What is the role of herbal therapy in BPH treatment?

This question is difficult to answer. Herbs are considered as food additives and not drugs and, as such, are not regulated by the FDA. The production and marketing of herbs are essentially unregulated. Therefore, few randomized studies evaluate the efficacy of herbal therapy in the treatment of BPH.

Phytotherapy, more commonly known as herbal therapy, has become increasingly popular in the treatment of BPH. About 30 herbal compounds have been used to treat prostatic urinary symptoms. The most popular of these is saw palmetto, which is the extract of the dried ripe fruit from the American dwarf saw palmetto plant, Serenoa repens.

Until recently, the efficacy of saw palmetto was unknown. A 2006 study in the New England Journal of Medicine (2006;354:557-566), however, demonstrated that there was no significant difference between saw palmetto and placebo as measured by symptom scores or urinary flow rates. Unless subsequent reports refute this well-done study, it would seem that saw palmetto has no documented benefit in the treatment of BPH.

What happens if medical therapy fails or one cannot tolerate the adverse effects of medical therapy?

For men who fail or cannot tolerate medical therapy there are a variety of additional options available for treatment of BPH. These options vary from minimally invasive procedures to open surgical procedures. The choice of procedure will be determined by your overall health status, the size of your prostate, the presence or absence of other problems, such as bladder stones, your preference, and your urologist's recommendations. Surgical interventions include open prostatectomy, transurethral prostatectomy, transurethral incision of the prostate, and various laser treatments of the prostate. Minimally invasive approaches to treatment of BPH include microwave therapy, transurethral needle ablation (TUNA), radiofrequency ablation of the prostate, and placement of pro-static stents. In those individuals in retention, in whom urodynamic studies have demonstrated poor bladder function, an indwelling foley catheter, suprapubic catheter, or clean intermittent catheterization are options.

What is an open prostatectomy?

An open prostatectomy is the removal of the obstructing portion of a benign prostate through a surgical incision. Open prostatectomies are usually reserved for large prostates that weigh more than 100 grams. The open prostatectomy allows for the greatest amount of prostate tissue to be removed, but the morbidity is greater than less invasive options because it is an open surgical procedure.

The most common approach to performing an open prostatectomy is through a lower abdominal incision that extends from the symphysis pubis to the umbilicus (belly button) (Figure 23).

Figure 23. Types of surgical incisions for simple prostatectomy: suprapubic or retropubic approach and perineal approach.

After the surgeon enters the abdomen through this incision, he or she has two surgical choices. The first is to make an incision in the front wall of the bladder to approach the prostate. This is called a suprapubic prostatectomy. After the surgeon has entered the bladder, he or she can enucleate, or shell out, the center of the prostate with his or her index finger. After the inner portion of the prostate is enucleated, stitches are placed in the prostatic fossa (the shell of prostate that is left). Postoperatively, the patient is left with a urethral catheter coming out of his penis and a suprapubic catheter coming out of the lower abdomen. A patient is usually in the hospital 3 or 4 days after a suprapubic prostatectomy.

A retropubic simple prostatectomy is similar to a suprapubic simple prostatectomy as it is also performed through a lower abdominal incision. When performing a retropubic simple prostatectomy, however, the urologist does not open the bladder but instead makes an incision through the prostate capsule. As is done with a suprapubic prostatectomy, the inner portion of the prostate is enucleated. Because the bladder is not opened, it is not necessary to leave a suprapubic tube postoperatively, but a urethral catheter is left in place. Like a suprapubic simple prostatectomy, the patient is usually in the hospital 3 or 4 days postoperatively. The retropubic approach tends to be associated with less bladder irritation after the procedure since the bladder itself is not opened.

In addition to the abdominal approaches described previously here, a benign prostate can be surgically approached via the perineum (Figure 23). When this approach is used, the perineal skin incision is used to expose the prostate; then an incision is made in the prostatic capsule, and the prostate is enucleated, similar to a simple retropubic prostatectomy. A urethral catheter is left postoperatively, and the patient is usually in the hospital 1 to 2 days.