Policies for the Commissioning of Healthcare

Policy for Surgical intervention for benign prostatic hyperplasia (BPH)

  Introduction 
  This document is part of a suite of policies that the CCG uses to drive its commissioning of healthcare. Each policy in that suite is a separate public document in its own right, but will be applied with reference to other policies in that suite.
   
1.  Policy
1.1 The CCG will commission surgical intervention for benign prostatic hyperplasia when the following conditions are met:
   a) The man has been counselled thoroughly regarding alternatives to and outcomes from surgery with regard to physical, emotional, psychological and sexual health.  If appropriate, carers should be involved.
  AND
   b) Due consideration to the surgical modality to be used has been undertaken (see Section 2.2)
  AND
   c) Due consideration to the surgical modality to be used has been undertaken (see Section 2.2)
  AND
   d) Conservative management options and drug treatments have been unsuccessful
  OR (instead of c and d)
   e) The man has complicated BPH with chronic urinary retention with renal impairment as evidenced by hydronephrosis and impaired Glomerular Filtration Rate (GFR)
   
2. Scope and definitions
   
2.1

This policy is based on the CCGs Statement of Principles for Commissioning of Healthcare (version in force on the date on which this policy is adopted).

   
2.2

The commonest and longest-standing surgical intervention for BPH is Transurethral resection of prostate (TURP).  This involves removing some tissue from the prostate using cystoscopy. TURP is undertaken on an in-patient basis, with a catheter left in place for 24-48 hours post-op.  It may be done under either general or spinal anaesthetic. 

TURP causes temporary discomfort, occasionally pain, haematuria and is associated with small risks of infection and acute urinary retention after removal of the catheter. There is also a risk of sexual dysfunction following TURP. There are small but significant risks of significant harm, including severe fluid and electrolyte imbalances associated with absorption of large volumes of irrigating fluid (TUR syndrome).

Other surgical modalities include, among others:

— Transurethral incision of the prostate (TUIP) or Bladder Neck Incision (BNI)

— Holmium LASER enucleation of the prostate

— 532 nm (‘Greenlight’) laser vaporisation of the prostate

— UroLift

— Transurethral needle ablation of the prostate (TUNA)

— Transurethral vaporisation of the prostate (TUVP)

— Transurethral water vapour therapy (Rezum).

Open simple/benign prostatectomy is uncommonly undertaken in men with very large prostates and problematic symptoms. Newer ablative therapies are currently under evaluation and non-surgical procedures such as prostatic artery embolisation (PAE).

   
2.3

The CCG recognises that a patient may have certain features, such as

a)    having benign prostatic hyperplasia;

b)    wishing to have a service provided for benign prostatic hyperplasia;

c)    being advised that they are clinically suitable for surgical intervention for benign prostatic hyperplasia, and

d)    being distressed by having benign prostatic hyperplasia, and by the fact that that they may not meet the criteria specified in this commissioning policy. 

Such features place the patient within the group to whom this policy applies and do not make them exceptions to it.
   
2.4

NICE guidance CG971 provides clear evidence, in clinical and cost-effectiveness terms, that patients with urinary voiding symptoms presumed secondary to BPH, should be offered surgical intervention only when those symptoms are severe, or when conservative management options have been unsuccessful.

TURP has long been the mainstay of surgical treatment for voiding LUTS

presumed secondary to BPH. The newer surgical modalities outlined

above in Section 2.2 have therefore been evaluated in comparison with TURP, as well as conservative management. NICE CG97 accordingly incorporated a comprehensive matrix of comparative studies between treatment modalities within its evidence review. This reflects increasing complexity in decision-making around surgical intervention, increasingly involving ‘which’, as well as ‘when’ or ‘whether’ surgery should be offered.

This policy, which is in accord with the national Evidence-Based Interventions List 2 Guidance2 reflects the full breadth of comparative studies between surgical intervention and conservative management, as well as between different modalities of surgical intervention forming the basis of NICE CG97
   
3 Appropiate Healthcare
   
3.1 The purpose of surgical intervention for benign prostatic hyperplasia is normally to treat symptoms of “prostatism”, principally difficulty voiding urine.
   
3.2 The CCG regards the achievement of this purpose as according with the Principle of Appropriateness. Therefore, this policy does not rely on the principle of appropriateness. Nevertheless, if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider the principle of appropriateness in the particular circumstances of the patient in question when considering an application to provide funding.
   
4 Effective Healthcare
   
4.1 The policy criteria are based on the Principle of Effectiveness as outlined in the national Evidence-Based Interventions List 2 Guidance1, NICE guidance CG 972 and the various studies as listed in the Section 10 (References).
   
5 Cost effectiveness
   
5.1 The CCG considers that an intervention cannot be cost-effective if it not effective, and therefore this policy is also based on the Principle of Cost Effectiveness.
   
6 Ethics
   
6.1 The CCG does not call into question the ethics of surgical intervention for benign prostatic hyperplasia and therefore this policy does not rely on the Principle of Ethics.   Nevertheless if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider whether the treatment is likely to raise ethical concerns in this patient when considering an application to provide funding.
   
7 Affordability
   
7.1 The CCG does not call into question the affordability of surgical interventions for benign prostatic hyperplasia and therefore this policy does not rely on the Principle of Affordability.  Nevertheless if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider whether the treatment is likely to be affordable in this patient when considering an application to provide funding.
   
8 Exceptions
   
8.1 The CCG will consider exceptions to this policy in accordance with the Policy for Considering Applications for Exceptionality to Commissioning Policies.
   
9 Force
   
9.1 This policy remains in force until it is superseded by a revised policy or by mandatory NICE guidance relating to this intervention, or to alternative treatments for the same condition.
   
9.2

In the event of NICE guidance referenced in this policy being superseded by new NICE guidance, then:

  • If the new NICE guidance has mandatory status, then that NICE guidance will supersede this policy with effect from the date on which it becomes mandatory.
  • If the new NICE guidance does not have mandatory status, then the CCG will aspire to review and update this policy accordingly. However, until the CCG adopts a revised policy, this policy will remain in force and any references in it to NICE guidance will remain valid as far as the decisions of this CCG are concerned.
   
10 References
 

1.NICE clinical guideline CG97. Lower urinary tract symptoms in men:

Management.  Last updated June 2015 https://www.nice.org.uk/guidance/cg97.

2.Evidence-Based Interventions List 2 Guidance.  Academy of Medical Royal Colleges, published November 2020. https://www.aomrc.org.uk/wp-content/uploads/2020/12/EBI_list2_guidance_150321.pdf

3. NICE guidance UroLift for treating lower urinary tract symptoms of benign

prostatic hyperplasia (Medical technologies guidance MTG 26): https://www.nice.org.uk/guidance/mtg26/

4. European Association of Urology guideline on the management of

non-neurogenic male LUTS: https://uroweb.org/guideline/treatment-of-non-neurogenic-male-luts/.

5. GIRFT Urology Report: https://www.gettingitrightfirsttime.co.uk/surgical-specialty/urology-surgery/
   
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