat LUTS caused by BPH. The technology uses a system which combines image guidance and robotics to target enlarged areas of the prostate with a high-speed jet of saline solution to ablate the prostate tissue.
Current RCT evidence of Aquablation is limited to a trial with a 12 month follow up. There is insufficient information about the longer-term efficacy, safety or cost effectiveness of this procedure to determine if it will be a good use of funds in comparison to other procedures available.
Rezum is an alternative to TURP to treat LUTS caused by BPH. The technology delivers water vapour to cells in the prostate through a retractable needle, when the vapour comes into contact with cells it converts back into water, releasing its energy into the cell membranes causing cell death.
The clinical and safety evidence of Rezum is limited to a comparison with a sham treatment. It is not known how Rezum compares to current treatment options, so it is not possible to ascertain if the commissioning of Rezum is a good use of money.
Please see Urology clinical referral guidelines
Where the circumstances of treatment for an individual patient do not meet the criteria described above exceptional funding can be sought. Individual cases will be reviewed by the appropriate panel of the CCG upon receipt of a completed application from the patient's GP, consultant or clinician. Applications cannot be considered from patients personally.
These have been agreed by NHS Devon CCG following discussion and recommendation by the Clinical Policy Committee.
Publication date: 28 May 2019