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Balanitis Xerotica Obliterans and Lichen Sclerosus of the Foreskin

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Balanitis xerotica obliterans—usually abbreviated to BXO, is the traditional urological name for male genital lichen sclerosus.

Lichen sclerosus is a chronic inflammatory skin condition that most commonly affects the foreskin and head of the penis. It can cause whitening, inflammation, splitting and progressive scarring of the foreskin. In some men it also narrows the urinary opening or extends into the urethra.

BXO is not simply an infection or ordinary balanitis. Early recognition and treatment can relieve symptoms and reduce permanent scarring. Long-term observation is also important because genital lichen sclerosus is associated with a small but genuine risk of penile squamous cell carcinoma.

Is BXO different from lichen sclerosus?

The names are often used interchangeably:

  • Lichen sclerosus is the preferred modern medical term.
  • Balanitis xerotica obliterans describes lichen sclerosus affecting the glans penis and foreskin, particularly when scarring has developed.

The condition may involve:

  • The inner and outer foreskin
  • The glans penis
  • The frenulum
  • The urinary opening—the meatus
  • The fossa navicularis and penile urethra

The disease is usually confined to the genital region in men, although lichen sclerosus can occasionally affect skin elsewhere.

What causes lichen sclerosus?

The exact cause remains uncertain. It is probably produced by a combination of inflammation, immune-system dysfunction, genetic susceptibility, skin injury and local environmental factors.

Possible associations include:

  • Autoimmune or inflammatory activity
  • Chronic exposure of susceptible skin to trapped urine
  • Repeated friction or minor trauma
  • A tight foreskin
  • Previous inflammation beneath the foreskin
  • Obesity and a “buried” penis
  • Diabetes or metabolic disease
  • Cigarette smoking
  • Genetic susceptibility

The moist, occluded environment beneath the foreskin may contribute to continuing inflammation in susceptible men.

Lichen sclerosus is:

  • Not caused by poor personal character or behaviour
  • Not usually a sexually transmitted infection
  • Not contagious
  • Not something that can be passed to a partner through ordinary sexual contact

Yeast or bacterial infection may occur at the same time, particularly in men with diabetes, but infection is not the underlying cause of lichen sclerosus.

Who can develop it?

Male genital lichen sclerosus can occur at any age.

It is recognised in:

  • Boys with acquired or severe scarring phimosis
  • Adolescents
  • Younger and middle-aged men
  • Older men
  • Men with a previously retractable foreskin that has gradually tightened

It is much less common in men who were circumcised early in life, although circumcision does not make the risk absolutely zero.

How does lichen sclerosus present?

The appearance varies considerably. Early disease can be subtle and may initially be mistaken for thrush, dermatitis, recurrent balanitis or ordinary phimosis.

Possible signs include:

  • White, pale or porcelain-coloured foreskin
  • A white, firm ring around the foreskin opening
  • Thickened or hardened skin
  • Shiny, crinkled or “cigarette-paper” skin
  • Red or inflamed areas
  • Small cracks or splits
  • Easy bleeding or bruising
  • Painful erosions
  • Adhesions between the foreskin and glans
  • Progressive tightening of the foreskin
  • Shortening or scarring of the frenulum
  • Whitening around the urinary opening
  • Narrowing of the meatus
  • Loss of the normal shape or definition of the glans and foreskin

Some men have significant visible disease with surprisingly little discomfort.

Symptoms patients may notice

Symptoms can include:

  • Difficulty retracting the foreskin
  • Inability to replace or retract the foreskin fully
  • Pain during erections
  • Splitting or bleeding during intercourse
  • Itching, burning or soreness
  • Recurrent “balanitis”
  • Pain or reduced enjoyment during sexual activity
  • Spraying or deflection of the urinary stream
  • A weak or narrowed stream
  • Straining to urinate
  • Dribbling after urination
  • Ballooning of the foreskin
  • Recurrent urinary infections
  • Difficulty emptying the bladder

A narrow urinary opening may be the first sign that the disease has extended beyond the foreskin.

Lichen sclerosus and phimosis

Phimosis means that the foreskin cannot be retracted comfortably behind the glans.

A non-retractile foreskin is normal in young boys and does not automatically indicate disease. However, a previously retractable foreskin that becomes tight, particularly when accompanied by a white scarred ring is suspicious for lichen sclerosus.

Forceful stretching of a scarred foreskin is not recommended. Repeated tearing may cause additional inflammation and scarring.

Paraphimosis, where a retracted tight foreskin becomes trapped behind the glans, requires urgent medical attention.

How is lichen sclerosus diagnosed?

The diagnosis is often made from the history and characteristic appearance.

Assessment should include examination of:

  • The complete foreskin
  • Glans penis
  • Frenulum
  • Urinary opening
  • Palpable tissue beneath abnormal skin
  • Urinary stream and bladder emptying when relevant
  • Groin lymph nodes if cancer is suspected

Other conditions that can resemble lichen sclerosus include:

  • Fungal or bacterial balanitis
  • Irritant or allergic dermatitis
  • Psoriasis
  • Lichen planus
  • Zoon balanitis
  • Vitiligo
  • Genital warts
  • Penile intraepithelial neoplasia: PeIN
  • Squamous cell carcinoma

Diabetes testing may be appropriate in men with recurrent inflammation or other risk factors.

Is a biopsy always necessary?

Not every typical case requires a biopsy before treatment. However, biopsy is important when:

  • The diagnosis is uncertain
  • Treatment has not produced the expected response
  • An erosion or ulcer does not heal
  • There is a persistent red or thickened area
  • A lump or hardened area can be felt
  • The skin bleeds easily without an obvious cause
  • Pigmentation changes unexpectedly
  • Penile intraepithelial neoplasia or cancer is suspected

When circumcision is performed for suspected lichen sclerosus, the foreskin should usually be sent for pathological examination.

A biopsy should be taken from any suspicious persistent lesion rather than relying only on the appearance.

Medical management

The goals of medical treatment are to:

  • Suppress inflammation
  • Relieve discomfort and itching
  • Prevent further scarring
  • Preserve foreskin and urinary function where possible
  • Identify patients who require surgery or biopsy

General skin care

Helpful measures include:

  • Washing gently with water or a non-soap cleanser
  • Avoiding perfumed soaps, antiseptics and harsh products
  • Drying the glans and foreskin gently after urination
  • Applying a bland barrier ointment or emollient
  • Avoiding forceful foreskin retraction
  • Using adequate lubrication during sexual activity
  • Stopping smoking
  • Managing diabetes carefully
  • Addressing obesity or a buried penis where relevant

Good hygiene means gentle care. Repeated scrubbing or strong antiseptics can worsen inflamed genital skin.

Potent topical corticosteroids

A prescribed potent or ultrapotent topical corticosteroid is the usual first-line medical treatment.

Clobetasol propionate 0.05% ointment is commonly used in specialist practice. A typical initial course may involve a small amount applied to the affected skin once daily for one to three months, but the exact regimen should be determined by the treating doctor.

Patients should be shown:

  • Exactly where to apply the medication
  • How much to use
  • How long to continue
  • Whether treatment should be reduced gradually
  • When follow-up is required

When used correctly for a defined course, topical corticosteroids can reduce inflammation, soreness and early tightening. They cannot always reverse established dense scar tissue.

Possible steroid-related effects include irritation, secondary infection, skin thinning or visible small blood vessels, although these are uncommon with appropriate genital use and medical supervision.

Other topical treatments

Topical calcineurin inhibitors such as tacrolimus or pimecrolimus may occasionally be considered by a dermatologist or experienced specialist when corticosteroids are unsuitable.

They are not generally preferred over potent topical corticosteroids as initial treatment. They can cause burning or irritation, and persistent suspicious lesions must be biopsied rather than repeatedly treated empirically.

Antifungal or antibiotic medication is only useful when a secondary infection is actually present. It does not treat the underlying lichen sclerosus.

When should circumcision be considered?

Circumcision is an important and often definitive treatment for foreskin lichen sclerosus.

It should be considered when there is:

  • Established scarring phimosis
  • Painful or recurrent splitting
  • Difficulty with hygiene
  • Recurrent balanitis
  • Paraphimosis
  • Failure to respond adequately to a prescribed steroid course
  • Rapid recurrence after apparently successful medical treatment
  • Significant functional or sexual difficulty
  • Concern about premalignant or malignant change
  • A need to obtain tissue for diagnosis

Complete circumcision removes the diseased foreskin and eliminates the moist, urine-exposed environment beneath it. Many men experience long-term resolution when the disease is limited to the foreskin.

Partial circumcision or simply making a slit in the scarred foreskin is generally less reliable because affected skin remains and may scar again.

Will circumcision cure lichen sclerosus?

Circumcision is often highly effective when the condition is limited to the foreskin. However, it is not an absolute guarantee of cure.

Disease may persist or recur on the:

  • Glans
  • Coronal sulcus
  • Frenulum
  • Urinary opening
  • Urethra

Ongoing symptoms or abnormal skin after circumcision should therefore be reviewed rather than assumed to be normal postoperative scarring.

Circumcision appears to reduce the risk associated with chronic inflammation and phimosis, but it does not completely eliminate the future risk of penile cancer.

Surgery for meatal narrowing

Lichen sclerosus can scar the urinary opening, producing meatal stenosis.

Symptoms may include:

  • A thin urinary stream
  • Spraying or deflection
  • Prolonged urination
  • Straining
  • Discomfort
  • Incomplete emptying

Treatment may require a meatotomy or meatoplasty, in which the opening is enlarged and reconstructed.

Simple dilatation may provide temporary improvement but often does not control active scar disease. Medical treatment of the surrounding lichen sclerosus and continued surveillance may still be required.

What if the disease involves the urethra?

In some men, scarring extends from the meatus into the penile urethra and occasionally further towards the bulbar urethra.

Assessment may include:

  • Urinary flow-rate testing
  • Post-void residual ultrasound
  • Flexible cystoscopy
  • Retrograde urethrogram
  • Voiding cystourethrogram
  • Urethral ultrasound in selected cases

Short strictures may sometimes be managed endoscopically, but repeated dilatation or urethrotomy has a significant recurrence risk when active lichen sclerosus remains.

Longer or recurrent strictures may require urethroplasty. Oral lining tissue, usually buccal mucosa from the inside of the cheek, is commonly used for reconstruction.

The European Association of Urology recommends that genital skin should not be used as a graft for lichen-sclerosus-related urethral strictures, because the disease can affect the graft and recurrence rates are poor.

Complex cases are best managed by a urologist experienced in reconstructive urethral surgery.

Other surgical options

Depending on the extent of disease, specialist procedures may include:

  • Frenuloplasty in carefully selected cases without extensive LS
  • Complete circumcision
  • Meatotomy or meatoplasty
  • Excision or biopsy of suspicious lesions
  • Glans resurfacing when premalignant disease is present
  • Oral-mucosa graft urethroplasty
  • Staged urethral reconstruction
  • Perineal urethrostomy for severe or recurrent extensive stricture disease

The operation should be tailored to the location and activity of the condition. Preserving diseased genital skin simply to avoid circumcision may produce repeated scarring and further procedures.

Lichen sclerosus and penile cancer

Male genital lichen sclerosus is associated with squamous cell carcinoma of the penis and with penile intraepithelial neoplasia, which is a precancerous change.

Published studies have reported widely differing cancer rates among men with genital lichen sclerosus, from close to zero in some groups to approximately 12.5% in highly selected specialist series. Frequently quoted estimates place the risk at roughly 2–6%, but the precise lifetime risk for an individual man remains uncertain.

This does not mean that most men with lichen sclerosus will develop penile cancer. Penile cancer remains rare, and appropriate treatment of inflammation and phimosis is expected to reduce risk.

It is also reported that lichen sclerosus is found in a substantial proportion of penile cancer specimens. This association cannot be reversed to mean that the same proportion of men with lichen sclerosus will develop cancer.

Risk is likely to be greater when there is:

  • Long-standing uncontrolled inflammation
  • Severe phimosis
  • Persistent ulceration or thickening
  • Poor visibility of the glans
  • Cigarette smoking
  • Immune suppression
  • Coexisting penile intraepithelial neoplasia
  • Failure to attend follow-up

Warning signs that require prompt review

A man with current or previous lichen sclerosus should seek medical assessment for:

  • A persistent ulcer or sore
  • A new lump or firm area
  • Skin thickening
  • An irregular red or velvety patch
  • A warty or cauliflower-like growth
  • Unexplained bleeding
  • Offensive discharge
  • Increasing pain
  • A lesion that does not respond to prescribed steroid treatment
  • A new lump in the groin

These findings do not necessarily mean cancer, but they should not be treated repeatedly as thrush or simple inflammation without further investigation.

Follow-up and self-examination

Lichen sclerosus can recur, and cancer-related changes may develop many years after initial treatment.

Patients should become familiar with the normal appearance of their penis and perform regular self-examination. When possible, the entire glans, foreskin and urinary opening should be inspected.

Medical follow-up should be tailored to disease severity. More frequent review is appropriate during active treatment, after surgery or when urethral involvement is present. Once stable, periodic or annual review may be appropriate, together with lifelong self-monitoring.

Circumcised men should still report new or persistent abnormalities.

The outlook

When recognised early, male genital lichen sclerosus can often be controlled successfully with appropriate topical corticosteroid treatment, good skin care and follow-up.

Established scarring is less likely to resolve with medication alone. Circumcision is usually highly effective for disease confined to the foreskin, while meatal and urethral disease may require more specialised reconstruction.

The important message is not to ignore a foreskin that is becoming progressively white, scarred or tight. Early assessment may prevent painful erections, urinary obstruction and more complex surgery.

The bottom line

Balanitis xerotica obliterans is the older name for male genital lichen sclerosus involving the foreskin and glans.

It commonly presents with white or scarred skin, acquired phimosis, splitting, painful erections or urinary-stream changes. Potent prescribed topical corticosteroids are the first medical treatment for suitable early disease, while circumcision is often required for established phimosis, recurrent disease or failure of medical treatment.

Meatal or urethral involvement requires urological assessment and may need reconstructive surgery.

The risk of penile squamous cell carcinoma is small but real. Persistent thickening, ulceration, bleeding, a lump or a lesion that does not respond to treatment requires prompt examination and often biopsy.

This article provides general information and does not replace personalised medical assessment. Do not use potent topical corticosteroids on genital skin without appropriate medical advice.

So guys, if you cannot retract the foreskin and has the typical appearance discussed in this article, take the time to review with your GP to have this checked out. There is effective management for this which will also then reduce your risk for penile cancer. Do not vary your head in the send and ignore this, have it seen to and let your GP refer you to your local Brisbane urologist, Dr Jo Schoeman.

References and further reading

Enlarged Prostate (BPH): Understanding Prescription Combination Therapy

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Benign prostatic hyperplasia (BPH), also called benign prostate enlargement, becomes more common as men get older. An enlarged prostate may narrow the urethra or affect the way the bladder works.

Possible symptoms include:

  • a slow or intermittent urinary stream
  • difficulty starting urination
  • straining to urinate
  • a feeling that the bladder has not emptied fully
  • urinary frequency or urgency
  • waking at night to urinate
  • dribbling after urination
  • urinary retention

These symptoms are not always caused by an enlarged prostate. Infection, overactive bladder, urethral narrowing, bladder stones, neurological conditions and prostate or bladder cancer can sometimes produce similar symptoms. An appropriate clinical assessment is therefore important before treatment is selected.

What treatments are available?

Management depends on symptom severity, prostate size, bladder emptying, general health and personal preferences. Options may include:

  • monitoring and lifestyle measures
  • prescription medicines
  • minimally invasive procedures
  • prostate surgery

No single option is best for every patient. A treatment that improves symptoms in one man may be unsuitable for another.

How prescription combination therapy works

For selected men, a doctor may prescribe two types of medicine together:

  1. An alpha blocker, such as tamsulosin, relaxes smooth muscle in the prostate and bladder neck. This may improve urine flow and symptoms relatively quickly, although response varies.
  2. A 5-alpha-reductase inhibitor, such as dutasteride or finasteride, alters the hormonal pathway involved in prostate growth. Over time, it may reduce prostate volume and lower the risk of urinary retention or BPH-related surgery in appropriately selected men.

These medicines are available only on prescription. They may be prescribed separately or, in some circumstances, in a fixed-dose combination. This article does not recommend a particular medicine or brand.

The prostate-reducing component acts gradually. Any benefit is generally assessed over months rather than days. Combination therapy is commonly considered as a longer-term treatment, but regular review remains important.

Who might be considered for combination therapy?

A doctor may consider combination treatment for a man who has moderate-to-severe urinary symptoms associated with a demonstrably enlarged prostate and an increased risk of BPH progression.

The decision may take account of:

  • how troublesome the symptoms are
  • prostate size and shape
  • PSA results, interpreted in clinical context
  • urinary flow rate
  • the amount of urine left in the bladder after voiding
  • previous urinary retention
  • the expected benefits, limitations and adverse effects of treatment
  • other illnesses and medicines
  • the patient’s preferences, including the importance of preserving sexual and ejaculatory function

Prostate size alone should not determine treatment. Some men with large prostates have few symptoms, while a smaller prostate can still cause obstruction because of its shape, a tight bladder neck or another condition.

Assessment before treatment

Depending on the individual, assessment may include:

  • a urinary, medical and medication history
  • a validated symptom questionnaire
  • physical examination, which may include a digital rectal examination
  • urine testing
  • PSA testing after discussion of its benefits and limitations
  • kidney-function blood tests
  • urinary flow measurement
  • ultrasound assessment of prostate size and post-void residual urine
  • a bladder diary
  • cystoscopy or urodynamic testing in selected cases

The purpose is to confirm the likely cause of the symptoms and identify complications or conditions that require a different approach.

Possible benefits and limitations

An alpha blocker may improve urine flow and some symptoms within days or weeks. It does not substantially shrink the prostate.

A 5-alpha-reductase inhibitor works more slowly. In men with prostate enlargement, it may reduce prostate volume and lower the long-term risk of acute urinary retention or BPH-related surgery. Not every patient will experience a worthwhile improvement.

Combination treatment may improve symptoms more than either medicine alone in appropriately selected patients, but it also exposes the patient to the adverse effects of both medicine classes. It controls BPH rather than permanently curing it. Symptoms may recur or progress, and a procedure may still be required.

Clinical-trial averages cannot predict an individual patient’s result. Benefits and harms should be reviewed with the prescribing doctor.

Possible adverse effects

Adverse effects differ between people. The Consumer Medicine Information supplied with the prescribed medicine should be read, and new or troublesome symptoms should be discussed with the prescriber or pharmacist.

Sexual and ejaculatory effects

Possible effects include:

  • reduced semen volume or absent ejaculation
  • semen passing backwards into the bladder
  • reduced sexual desire
  • difficulty achieving or maintaining an erection
  • changes in fertility or semen characteristics

Some sexual adverse effects have been reported to persist after a 5-alpha-reductase inhibitor is stopped, although their frequency, cause and predictors remain uncertain. Persistent symptoms deserve appropriate assessment.

Dizziness and low blood pressure

Alpha blockers may cause dizziness, light-headedness, weakness or, less commonly, fainting—particularly when standing up. The risk may be greater when treatment begins or when combined with other medicines that lower blood pressure. Patients who become dizzy should take care to avoid falls and seek medical advice.

Breast and other changes

5-alpha-reductase inhibitors may cause breast tenderness or enlargement. A breast lump, nipple discharge or persistent one-sided change requires medical assessment rather than being assumed to be a medicine effect.

Other reported adverse effects can include headache, tiredness, palpitations, nasal congestion, gastrointestinal discomfort, skin reactions, testicular symptoms and mood changes. The exact safety information depends on the medicine prescribed.

Seek urgent help

Urgent medical attention is appropriate for symptoms such as:

  • swelling of the face, tongue or throat, or difficulty breathing
  • collapse or fainting
  • a painful, prolonged erection
  • a severe blistering or peeling skin reaction
  • suicidal thoughts or severe psychological distress
  • inability to pass urine, especially with increasing lower abdominal pain

In Australia, call Triple Zero (000) in an emergency. Lifeline is available on 13 11 14 for crisis support. These services do not replace assessment by the treating clinician.

PSA monitoring

5-alpha-reductase inhibitors commonly lower PSA. This does not eliminate the possibility of prostate cancer.

A new PSA baseline may need to be established after treatment begins. Later results must be interpreted with knowledge that the patient is taking this type of medicine. A confirmed increase from the lowest PSA reached may require further assessment, even if the result falls within a laboratory’s usual reference range.

Patients should tell any clinician ordering or interpreting a PSA test about all current and recent prostate medicines.

Cataract or glaucoma surgery

Tamsulosin and some other alpha blockers are associated with intraoperative floppy iris syndrome, which may complicate cataract or glaucoma surgery.

Patients should tell their ophthalmologist about current or previous alpha-blocker use. They should not stop a prescribed medicine solely for an eye operation unless advised by the relevant treating clinicians, because stopping it may not remove the surgical risk.

Mood and persistent symptoms

Sexual, cognitive and mood symptoms have been reported during or after treatment with 5-alpha-reductase inhibitors. The evidence about persistent syndromes, their frequency and causation continues to evolve.

This uncertainty should be discussed without either assuming that persistent symptoms will occur or dismissing symptoms that a patient experiences. New depression, marked anxiety or sexual dysfunction should be reviewed. Suicidal thoughts require urgent assistance.

Monitoring treatment

Follow-up may include review of:

  • symptom response and quality of life
  • dizziness and postural blood pressure
  • sexual and ejaculatory function
  • mood changes
  • urinary flow and post-void residual urine
  • PSA results
  • kidney function when clinically indicated

Lack of early improvement does not necessarily mean the slower-acting component has failed. However, severe or worsening symptoms should not be managed by continuing medicine indefinitely without reassessment.

When might a procedure or surgery be considered?

A procedure may be discussed when there is:

  • recurrent or persistent urinary retention
  • catheter dependence
  • recurrent infection associated with poor bladder emptying
  • bladder stones
  • recurrent visible bleeding attributed to BPH
  • kidney or upper urinary tract effects from obstruction
  • a high or increasing post-void residual volume
  • persistent troublesome symptoms despite appropriate conservative treatment
  • unacceptable medicine adverse effects
  • a preference for a procedural option after informed discussion

Procedural choices include established operations and selected minimally invasive treatments. Suitability depends on prostate anatomy, bladder function, general health, bleeding risk, expected durability and the importance of preserving ejaculation. Each option has potential benefits, limitations and complications.

Questions to discuss with your doctor

  • What is the most likely cause of my urinary symptoms?
  • Is my prostate enlarged, and am I at risk of progression?
  • What are the reasonable alternatives, including observation, medicines and procedures?
  • How likely is each option to help in my circumstances?
  • What sexual, ejaculatory, blood-pressure and mood effects should I consider?
  • How will treatment affect the interpretation of my PSA?
  • When should treatment be reviewed or changed?
  • Which symptoms require urgent assessment?

The bottom line

Prescription combination therapy can be one option for selected men with bothersome urinary symptoms, prostate enlargement and a risk of BPH progression. It is not suitable for every urinary problem and does not guarantee that surgery will be avoided.

The choice should follow an individual assessment and a balanced discussion of expected benefit, possible harm, alternatives and the option of no immediate treatment. Do not start, stop or change a prescription medicine without advice from the prescribing clinician.

This article provides general educational information. It is not medical advice and does not promote or recommend a particular prescription medicine or brand. Treatment decisions should be made with an appropriately qualified health professional after individual assessment.

References and further reading

 

Focal Therapy for Prostate Cancer: Targeting the Cancer While Preserving the Prostate

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Established management of localised prostate cancer includes active surveillance for suitable low-risk disease and whole gland treatment with surgery or radiotherapy when treatment is indicated. ProFocal® is a newer focal approach that uses laser energy to destroy a selected cancerous area while leaving much of the surrounding prostate untreated.

This approach is known as focal laser therapy or focal laser ablation. Its intended aim is to control the treated cancer focus while reducing urinary and sexual side effects. Whether it provides cancer control equivalent to established whole-gland treatments over the long term has not been demonstrated.

Early Australian research is encouraging. However, ProFocal remains an investigational treatment, and important questions about its long-term cancer control have not yet been answered.

What is ProFocal therapy?

ProFocal is an Australian-developed focal therapy system designed to treat a carefully selected area of prostate cancer.

A fine laser applicator is inserted through the skin between the scrotum and anus, the perineum, and guided into the prostate using imaging. Laser energy heats the targeted tissue to a temperature that causes cancer-cell death.

The system incorporates cooling and real-time temperature monitoring. This is intended to make the area of ablation more predictable and to limit unintended heat damage to nearby structures such as the:

  • Urinary sphincter
  • Urethra
  • Bladder neck
  • Rectum
  • Neurovascular bundles involved in erections

Unlike radical prostatectomy, ProFocal does not remove the prostate. Unlike conventional radiotherapy, it does not expose the whole prostate to radiation.

Is ProFocal approved by the TGA?

This requires careful clarification.

As at September 2026, the manufacturer states that ProFocal is not included in the Australian Register of Therapeutic Goods, ARTG. It therefore does not have general TGA market authorisation for routine supply and use in Australia.

This is different from saying that the treatment has received unrestricted “TGA approval.”

ProFocal may be accessible in Australia through a clinical trial or a specific TGA pathway for an unapproved therapeutic good, such as the Authorised Prescriber Scheme or Special Access Scheme. These pathways permit access in defined circumstances; they are not equivalent to ARTG inclusion or routine TGA market authorisation. The applicable approval, governance and consent arrangements should be confirmed for the individual patient.

Authorised Prescriber access does not mean that the device has been entered on the ARTG or endorsed as routine standard treatment. Regulatory status, trial availability and funding arrangements should always be confirmed directly before treatment.

Medicare, private insurance and professional oversight in Australia

The Medicare Benefits Schedule (MBS) lists professional medical services subsidised by the Australian Government. As at September 2026, no specific MBS item for “ProFocal” or focal laser ablation of prostate cancer was identified in the current public MBS material reviewed for this article. This should not be interpreted as a definitive ruling on every component of an episode of care: consultations, anaesthesia, imaging, pathology or hospital services may each have different billing arrangements.

An MBS rebate for an associated service would not establish that ProFocal itself is TGA-approved, guideline-endorsed or proven effective. Conversely, lawful access through a TGA pathway does not guarantee Medicare or private-insurance funding. The Department of Health and Aged Care’s Medical Services Advisory Committee (MSAC) is the independent body that advises government on whether public funding of medical services and technologies is supported by evidence of safety, clinical effectiveness and cost-effectiveness.

The Australian Medical Association (AMA) is a professional representative body, not the regulator of therapeutic goods and not the agency that creates Medicare items. No AMA clinical guideline specifically recommending ProFocal was identified for this review. It would therefore be inappropriate to imply AMA endorsement. Relevant professional duties instead arise from the Medical Board of Australia’s code of conduct: patients should receive understandable information about the proposed treatment, reasonable alternatives, material risks, uncertainties, costs and any practitioner conflicts of interest so that consent is genuinely informed.

Who may be considered for ProFocal therapy?

ProFocal is principally being studied in men with localised, non-metastatic and MRI-visible prostate cancer.

In the first prospective phase II ProFocal study, eligible men had:

  • Prostate cancer confined to the prostate
  • An MRI-visible cancer target
  • ISUP Grade Group 2 or 3 disease
  • A PSA of 15 ng/mL or lower
  • A clinical stage of T2c or lower
  • Biopsy findings corresponding with the abnormality seen on MRI

Outside a clinical trial, suitability would need to be assessed individually by a multidisciplinary prostate cancer team.

A potential candidate generally requires a cancer that can be clearly identified, biopsied and safely surrounded by an adequate treatment margin. Detailed assessment usually includes:

  • Multiparametric prostate MRI
  • Targeted and systematic transperineal biopsies
  • PSA and PSA-density assessment
  • Clinical staging
  • Consideration of PSMA PET/CT in selected men
  • Review of the MRI and pathology at a multidisciplinary meeting

When may ProFocal be unsuitable?

ProFocal would generally not be considered appropriate when there is:

  • Metastatic prostate cancer
  • High-risk or locally advanced disease requiring comprehensive treatment
  • Cancer outside the prostate
  • Extensive cancer involving several areas of the gland
  • Cancer that cannot be reliably identified on MRI
  • A tumour position where an adequate and safe treatment margin cannot be achieved
  • Significant uncertainty about the true extent or grade of the cancer
  • An inability or unwillingness to undergo ongoing MRI scans and repeat biopsies
  • A medical condition that makes anaesthesia or the procedure unacceptably risky

Men with low-risk Grade Group 1 prostate cancer may be better managed with active surveillance, avoiding treatment and its potential complications altogether.

Focal therapy should not be regarded as an easier substitute for appropriate surgery or radiotherapy in men with aggressive, high-volume or advanced prostate cancer.

How is ProFocal treatment performed?

ProFocal is usually performed as a day procedure under general anaesthesia.

Treatment planning

The cancer identified on MRI and biopsy is mapped carefully. The treatment plan includes the visible tumour and an additional safety margin intended to treat microscopic cancer immediately around it.

Placement of the laser applicator

With the patient under anaesthesia, a transrectal ultrasound probe is used to visualise the prostate. A fine laser applicator is inserted through the perineum and positioned within the selected treatment area.

The route is similar to that used for a transperineal prostate biopsy.

Laser ablation

Controlled laser energy heats and destroys the targeted prostate tissue. Temperature monitoring helps the surgeon assess treatment delivery and protect surrounding structures. More than one applicator position may be needed to cover the planned treatment zone.

The published phase II study reported a median treatment time of approximately 60 minutes, although the complete anaesthetic and theatre procedure may take longer.

Recovery

A urinary catheter may be required temporarily because prostate swelling can make urination difficult. Many patients can return home on the day of treatment or after a short admission, depending on their recovery and ability to pass urine.

What are the potential advantages?

The proposed advantages of ProFocal include:

  • Treatment directed at the known cancer rather than the whole prostate
  • No abdominal incision
  • A transperineal, minimally invasive approach
  • Short hospital stay
  • Faster initial recovery than major surgery
  • No ionising radiation
  • Preservation of untreated prostate tissue
  • A potentially lower risk of persistent urinary incontinence
  • A potentially lower risk of erectile dysfunction than whole gland treatment
  • The possibility of further focal or whole-gland treatment if cancer remains or returns

These are potential benefits and should not be interpreted as guarantees.

How does it compare with established alternatives?

There is no mature randomised evidence showing that ProFocal gives the same long-term protection from metastasis or prostate-cancer death as radical prostatectomy or radiotherapy. A balanced consultation should therefore compare all reasonable options:

  • Active surveillance: avoids or delays treatment side effects and is preferred for many men with low-risk disease, but requires PSA testing, MRI and repeat biopsy, with treatment if the cancer progresses.
  • Radical prostatectomy: removes the prostate and provides complete surgical pathology. It has long-term cancer-control data, but carries risks including urinary incontinence, erectile dysfunction, loss of ejaculation and surgical complications.
  • Radiotherapy: has established long-term cancer-control data and avoids surgery, but may cause urinary, bowel and sexual adverse effects; androgen-deprivation therapy may be advised for some risk groups.
  • ProFocal/focal laser ablation: may offer quicker recovery and less short-term urinary or sexual morbidity for carefully selected men, but leaves untreated prostate tissue, requires MRI and repeat-biopsy surveillance, and has uncertain long-term comparative cancer-control outcomes.

The most appropriate option depends on cancer grade, volume and location; PSA and stage; age and general health; baseline urinary and sexual function; personal priorities; and willingness to accept surveillance or treatment uncertainty. A multidisciplinary opinion and, where useful, separate discussions with a urologist and radiation oncologist can reduce treatment-selection bias.

What did the early ProFocal study find?

The first published phase II trial included 100 men with localised, MRI-visible Grade Group 2 or 3 prostate cancer.

At the three-month biopsy:

  • 84% had no clinically significant Grade Group 2 or higher cancer within the treated area
  • Approximately 16% therefore had residual clinically significant cancer within the treatment zone
  • Erectile dysfunction was reported in 12%
  • The average sexual-function scores decreased by approximately 15%
  • Urinary-domain scores decreased by approximately 4.5%
  • No significant deterioration was reported in the other measured functional outcomes

These results are promising, but they represent very early follow-up. The study had no surgery, radiotherapy or active surveillance control group. It therefore cannot establish whether ProFocal provides equivalent long-term protection against recurrence, metastasis or death from prostate cancer.

Possible side effects and complications

Short-term effects may include:

  • Bruising or discomfort in the perineum
  • Blood in the urine
  • Blood in the semen
  • Burning or discomfort when urinating
  • Urinary frequency or urgency
  • Temporary difficulty passing urine
  • Temporary catheterisation
  • Urinary tract infection
  • Pelvic or rectal discomfort
  • Fatigue following anaesthesia

Potential longer-term or less common problems include:

  • New or worsening erectile dysfunction
  • Reduced ejaculatory volume
  • Retrograde ejaculation
  • Urinary incontinence
  • Urethral or bladder-neck scarring
  • Persistent urinary symptoms
  • Damage to tissue outside the intended treatment zone
  • Infection or abscess
  • A fistula involving the urinary tract and rectum, expected to be rare
  • Incomplete cancer treatment
  • Cancer developing or becoming apparent elsewhere in the untreated prostate
  • A requirement for repeat focal therapy, radiotherapy or radical prostatectomy

The risk of sexual or urinary dysfunction depends partly on the size and location of the tumour. A lesion near the neurovascular bundles, urethra, urinary sphincter or bladder neck may be more difficult to treat without affecting function.

The untreated prostate remains important

Prostate cancer is frequently multifocal, meaning that separate areas of cancer may exist within the same prostate. MRI is very useful but cannot detect every small or biologically significant tumour.

ProFocal treats the selected target, not every prostate cell.

This creates two possible patterns of treatment failure:

  1. In-field disease: cancer remains or returns inside the treated area.
  2. Out-of-field disease: cancer is subsequently found elsewhere in the untreated prostate.

A successful early scan does not prove that all clinically significant cancer has been eliminated.

Follow-up after ProFocal therapy

Follow-up is more intensive than simply checking the PSA.

Because the prostate remains in place, PSA will not normally fall to an undetectable level. There is also no universally accepted PSA threshold that defines successful focal treatment or recurrence.

Follow-up may include:

  • Regular PSA testing
  • Clinical review and symptom assessment
  • Multiparametric MRI
  • Quality-of-life and erectile function assessment
  • Repeat targeted biopsy of the treated area
  • Systematic biopsy of the untreated prostate
  • Additional imaging when recurrence is suspected

The Prostate Cancer Foundation of Australia cautions that PSA testing alone is not sufficient to exclude recurrent cancer after focal therapy. Patients must be willing to undergo long-term imaging and, when recommended, further prostate biopsies.

Can treatment be repeated?

Repeat focal treatment may be possible when residual or recurrent cancer remains localised and clearly targetable.

Depending on the findings, subsequent options may include:

  • Repeat focal ablation
  • Radical prostatectomy
  • External-beam radiotherapy
  • Another focal therapy technique
  • Active surveillance for selected low-volume disease
  • Systemic treatment if the cancer has spread

Salvage surgery or radiotherapy may still be possible after focal therapy, but treatment can sometimes be technically more complex because of scarring and tissue changes. The likely salvage options should therefore be discussed before proceeding with ProFocal.

Important limitations

Patients considering ProFocal should understand that:

  • ProFocal is not currently included on the Australian ARTG
  • It is not established as routine standard-of-care treatment
  • Published ProFocal evidence currently comes from a small number of men
  • The pivotal study was single-arm and had very short follow-up
  • Long-term rates of metastasis-free, cancer-specific and overall survival are unknown
  • There are no mature randomised comparisons with prostatectomy, radiotherapy or modern active surveillance
  • Approximately 16% of men in the initial study had clinically significant cancer remaining in the treated area at three months
  • Cancer may be missed elsewhere in the prostate
  • Repeat MRI scans and biopsies are required
  • Further cancer treatment may be needed
  • Access may be limited to trials or special regulatory pathways
  • Medicare or private health insurance may not cover treatment or follow-up costs

What do Australian and international guidance sources say?

The Prostate Cancer Foundation of Australia (PCFA) describes focal therapies as emerging and experimental. It notes that focal treatment may reduce side effects but that the prostate remains in place, PSA monitoring is less straightforward, and ongoing MRI and biopsy are required.

Australian evidence-based resources regard active surveillance, radical prostatectomy and radiotherapy as established pathways for appropriately selected localised disease. ProFocal has not yet acquired the same evidence base or standard-of-care status. The absence of a treatment-specific recommendation should not be reframed as support.

The European Association of Urology (EAU) states that focal therapy has favourable functional outcomes but that definitive evidence of long-term oncological benefit remains unavailable. Its guideline recommends focal HIFU or cryotherapy only within a prospective registry and other ablative methods—including focal laser therapy—only within a well-designed prospective clinical trial.

The American Urological Association and American Society for Radiation Oncology advise clinicians that comparative evidence for focal ablation is lacking and that patients must be informed that further treatment may be required. Focal or whole-gland ablation should not be offered for high-risk prostate cancer outside a clinical trial.

The UK National Institute for Health and Care Excellence (NICE) guidance for focal HIFU and focal cryoablation—not ProFocal specifically—also emphasises special governance, consent, audit/research arrangements and uncertainty about long-term cancer control. This is relevant context for focal therapy but must not be represented as device-specific approval of ProFocal.

The Prostate Cancer Foundation of Australia similarly describes focal therapies as experimental and emphasises the need for continuing MRI, biopsies and careful long-term monitoring.

The bottom line

ProFocal is an Australian-developed investigational technology that may eventually provide selected men with an additional option between surveillance and whole-gland treatment.

Its early results suggest that precisely delivered cooled laser therapy can destroy an MRI-visible prostate cancer target with relatively limited short-term urinary morbidity. However, early cancer clearance is not the same as proven long-term cancer control.

At present, ProFocal should be considered an investigational focal therapy. Consistent with current guidance for focal laser ablation, its most defensible use is within a well-designed prospective clinical trial with ethics and regulatory oversight, multidisciplinary assessment, explicit informed consent, independent outcome reporting and mandatory long-term follow-up.

The decision should be made only after comparing ProFocal with all appropriate alternatives, including active surveillance, radical prostatectomy and radiotherapy.

This article provides general information and does not replace individual medical advice. Regulatory status and treatment availability can change and should be confirmed at the time of consultation.

References and further reading

Peyronie’s Disease: When a Curved Erection Becomes a Medical Problem

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Peyronie’s disease is a condition in which scar tissue develops within the penis, causing it to bend or curve during an erection.

A slight natural curve can be completely normal. Peyronie’s disease is different because the change is usually new, may worsen over time, and can sometimes cause pain or make sexual intercourse difficult.

What causes Peyronie’s disease?

The exact cause is not always clear.

In many cases, the condition may develop after repeated minor injury or trauma to the penis. This can lead to the formation of fibrous scar tissue, known as a plaque.

The plaque does not stretch normally during an erection, causing the penis to bend toward the affected area.

Some men do not remember any specific injury.

Common symptoms

Symptoms of Peyronie’s disease can include:

  • A new bend or curve in the penis
  • A hard area or plaque beneath the skin
  • Pain during erections
  • Shortening of the penis
  • Narrowing or indentation of the shaft
  • Difficulty with sexual intercourse
  • Erectile dysfunction

The severity can vary considerably between patients.

Does Peyronie’s disease get worse?

Peyronie’s disease commonly develops in phases.

During the early or active phase, the curvature may continue to change and erections may be painful.

After a period of time, the condition often becomes more stable.

In some men the pain settles, while the curvature remains.

When should you see a urologist?

A new or worsening penile curvature should be assessed, particularly when it causes pain, affects erections or interferes with sexual activity.

A urologist can assess the degree of curvature, check for plaque formation and determine whether treatment is necessary.

Not every patient requires surgery.

Treatment options

Treatment depends on the severity of the condition, how long it has been present and whether it is affecting sexual function.

Options may include:

  • Observation
  • Medication in selected cases
  • Penile traction therapy
  • Injection treatments
  • Surgical correction

Surgery is generally considered when the condition is stable and the curvature significantly affects sexual intercourse.

Peyronie’s disease and erectile dysfunction

Some men with Peyronie’s disease also develop erectile dysfunction.

This may occur because of changes in penile structure, blood flow or anxiety related to pain and curvature.

Assessment is therefore important so that both problems can be considered together.

Specialist assessment in Brisbane

Peyronie’s disease can be uncomfortable to discuss, but it is a recognised medical condition and treatment options are available.

If you have noticed a new change in penile shape, persistent pain during erections or difficulty with sexual activity, speak with your GP or arrange an assessment with a urologist.

 

Penis Problems: 7 Signs You Should See a Urologist

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Problems affecting the penis can be difficult or embarrassing to talk about, but they are also surprisingly common.

Pain, swelling, changes in shape, difficulty with erections or unusual lumps can have many different causes. Some are minor and temporary, while others may need proper medical assessment.

If a problem persists, becomes painful or begins affecting sexual or urinary function, speaking with your GP or a urologist in Brisbane may be the right next step.

Here are seven signs that should not simply be ignored.

1. Persistent Pain in the Penis

Penile pain can occur for several reasons.

Minor irritation or injury may settle on its own, but persistent pain should be assessed, particularly when it occurs during erections or sexual activity.

Possible causes can include injury, inflammation, infection or conditions such as Peyronie’s disease.

Sudden severe pain following an injury to an erect penis can be particularly important.

A penile fracture involves tearing of tissue within the penis and may cause sudden pain, swelling, bruising or a noticeable popping sensation.

This requires urgent medical attention.

2. A New Bend or Curve During Erections

A small natural curve in the penis is common.

However, if the penis gradually becomes noticeably more curved, particularly if erections become painful or intercourse becomes difficult, it could be a sign of Peyronie’s disease.

Peyronie’s disease occurs when scar tissue develops inside the penis.

This can cause:

  • Curvature during an erection
  • Pain
  • A palpable hard area or lump
  • Shortening or narrowing of the penis
  • Difficulty with sexual intercourse
  • Erectile dysfunction

Some men delay seeking help because they assume the problem will disappear.

If the curvature is new or worsening, a urologist can assess the condition and discuss available treatment options.

3. Difficulty Getting or Maintaining an Erection

Occasional difficulty achieving an erection can happen to many men.

Persistent erectile dysfunction is different.

Erectile dysfunction, commonly referred to as ED, can have physical, psychological or combined causes.

Possible physical factors include problems with blood flow, diabetes, cardiovascular disease, hormonal issues, prostate conditions and certain medications.

Peyronie’s disease can also contribute to erectile problems.

Because erectile dysfunction can sometimes be associated with broader health conditions, persistent ED is worth discussing with a doctor rather than simply treating the symptom yourself.

A Brisbane urologist may also be involved when the problem relates to the urinary or male reproductive system.

4. Lumps or Hard Areas in the Penis

Finding a lump or hardened area can understandably cause concern.

Not every lump is cancerous.

Some may be related to scar tissue, blocked glands or other benign conditions.

A hard plaque beneath the skin may, for example, occur with Peyronie’s disease.

However, any new or unexplained lump that persists should be properly assessed.

Changes that should be checked include:

  • A persistent lump
  • Thickening of the skin
  • A hard area beneath the skin
  • Changes in colour or texture
  • A sore that does not heal

Early assessment can determine whether further investigation is necessary.

5. Persistent Swelling, Redness or Inflammation

Temporary swelling can occur after injury or irritation.

Persistent swelling, however, may indicate inflammation, infection or another underlying problem.

The penis may become:

  • Red
  • Tender
  • Painful
  • Itchy
  • Swollen
  • Difficult to retract if the foreskin is involved

Inflammation of the head of the penis is known as balanitis and can sometimes affect the foreskin as well.

Poor hygiene, irritation and infection can all contribute.

Persistent or recurrent inflammation should be discussed with a doctor.

6. Discharge, Sores or Unusual Lesions

Discharge from the penis or the appearance of sores, ulcers or unusual lesions can sometimes be associated with a sexually transmitted infection.

Possible STIs include gonorrhoea, chlamydia, herpes and syphilis.

Not every sore or discharge is caused by an STI, but these symptoms should be assessed rather than self-diagnosed.

If you believe you may have been exposed to an STI, your GP or a sexual health clinic is usually the appropriate first point of contact.

STI testing can identify infections even when symptoms are mild or absent.

What About HIV?

HIV is a viral infection that affects the immune system and is not primarily treated by a urologist.

Importantly, HIV cannot be diagnosed by looking at the penis or by relying on symptoms alone.

Someone who believes they may have been exposed to HIV should seek medical advice and appropriate testing through a GP or sexual health service.

Modern HIV treatment is highly effective, and people receiving effective treatment can live long and healthy lives.

7. Problems With the Foreskin

Foreskin problems are another common reason men seek medical advice.

These can include:

  • Difficulty retracting the foreskin
  • Pain when retracting it
  • Recurrent infections
  • Cracking or bleeding
  • Swelling
  • Difficulty cleaning underneath the foreskin

A tight foreskin is known as phimosis.

In some cases it can cause pain, infections or difficulty urinating.

Treatment depends on the severity of the problem and may include medication or, in some circumstances, a surgical procedure.

A foreskin that has been pulled back and becomes trapped behind the head of the penis is known as paraphimosis.

This can restrict blood flow and requires urgent medical treatment.

When Should You See a Doctor?

It is worth arranging an assessment if you notice a penile problem that:

  • Persists for more than a short period
  • Is becoming worse
  • Causes significant pain
  • Affects erections or sexual activity
  • Causes difficulty urinating
  • Involves a persistent lump or sore
  • Causes recurrent swelling or inflammation
  • Is associated with discharge
  • Follows a significant injury

Some problems can be treated relatively simply once the cause has been identified.

Waiting because the issue feels embarrassing can sometimes allow the problem to become more difficult to manage.

When Is It an Emergency?

Seek urgent medical attention if you experience:

  • A significant injury to an erect penis
  • Sudden severe pain and swelling
  • Heavy bleeding
  • An erection lasting several hours that will not go away
  • Inability to urinate
  • A foreskin trapped behind the head of the penis with increasing swelling or pain

These situations should not wait for a routine appointment.

Seeing a Urologist in Brisbane

Urologists specialise in conditions affecting the urinary system and the male reproductive system.

Depending on the problem, a urologist may investigate penile pain, erectile dysfunction, penile curvature, foreskin problems, injuries and other conditions affecting male genital health.

If you have a persistent penile problem or have been referred for specialist assessment speak with your GP about whether a urology referral is appropriate.

Ignoring a problem because it feels embarrassing rarely makes it easier.

Getting the right diagnosis is the first step toward deciding whether treatment is actually needed.

Clips for Benign Prostatic Enlargement: A Minimally Invasive Treatment That Preserves Ejaculation

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Benign prostatic hyperplasia, or BPH, is a non-cancerous enlargement of the prostate. As the prostate enlarges, its lateral lobes may compress the urethra and obstruct the flow of urine from the bladder.

Common lower urinary tract symptoms include:

  • A weak or interrupted urinary stream
  • Difficulty starting urination
  • Straining to pass urine
  • Urinary frequency and urgency
  • Getting up repeatedly at night
  • Dribbling after urination
  • A feeling that the bladder has not emptied properly

Medication is usually the first treatment offered to men with troublesome symptoms. However, tablets may provide insufficient relief or cause dizziness, tiredness, reduced libido, erectile problems or altered ejaculation.

The UroLift procedure, also called a prostatic urethral lift or PUL, is a minimally invasive surgical therapy, or MIST, that may provide an alternative to long-term medication and conventional prostate surgery.

What is a MIST procedure?

Minimally invasive surgical therapies are designed to improve urinary symptoms with less tissue damage, less bleeding and a shorter recovery than conventional procedures such as TURP or prostate laser surgery.

Different MIST procedures work in different ways. Some use steam or other forms of energy to destroy prostate tissue. Some temporarily remodel the urinary passage. UroLift mechanically moves the obstructing prostate tissue away from the urethra using small permanent implants.

Its principal attractions are:

  • No cutting or removal of prostate tissue
  • No heat, laser or steam
  • Rapid improvement in many patients
  • Usually brief catheterisation, if any
  • Short recovery
  • A low reported risk of new erectile or ejaculatory dysfunction

The trade-off is that symptom improvement is generally more modest than after a tissue-removing operation, permanent implants remain within the prostate, and some patients will eventually require further treatment.

How does Clips work?

The UroLift system uses small implants to hold the enlarged lateral lobes of the prostate away from the urethra.

Each implant consists of:

  • A small capsular tab placed on the outside of the prostate
  • A stainless-steel urethral end-piece
  • A permanent suture connecting the two components

The implant compresses and retracts the obstructing prostate tissue, widening the urinary channel without cutting, burning or removing tissue.

Most patients require several implants. The exact number depends on the length, size and shape of the prostate and the degree of obstruction. These implants remain permanently in position.

Who may benefit from Clips?

UroLift may be considered for men who:

  • Have moderate or severe urinary symptoms caused by BPH
  • Have obtained inadequate relief from medication
  • Cannot tolerate the side effects of BPH medication
  • Prefer not to take daily medication indefinitely
  • Want a less invasive alternative to TURP or laser surgery
  • Place a high priority on preserving forward ejaculation
  • Want a relatively rapid return to normal activities
  • Have prostate anatomy suitable for a prostatic urethral lift
  • Understand the possibility of future retreatment

It is particularly attractive for sexually active men who wish to improve their urinary symptoms while minimising the risk of dry or retrograde ejaculation.

What prostate size is suitable?

Clinical guidelines and manufacturer labelling are not identical.

Current European Association of Urology guidance recommends offering prostatic urethral lift to men interested in preserving ejaculation who have prostates smaller than 70 mL and no obstructing middle lobe.

American Urological Association guidance supports the procedure for selected men with prostates approximately 30–80 mL and without an obstructing middle lobe.

Manufacturer and regulatory indications may extend to prostates as large as 100 mL and may include selected median-lobe anatomy in some jurisdictions. However, treatment outside the populations best supported by clinical guidelines requires careful patient selection and counselling.

Prostate volume alone does not determine suitability. The shape of the prostate, length of the prostatic urethra, bladder-neck anatomy, degree of obstruction and strength of the bladder muscle must also be considered.

What about an obstructing median lobe?

The median lobe is prostate tissue that projects upwards towards the bladder and may act like a ball valve over the bladder outlet.

UroLift can be used to treat selected obstructing median lobes, and the MedLift study reported encouraging outcomes. Nevertheless, major guideline recommendations remain more conservative because the strongest long-term randomised evidence relates mainly to lateral-lobe obstruction.

A large, mobile or unusually shaped median lobe may be better treated with TURP, laser surgery, Rezūm, Aquablation or another procedure capable of removing or reducing the obstructing tissue.

This is an important anatomical caveat to discuss before choosing UroLift.

Assessment before treatment

Not every urinary symptom is caused by BPH. Infection, urethral stricture, bladder weakness, overactive bladder, neurological disease, medication and prostate or bladder cancer may produce similar symptoms.

Assessment may include:

  • Medical history and examination
  • International Prostate Symptom Score
  • Urine testing
  • PSA testing when appropriate
  • Urinary-flow measurement
  • Ultrasound measurement of residual urine
  • Prostate imaging or ultrasound
  • Flexible cystoscopy
  • Urodynamic testing in selected patients

Cystoscopy may be particularly useful because it allows the urologist to assess the lateral lobes, bladder neck, median lobe and length of the obstructing prostate.

Any urinary infection should be treated before the procedure.

Patients taking aspirin, warfarin, clopidogrel, apixaban, rivaroxaban or other blood-thinning medication require an individual plan. Do not stop blood-thinning medication without instructions from your prescribing doctor and urologist.

How is the UroLift procedure performed?

UroLift is usually performed as a day procedure under local anaesthetic with sedation or a short general anaesthetic.

A cystoscope and specialised delivery device are passed through the urethra. No external incision is required.

The urologist:

  1. Examines the urethra, prostate and bladder.
  2. Positions the delivery device within the prostatic urethra.
  3. Moves the obstructing prostate tissue away from the urinary channel.
  4. Deploys an implant to hold the tissue in its new position.
  5. Repeats the process at selected points until an adequate channel has been created.
  6. Inspects the bladder outlet and controls any bleeding.

The procedure commonly takes less than an hour, although this varies with prostate anatomy and the number of implants required.

Because no prostate tissue is removed, there is usually no specimen for laboratory examination.

Will I need a catheter?

Many men can pass urine after the procedure and go home without a catheter. A catheter may nevertheless be required if there is:

  • Significant prostate swelling
  • Inability to pass urine
  • Pre-existing urinary retention
  • A weak bladder muscle
  • Bleeding or clot formation
  • A high residual urine volume

When required, the catheter is usually temporary. Patients with chronic retention or poor bladder function have a greater risk of failing an early trial without a catheter.

What should I expect after UroLift?

Temporary urinary irritation is common during the first few days.

You may experience:

  • Burning or stinging when passing urine
  • Urinary urgency and frequency
  • Pelvic, perineal or penile discomfort
  • Light blood in the urine
  • Bladder spasms
  • A temporarily weaker or more irregular stream
  • Increased night-time urination
  • A feeling of incomplete emptying

These symptoms generally improve over several days, although urinary irritation may occasionally persist for a few weeks.

Some men notice an improved stream soon after treatment. For others, the benefit develops over the following two to six weeks as swelling and irritation settle.

Managing pain and urinary discomfort

Discomfort after UroLift is usually mild to moderate.

Management may include:

Paracetamol

Paracetamol is commonly sufficient for mild discomfort. Take it according to the instructions provided by your doctor or the directions on the packet.

Avoid accidentally taking additional paracetamol contained in cold, influenza or combination pain medicines.

Anti-inflammatory medication

Ibuprofen or another anti-inflammatory medicine may help when medically appropriate. These medicines may not be suitable for patients with kidney impairment, stomach ulcers, certain heart conditions, bleeding disorders, anti-inflammatory-sensitive asthma or anticoagulant medication.

Check with your doctor or pharmacist before taking an anti-inflammatory medicine.

Medication for urinary symptoms

An alpha blocker may be continued temporarily to assist urine flow while swelling settles. Medication for bladder spasm or urinary burning may occasionally be prescribed.

Practical measures

It may help to:

  • Maintain normal hydration without forcing excessive fluids
  • Limit coffee, tea, alcohol, fizzy drinks and energy drinks
  • Avoid constipation
  • Avoid heavy lifting and vigorous exercise for several days
  • Take pain relief before discomfort becomes severe

Severe or worsening pain should be reported rather than simply tolerated.

Possible complications

Most side effects are mild and temporary, but complications can occur.

Common temporary effects

These include:

  • Pain or burning during urination
  • Blood in the urine
  • Urinary urgency
  • Increased frequency
  • Pelvic discomfort
  • Temporary urinary leakage associated with urgency

Urinary retention

Some men cannot pass urine after the procedure and require temporary catheterisation. The risk may be greater in patients with high residual urine volumes, chronic retention, severe obstruction or a weak bladder muscle.

Urinary tract infection

Infection may cause worsening burning, cloudy or offensive urine, fever, chills or feeling generally unwell. Antibiotics may be required.

Bleeding

Light haematuria is common. Significant bleeding, clot retention or the need for further intervention is uncommon but possible.

Implant-related problems

Potential implant complications include:

  • Incorrect placement
  • Implant exposure within the bladder
  • Encrustation or stone formation
  • Migration or loosening
  • Persistent pelvic discomfort
  • The need to remove an implant
  • Difficulty or irritation during later prostate surgery

Implants placed too close to or within the bladder are more likely to develop encrustation and may require endoscopic removal.

Persistent symptoms

UroLift treats obstruction but does not correct every cause of lower urinary tract symptoms. Urgency, frequency and nocturia may persist when they are caused by bladder overactivity, excessive night-time urine production, sleep apnoea, fluid intake, diabetes or other medical conditions.

Need for further treatment

Some patients obtain insufficient relief or develop recurrent symptoms as the prostate continues to enlarge. Further treatment may involve medication, additional implants, removal of exposed implants or another procedure such as TURP, GreenLight laser, HoLEP, Rezūm or Aquablation.

When should I seek urgent help?

Contact your urologist or attend an emergency department if you:

  • Cannot pass urine
  • Develop fever, shaking or chills
  • Feel generally unwell or confused
  • Pass large blood clots
  • Have heavy or persistent bright-red bleeding
  • Develop severe or increasing pelvic pain
  • Cannot keep fluids down
  • Experience pain that is not controlled by the recommended treatment

Does UroLift affect erections or ejaculation?

Preserving sexual function is one of the main reasons patients choose UroLift.

The pivotal L.I.F.T. study reported no new sustained erectile or ejaculatory dysfunction during five years of follow-up. Because the bladder neck, prostate tissue and ejaculatory pathways are not routinely cut or heated, the risk of retrograde ejaculation is substantially lower than with conventional TURP and many tissue-removing procedures.

However, no treatment can guarantee unchanged erections, sensation, orgasm or ejaculation in every patient.

Men who already have erectile or ejaculatory difficulties should not assume that UroLift will correct those problems. It is primarily a treatment for urinary obstruction.

How effective are Clips?

Clinical studies show meaningful average improvement in:

  • Urinary symptom scores
  • Quality of life
  • Peak urinary-flow rate
  • The patient’s perception of urinary function

Symptoms may improve quickly because the urethra is mechanically opened during the procedure.

However, the average improvement in urinary flow and symptoms is generally less than that achieved with TURP or prostate enucleation. UroLift is therefore best understood as a compromise: less invasive treatment and better preservation of ejaculation in exchange for more modest de-obstruction and a greater chance of later retreatment.

How long do Clips last?

The implants are permanent, but the symptom relief is not necessarily lifelong.

The pivotal L.I.F.T. study demonstrated sustained average improvements for five years. The reported surgical retreatment rate was approximately 13.6% over five years, or roughly 2–3% per year.

Retreatment estimates vary among studies and real-world populations. The need for further treatment may be influenced by:

  • Prostate size and anatomy
  • Median-lobe obstruction
  • Implant position
  • Severity of the original obstruction
  • Bladder function
  • Continued prostate growth
  • The definition of retreatment used in a study

Patients should distinguish between an implant remaining in position and the treatment continuing to control symptoms. A permanent implant does not guarantee permanent symptom relief.

MRI considerations

UroLift implants are classified as MR Conditional, meaning MRI can generally be performed under specified scanner conditions. Patients should tell the radiology service that they have UroLift implants and provide the implant information card whenever possible.

The metallic components can create image artefact, particularly during prostate MRI. This may obscure portions of the prostate and reduce the diagnostic quality of an MRI used to investigate suspected prostate cancer.

This caveat is particularly relevant for:

  • Younger men with a long future need for prostate surveillance
  • Patients with an elevated or rising PSA
  • Men already undergoing prostate cancer monitoring
  • Patients likely to require prostate MRI or targeted biopsy

Appropriate prostate cancer assessment should be completed before UroLift when clinically indicated.

Can prostate surgery still be performed later?

Yes. TURP, laser surgery, HoLEP and other BPH procedures can be performed after UroLift.

However, the surgeon must account for the permanent implants. Clips may be encountered during resection or enucleation, may affect instruments or laser fibres, and may require removal. Some surgeons therefore consider later surgery technically more complex than treatment of an implant-free prostate.

UroLift does not close the door to future treatment, but it does leave permanent material that the future surgeon must manage.

Who should not undergo a Clip procedure?

Manufacturer contraindications include:

  • Active urinary tract infection
  • Current visible or gross haematuria
  • Urinary incontinence caused by an incompetent urinary sphincter
  • A urethral condition that prevents safe insertion of the delivery device
  • A prostate larger than the maximum permitted by the applicable product labelling

UroLift may also be unsuitable or less predictable in men with:

  • Severe chronic urinary retention
  • A poorly contracting bladder
  • Very high residual urine volumes
  • Urethral stricture disease
  • Bladder stones
  • Recurrent urinary infections
  • Significant ongoing bleeding
  • A very high bladder neck
  • A large or unfavourably shaped median lobe
  • A very large prostate
  • Suspected or untreated prostate cancer
  • Symptoms primarily caused by overactive bladder rather than obstruction
  • A need for maximal and durable removal of obstructing tissue

Advantages of Clips

Potential advantages include:

  • Minimally invasive day procedure
  • No prostate tissue removed
  • No laser, heat or steam
  • Rapid relief in many patients
  • Short recovery
  • Catheter often avoided
  • Low reported risk of new erectile dysfunction
  • Low reported risk of dry or retrograde ejaculation
  • Future BPH treatments remain possible

Limitations and important caveats

Patients should understand that:

  • Several permanent implants remain inside the prostate
  • Symptom and flow improvements are usually less than after TURP or enucleation
  • Retreatment is more common than after tissue-removing surgery
  • Not all median lobes are suitable
  • UroLift does not prevent continued prostate growth
  • Urgency and nocturia may persist if they have a bladder or medical cause
  • The implants may reduce the quality of future prostate MRI
  • Later prostate surgery remains possible but may be technically more complicated
  • Prostate cancer should be appropriately assessed before treatment
  • UroLift does not provide prostate tissue for laboratory examination

Are Clips the right option for me?

UroLift can be an excellent option for a carefully selected man who wants meaningful improvement in urinary symptoms, a rapid recovery and a low risk of ejaculatory dysfunction.

It may be less suitable for someone with severe obstruction, chronic retention, weak bladder function, unfavourable median-lobe anatomy or a need for the most powerful and durable improvement possible.

The decision should take account of:

  • Prostate size and shape
  • Presence of a median lobe
  • Severity of symptoms and obstruction
  • Bladder strength and residual urine
  • PSA and prostate cancer risk
  • Previous treatment
  • General health and medication
  • Importance of preserving ejaculation
  • Acceptance of permanent implants
  • Willingness to undergo future retreatment

A urological assessment allows UroLift to be compared fairly with medication, iTind, Rezūm, Aquablation, TURP, GreenLight laser, HoLEP and other appropriate options.

This information is intended for general education and does not replace individual medical advice. Treatment suitability, availability and costs vary. Always follow the instructions provided by your treating urologist.

References

  1. European Association of Urology: Management of non-neurogenic male lower urinary tract symptoms.
  2. American Urological Association: BPH clinical guideline.
  3. Roehrborn CG, et al. Five-year results of the prospective randomised controlled prostatic urethral L.I.F.T. study. Canadian Journal of Urology. 2017;24:8802–8813.
  4. Rukstalis D, et al. Prostatic urethral lift for the treatment of an obstructive median lobe: 12-month results of the MedLift study. Prostate Cancer and Prostatic Diseases. 2019;22:411–419.
  5. UroLift manufacturer safety information.
  6. Benidir T, et al. Impact of the UroLift device on prostate magnetic resonance image quality. Journal of Urology. 2023.

A Temporary Stent for Benign Prostatic Enlargement: Temporary Treatment Without a Permanent Implant

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Benign prostatic hyperplasia or BPH is a non-cancerous enlargement of the prostate. As the prostate grows, it may compress the urethra and interfere with emptying the bladder.

Typical symptoms include:

  • A weak or interrupted urinary stream
  • Difficulty starting urination
  • Straining to pass urine
  • Urinary frequency or urgency
  • Getting up repeatedly at night
  • Dribbling after urination
  • A feeling that the bladder has not emptied completely

Medication is often the first treatment. However, tablets do not help every patient and may cause dizziness, tiredness, reduced ejaculation, erectile difficulties or reduced libido. The iTind procedure offers selected men a minimally invasive alternative to long-term medication or conventional prostate surgery.

What is iTind / Temporary Stent?

The iTind is a small temporary device made from nitinol, a flexible nickel–titanium alloy with “shape memory.”

It is sometimes called a temporary prostatic stent, although it differs from a traditional stent because it is not intended to remain permanently within the prostate. The device is left in place for only five to seven days and is then removed completely.

While in position, three expanding struts apply controlled pressure to specific areas of the prostate and bladder neck. This remodels the prostatic urethra and creates channels through which urine can flow more easily.

The procedure does not:

  • Permanently implant metal within the prostate
  • Remove prostate tissue
  • Use laser, heat or steam
  • Prevent future prostate treatments if symptoms return

Who may benefit from iTind?

iTind may be considered for men who have bothersome urinary symptoms caused by BPH and who:

  • Have obtained insufficient benefit from medication
  • Have developed side effects from BPH tablets
  • Prefer not to take daily medication indefinitely
  • Want a less invasive alternative to TURP or laser surgery
  • Wish to minimise the risk of ejaculatory or erectile side effects
  • Prefer not to have a permanent prostatic implant
  • Have prostate size and anatomy suitable for the device

The procedure is generally best suited to men with moderate-to-severe symptoms and a prostate measuring approximately 25–75 mL, without a significantly obstructing median lobe.

These measurements are a guide rather than a guarantee of suitability. The shape of the prostate, severity of obstruction and function of the bladder are as important as prostate size.

Assessment before treatment

Urinary symptoms are not always caused by an enlarged prostate. Similar problems can result from infection, urethral narrowing, bladder weakness, an overactive bladder, neurological disease, medication or, less commonly, cancer.

Assessment may therefore include:

  • Medical history and examination
  • International Prostate Symptom Score
  • Urine testing
  • PSA testing when appropriate
  • Urinary-flow measurement
  • Ultrasound measurement of residual urine
  • Prostate ultrasound or other imaging
  • Flexible cystoscopy
  • Urodynamic testing in selected patients

Any urinary infection should be treated before the procedure.

Patients taking aspirin, warfarin, clopidogrel, apixaban, rivaroxaban or other blood-thinning medication require an individual management plan. Do not stop blood thinners without instructions from your prescribing doctor and urologist.

How is the iTind procedure performed?

Insertion

The folded iTind device is passed through the urethra using a small cystoscope. It is positioned in the prostatic urethra immediately below the bladder neck and then released.

The procedure is usually performed as day surgery. Depending on the patient and treatment setting, local anaesthetic, intravenous sedation or a short general anaesthetic may be used.

A soft retrieval string remains attached to the device and passes out through the urethra. It is usually secured to the penis until the device is removed.

Most patients can return home on the same day without a urinary catheter. Occasionally, temporary catheterisation is necessary if the patient is unable to pass urine.

The treatment period

The device remains inside the prostate for five to seven days. Its struts gradually apply pressure to the prostate and bladder neck, creating three longitudinal channels within the urinary passage.

Patients remain at home during this treatment period.

Removal

The device must be removed after five to seven days. It is collapsed into a soft catheter and withdrawn in one piece, usually during a brief outpatient visit.

Local anaesthetic gel is often sufficient, although additional pain relief or sedation may be offered when appropriate. No metal or permanent implant remains inside the prostate after removal.

What should I expect while the device is in place?

The five-to-seven-day treatment period is generally the most uncomfortable part of the process. Common temporary symptoms include:

  • Pelvic or perineal pressure
  • Burning or stinging when passing urine
  • Urinary urgency and frequency
  • Discomfort at the tip of the penis
  • Bladder spasms
  • Light bleeding in the urine
  • Interrupted sleep
  • Awareness of the retrieval string
  • A temporarily weak or irregular urinary stream

These symptoms are usually mild to moderate and commonly improve soon after the device is removed.

Patients should generally avoid heavy lifting, vigorous exercise, cycling and sexual activity while the device and retrieval string are in place. Follow the particular instructions provided by your urologist.

The retrieval string should not be pulled, cut, repositioned or removed by the patient.

How can pain and discomfort be managed?

Pain varies considerably between patients. Some men experience only mild pressure, while others find urinary urgency, bladder spasm or discomfort from the retrieval string more troublesome.

A pain-management plan may include the following measures.

Paracetamol

Paracetamol is usually the first choice for mild-to-moderate discomfort. Take it according to your doctor’s instructions or the directions on the packet.

Check cold, influenza and combination pain medicines carefully, as these may also contain paracetamol. Do not exceed the recommended daily dose.

Patients with significant liver disease or heavy alcohol consumption should discuss paracetamol use with their doctor.

Anti-inflammatory medication

An anti-inflammatory medicine such as ibuprofen may help reduce pain and inflammation when medically appropriate.

These medications may not be suitable for patients with:

  • Kidney impairment
  • Stomach ulcers or gastrointestinal bleeding
  • Heart failure or certain cardiovascular conditions
  • Asthma triggered by anti-inflammatory medication
  • Bleeding disorders
  • Anticoagulant or antiplatelet treatment

Check with your urologist, general practitioner or pharmacist before taking an anti-inflammatory medication.

Medication for bladder irritation

An alpha blocker may occasionally be continued or prescribed temporarily to help urine flow. A bladder-calming medication may be considered if urgency or bladder spasms are particularly troublesome.

These medicines are not necessary for every patient and have their own potential side effects.

Practical measures

It may also help to:

  • Maintain normal hydration without forcing excessive fluids
  • Reduce coffee, tea, cola drinks, alcohol and energy drinks
  • Avoid constipation
  • Wear loose, supportive underwear
  • Avoid heavy lifting and strenuous exercise
  • Take pain relief early rather than waiting until discomfort becomes severe

Strong opioid medication is not usually required. It may worsen constipation and, in susceptible patients, contribute to difficulty emptying the bladder.

Severe or increasing pain is not considered something that should simply be tolerated. Contact the treating practice if the discomfort is not controlled by the recommended measures.

What happens after removal?

Burning, urinary urgency and light bleeding may continue briefly after the device is removed, but these symptoms should progressively improve.

Some patients notice an improvement in their stream soon after removal. For others, improvement develops more gradually over several weeks as irritation settles and the remodelled urinary channels stabilise.

Many patients return to normal daily activities within a few days. Your urologist will advise when you may resume strenuous exercise and sexual activity.

Follow-up may include:

  • Review of urinary symptoms
  • Repeat symptom scoring
  • A urinary-flow test
  • Measurement of residual urine
  • Discussion about continuing or stopping BPH medication

Do not stop established prostate medication unless advised to do so.

Side effects and possible complications

Most side effects are temporary and occur while the device is in place. Reported problems include:

  • Burning during urination
  • Urinary frequency and urgency
  • Pelvic discomfort or pain
  • Blood in the urine
  • Temporary difficulty passing urine
  • Urinary tract infection
  • Bladder spasm
  • Movement or incorrect positioning of the device
  • Temporary catheterisation
  • Failure to obtain sufficient symptom relief

Published studies report different complication rates, but most events have been mild and self-limiting. Temporary haematuria, dysuria, urgency and pelvic discomfort are the most frequently reported problems.

Acute urinary retention, urinary infection or significant bleeding are less common but important complications.

When should I seek urgent medical attention?

Contact your urologist or attend an emergency department if you:

  • Cannot pass urine
  • Develop fever, shaking or chills
  • Feel generally unwell or confused
  • Develop severe or increasing pelvic pain
  • Pass large blood clots
  • Have heavy or persistent bright-red bleeding
  • Cannot keep fluids down
  • Notice that the retrieval string or device has moved
  • Develop pain that is not controlled by the agreed treatment plan

Does iTind affect erections or ejaculation?

One of the principal attractions of iTind is its favourable sexual side-effect profile.

Clinical studies have reported preservation of erectile and ejaculatory function in most treated patients. This contrasts with tissue-removing prostate procedures, which may carry a significant risk of retrograde or absent ejaculation.

Nevertheless, no treatment can guarantee that sexual or ejaculatory function will remain unchanged in every patient.

How effective is iTind?

Studies have demonstrated average improvements in:

  • Urinary symptom scores
  • Quality of life
  • Peak urinary-flow rate
  • The patient’s perception of urinary function

The improvement may be less dramatic than that achieved with a tissue-removing operation such as TURP or laser enucleation. The advantage is that iTind is less invasive, usually requires little recovery time and has a low reported risk of sexual side effects.

It is therefore best viewed as a balance between symptom improvement and treatment invasiveness.

How long does the benefit last?

Although the implant remains in place for only five to seven days, the channels produced within the prostate may remain open for several years.

Prospective studies have demonstrated sustained benefit for more than four years in some appropriately selected patients. This does not mean that iTind is guaranteed to last for four years—or that it will provide lifelong relief.

BPH may continue to progress as a man ages. Some patients will eventually need to restart medication or undergo another procedure. Longer-term evidence for iTind remains more limited than that available for established procedures such as TURP or laser enucleation.

Because nothing is left permanently inside the prostate, iTind does not generally prevent later treatment. Options may include medication, another minimally invasive procedure, TURP, GreenLight laser treatment, HoLEP or another form of prostate surgery.

Who should not undergo iTind?

Contraindications described in the manufacturer’s information include:

  • Active urinary tract infection
  • Acute prostatitis
  • Known prostate cancer
  • Known bladder cancer
  • An artificial urinary sphincter or another implant within the urethra
  • Bladder atonia or a non-contractile bladder
  • Neurogenic bladder dysfunction
  • Urinary obstruction caused by a urethral stricture or something other than BPH

The procedure may also be unsuitable or less predictable in men with:

  • A significantly obstructing median prostatic lobe
  • A prostate outside the best-studied size range
  • Severe chronic urinary retention
  • Very high residual urine volumes
  • Recurrent urinary infections
  • Bladder stones
  • Significant ongoing haematuria
  • Advanced bladder weakness
  • A need for rapid and substantial removal of obstructing tissue
  • Anatomy that prevents safe cystoscopic access

Previous prostate surgery, urethral surgery, nickel sensitivity and blood-thinning medication require individual consideration.

Patients with obstruction causing kidney impairment, repeated retention, recurrent infections, bladder stones or significant bleeding may receive more reliable relief from a definitive tissue-removing procedure.

Advantages of iTind

Potential advantages include:

  • Minimally invasive day procedure
  • No cutting, laser, steam or thermal energy
  • No permanent implant
  • Usually no postoperative catheter
  • Rapid return to ordinary activities
  • Low reported risk of new erectile dysfunction
  • Low reported risk of ejaculatory dysfunction
  • Does not usually compromise future BPH treatment

Limitations of iTind

Potential limitations include:

  • Discomfort during the treatment week
  • A retrieval string for five to seven days
  • A second procedure to remove the device
  • Not suitable for every prostate shape or size
  • Less improvement than some tissue-removing procedures
  • Possibility of persistent or recurrent symptoms
  • Potential need for future medication or surgery
  • Less very-long-term evidence than TURP or laser enucleation

Is iTind the right treatment for me?

iTind is not simply a smaller version of TURP. It offers a different compromise: a less invasive procedure with no permanent implant and a favourable sexual side-effect profile, but generally more modest improvement and less long-term evidence than tissue-removing surgery.

The best treatment depends on:

  • The severity of your symptoms
  • The size and shape of your prostate
  • The amount of urinary obstruction
  • Bladder strength and residual urine
  • Previous treatment
  • General health and medication
  • The importance of preserving ejaculation
  • Your willingness to accept possible future retreatment

A urological assessment is essential to confirm that BPH is responsible for the symptoms and to compare iTind fairly with medication, Rezūm, UroLift, TURP, GreenLight laser, HoLEP and other appropriate treatments.

This information is intended for general education and does not replace individual medical advice. Treatment suitability, availability and costs vary. Always follow the instructions provided by your treating urologist.

References

  1. Sandhu JS, et al. Management of Lower Urinary Tract Symptoms Attributed to Benign Prostatic Hyperplasia: AUA Guideline Amendment 2023. Journal of Urology. 2024.
  2. Chughtai B, et al. The iTind Temporarily Implanted Nitinol Device for the Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A Multicentre, Randomised, Controlled Trial. Urology. 2021;153:270–276.
  3. Kadner G, et al. Second generation of temporary implantable nitinol device in men with lower urinary tract symptoms: two-year results of the MT-02 study. World Journal of Urology. 2020;38:3235–3244.
  4. Amparore D, et al. Three-year results following treatment with the second-generation temporary implantable nitinol device. Prostate Cancer and Prostatic Diseases. 2021;24:349–357.
  5. Amparore D, et al. Temporary implantable nitinol device for BPH-related lower urinary tract symptoms: over 48-month results. Minerva Urology and Nephrology. 2023;75:743–751.
  6. NICE: iTind for lower urinary tract symptoms caused by BPH.
  7. Olympus: iTind clinical and procedural information.

Penile Cancer: Symptoms, Diagnosis and Treatment in Australia

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Penile cancer is rare, but early diagnosis matters

Penile cancer is an uncommon cancer affecting the skin and tissues of the penis. In Australia, approximately 165 men were estimated to be diagnosed with penile cancer in 2025, with the average age at diagnosis around 68 years. About 95% of penile cancers are squamous cell carcinomas (SCC).

Although the diagnosis can understandably be frightening, there is an important message:

When penile cancer is detected early, treatment is frequently curative and, in many men, much or all of the penis can be preserved.

Modern treatment has therefore moved increasingly towards penile-preserving therapy whenever this can be achieved safely.

Treatment in Australia will depend on:

  • whether the abnormality is precancerous or invasive cancer
  • the size and location of the tumour
  • how deeply it has invaded
  • the grade of the cancer
  • whether lymph nodes in the groin are involved
  • whether cancer has spread elsewhere
  • the man’s general health and personal preferences.

Because penile cancer is rare, patients with invasive or complicated disease benefit from discussion by a multidisciplinary team (MDT) involving urology, medical oncology, radiation oncology, radiology, pathology and specialist nursing.

 

What causes penile cancer?

There is rarely one single identifiable cause.

Important risk factors include:

  • infection with human papillomavirus (HPV)
  • smoking
  • phimosis, where the foreskin cannot be retracted
  • chronic inflammation of the penis
  • penile intraepithelial neoplasia (PeIN)
  • increasing age
  • some chronic penile skin disorders
  • immunosuppression.

HPV plays an important role in a proportion of penile cancers, although penile cancer can certainly occur without HPV infection.

What symptoms should men look for?

Penile cancer often begins as a visible or palpable abnormality, particularly involving the glans or foreskin.

Symptoms can include:

  • a red or discoloured area that does not disappear
  • persistent irritation or inflammation
  • thickening of the skin
  • a lump
  • a wart-like growth
  • an ulcer or sore that does not heal
  • bleeding
  • persistent discharge
  • an unpleasant smell from beneath the foreskin
  • increasing difficulty retracting the foreskin
  • pain or tenderness
  • swelling of the end of the penis
  • a lump beneath the foreskin
  • enlarged lymph nodes or lumps in the groin.

More advanced disease can occasionally cause difficulty passing urine, fatigue or unexplained weight loss.

A persistent penile lesion deserves examination

Most rashes, spots and lumps on the penis are not cancer. Infection, inflammation, dermatitis and benign skin conditions are much more common.

The important issue is persistence.

A penile ulcer, lump, bleeding area or unusual skin change that does not resolve should not be hidden away in the hope that it will disappear.

Embarrassment is considerably easier to treat than advanced cancer.

How is penile cancer diagnosed?

Examination

The first step is careful examination of the penis and foreskin.

The urologist will assess:

  • the site of the lesion
  • its size
  • whether it involves the glans, foreskin or shaft
  • whether deeper tissues appear involved
  • whether the foreskin can be retracted
  • whether there are enlarged lymph nodes in either groin.

Both groins are particularly important because penile cancer usually spreads first through the lymphatic system to the inguinal lymph nodes.

Biopsy

The diagnosis usually requires a biopsy.

A small piece of the abnormal tissue is removed and examined by a pathologist.

Depending upon the lesion, this may be:

  • a punch biopsy
  • an incisional biopsy, taking part of the lesion
  • an excisional biopsy, removing the whole small lesion.

A biopsy determines whether cancer is present and, importantly, identifies the type and grade of the tumour.

Histological confirmation is particularly important before treatments such as topical therapy, laser treatment or radiotherapy.

What is PeIN?

Penile intraepithelial neoplasia (PeIN) is a precancerous or very early cancerous change confined to the surface epithelium.

It has previously been described using terms such as carcinoma in situ.

PeIN is important because it can progress to invasive squamous cell carcinoma. Current European guidelines estimate progression to invasive disease despite treatment in approximately 2.6–13% of patients.

The good news is that PeIN can often be treated without removing part of the penis.

Treatment: from creams to major surgery

There is no single operation or treatment for penile cancer.

Modern management follows a ladder, beginning with the least invasive treatment capable of reliably controlling the cancer.

1. Circumcision

For abnormalities confined to the foreskin, circumcision may remove the lesion completely.

Circumcision is also frequently an important first step when PeIN involves the glans and foreskin because it allows the glans to be properly examined and treated.

For superficial disease, contemporary guidelines regard circumcision as an important primary surgical treatment.

2. Treatment with creams

Selected cases of biopsy-confirmed PeIN can be treated with medication applied directly to the penis.

The two most commonly used treatments are:

5-fluorouracil (5-FU)

5-FU is a topical chemotherapy medication.

It destroys abnormal rapidly dividing cells in the superficial layers of the penis.

Treatment usually produces inflammation of the treated area, which can include:

  • redness
  • burning
  • crusting
  • discomfort
  • erosion of the surface skin.

Imiquimod

Imiquimod is different. Rather than being conventional chemotherapy, it stimulates the local immune system to attack abnormal cells.

It can similarly cause substantial redness, swelling, ulceration or crusting during treatment.

These reactions can look alarming but often indicate that the medication is producing its intended biological effect.

Current EAU-ASCO guidance supports either 5-FU or imiquimod for appropriately selected biopsy-confirmed PeIN.

Importantly, the area must be reassessed after treatment.

If the abnormality persists, repeat biopsy or alternative treatment may be necessary. Repeated courses of topical treatment should not simply continue indefinitely when the lesion has failed to respond, because invasive cancer may be hiding beneath the surface.

3. Laser and other local treatments

Very superficial lesions can sometimes be treated using laser therapy.

Depending upon expertise and availability, other local treatments such as photodynamic therapy or cryotherapy have also been used.

These approaches can preserve the penis but require careful long-term surveillance because local recurrence is possible.

4. Penile-preserving surgery

One of the major changes in penile cancer surgery has been the move away from automatically removing a substantial portion of the penis.

Whenever oncologically safe, the aim is:

remove the cancer, obtain clear margins and preserve as much normal penis as possible.

Operations may include:

Wide local excision

The cancer and a margin of surrounding tissue are removed.

The defect may be closed directly or reconstructed with a skin graft.

Glans resurfacing

The abnormal surface layer of the glans is removed while preserving the deeper erectile tissue.

A skin graft is then placed over the glans.

This can be particularly useful for extensive superficial disease.

Glansectomy

If cancer is confined to the glans but is too extensive or invasive for simpler treatment, part or all of the glans may be removed.

Reconstruction can then be performed, often using a skin graft to create a new glans-like surface.

Current guidelines favour organ-preserving surgery for appropriately selected PeIN and T1–T2 tumours involving the glans or prepuce, provided the patient understands the need for careful follow-up.

5. Partial penectomy

More deeply invasive cancer may require removal of part of the penis.

This is called a partial penectomy.

The surgeon attempts to retain enough penile length to permit comfortable urination and, where possible, sexual function.

This may be necessary when cancer extends more deeply into the erectile tissues and cannot be reliably removed using penile-preserving techniques.

6. Total penectomy

Occasionally a cancer is too large, too proximal or too deeply invasive for part of the penis to be safely preserved.

A total penectomy may then provide the best opportunity for cure.

This understandably sounds confronting. It is generally reserved for circumstances in which less radical treatment would compromise cancer control.

Current EAU-ASCO recommendations support total penectomy with perineal urethrostomy for large invasive tumours that cannot safely be treated by partial penectomy.

What is a perineal urethrostomy?

This is sometimes mistakenly referred to as a “perineotomy”.

Following total removal of the penis, urine still needs a pathway from the bladder to the outside world.

The urethra is therefore brought to the skin of the perineum, the area between the scrotum and anus.

This opening is called a:

Perineal urethrostomy

The patient subsequently passes urine through this opening while sitting on the toilet.

A catheter is generally left temporarily while the area heals.

Once healed, most men can empty their bladder normally through the new opening and do not require a permanent catheter.

Potential problems include:

  • narrowing or stenosis of the opening
  • spraying
  • infection
  • wound complications
  • occasionally the need for further surgery.

A perineal urethrostomy does not mean that the bladder or kidneys have stopped functioning. It simply changes the final few centimetres of the urinary plumbing.

The lymph nodes are extremely important

Treating the penis itself is only one half of penile cancer management.

The other half is determining whether cancer has reached the inguinal lymph nodes in the groin.

Penile cancer generally spreads in a predictable sequence:

Penis → inguinal lymph nodes → pelvic lymph nodes → distant organs

Lymph-node involvement is the single most important prognostic factor in penile cancer.

What if there are no enlarged lymph nodes?

Unfortunately, normal-feeling groins do not completely exclude microscopic cancer.

Men with higher-risk primary tumours may therefore require further lymph-node assessment despite having no palpable lumps.

This may involve:

  • ultrasound of the groins
  • ultrasound-guided needle biopsy of abnormal nodes
  • dynamic sentinel lymph-node biopsy
  • inguinal lymph-node dissection in selected circumstances.

Current EAU-ASCO guidance recommends surgical lymph-node staging for patients at significant risk of microscopic metastatic disease, particularly T1b disease or higher.

What if a groin lymph node is enlarged?

An abnormal lymph node may be assessed using ultrasound and needle biopsy.

If metastatic penile cancer is confirmed, treatment may involve:

  • inguinal lymph-node dissection
  • pelvic lymph-node dissection in selected patients
  • chemotherapy
  • radiotherapy
  • combinations of these treatments.

Patients with clinically node-positive disease are generally staged with CT or FDG-PET/CT to assess pelvic and distant disease before definitive treatment.

Early treatment of lymph-node disease is extremely important.

Radiation therapy

Radiotherapy has an important but selective role in penile cancer.

Treatment of the primary cancer

Selected smaller T1 or T2 cancers can potentially be treated with radiation instead of surgery.

Treatment can involve:

External beam radiotherapy

Radiation is directed at the tumour from outside the body.

Brachytherapy

Radioactive sources are temporarily positioned within or very close to the tumour, allowing a concentrated radiation dose to be delivered while limiting exposure to surrounding tissues.

Radiotherapy may therefore provide another means of preserving the penis in appropriately selected patients.

Potential complications can include:

  • skin irritation
  • ulceration
  • fibrosis
  • narrowing of the urethra
  • changes in penile sensation
  • erectile dysfunction
  • tissue damage or necrosis in uncommon circumstances.

Radiotherapy is also used in selected patients for regional lymph-node disease, as part of chemoradiotherapy for advanced disease, or for palliation of symptoms from metastatic cancer.

Chemotherapy

Chemotherapy is generally reserved for more advanced penile cancer, particularly when significant lymph-node disease or metastatic disease is present.

In Australia, contemporary treatment may involve platinum-based combination chemotherapy.

One regimen used in advanced disease is:

TIP: paclitaxel + ifosfamide + cisplatin

Australia’s eviQ cancer treatment resource includes TIP as an option in neoadjuvant, adjuvant and metastatic penile cancer settings.

For bulky or fixed inguinal lymph-node disease or pelvic lymph-node involvement, chemotherapy may be given before surgery.

This is called neoadjuvant chemotherapy.

The aim is to:

  1. treat microscopic disease throughout the body,
  2. shrink the cancer in the lymph nodes,
  3. determine whether the cancer is responding,
  4. make subsequent surgery more effective or technically achievable.

Current international guidance recommends cisplatin- and taxane-based neoadjuvant chemotherapy for suitable patients with extensive inguinal or pelvic nodal disease, followed by surgery when appropriate.

Chemoradiotherapy

Radiotherapy and chemotherapy can sometimes be combined.

This may be considered for selected patients with:

  • locally advanced disease
  • unresectable cancer
  • extensive lymph-node disease
  • disease where major surgery is unsuitable
  • palliative treatment requirements.

The evidence is evolving, and these decisions should generally be made through a specialist penile cancer MDT.

What about immunotherapy?

Immunotherapy is an exciting area of cancer treatment, but its role in penile cancer is still developing.

Checkpoint inhibitors such as pembrolizumab and related drugs have demonstrated activity in some patients with advanced penile cancer, and newer combinations of chemotherapy and immunotherapy are being investigated.

However, response rates to checkpoint inhibitors alone are relatively modest and there is not yet sufficient evidence to use biomarkers such as HPV or PD-L1 routinely to determine which penile cancer patients should receive immunotherapy.

Clinical trials are particularly important for men whose cancer progresses despite standard platinum-based chemotherapy.

What happens to sexual function?

This depends enormously on treatment.

After topical treatment, circumcision, laser therapy, glans resurfacing or limited local excision, satisfactory sexual function may often be preserved.

After glansectomy or partial penectomy, intercourse may remain possible depending upon remaining penile length, erectile function and reconstruction.

After total penectomy, penetrative intercourse using the penis is no longer possible.

This does not mean that intimacy, sexual sensation or orgasm automatically disappears.

Sexual rehabilitation, psychological support and discussion with the patient and his partner can be an important component of recovery.

These conversations should ideally begin before treatment, not after it.

What is the prognosis?

Penile cancer is potentially highly curable when diagnosed before it has spread to lymph nodes.

The most important predictor of survival is not simply the size of the penile lesion but whether cancer has reached the lymph nodes.

Current EAU-ASCO data report approximate five-year cancer-specific survival according to nodal stage of:

Lymph-node stage Approximate 5-year cancer-specific survival
N0 – no lymph-node metastases 95%
N1 80%
N2 65%
N3 – advanced nodal disease 35%

These are population figures, not predictions for an individual patient.

Prognosis depends upon the tumour’s stage and grade, lymph-node involvement, response to treatment, general health and other pathological features.

The figures do, however, demonstrate why early diagnosis and appropriate assessment of the groin lymph nodes are so important.

Follow-up after treatment

Penile cancer requires ongoing surveillance.

Follow-up may include:

  • examination of the penis or reconstructed area
  • examination of both groins
  • assessment of the perineal urethrostomy where applicable
  • imaging in higher-risk patients
  • biopsy of suspicious recurrent lesions
  • monitoring urinary and sexual function
  • psychological and sexual-health support.

Penile-preserving treatment requires particularly careful surveillance because local recurrence can occur.

Importantly, a local recurrence identified early can often still be successfully treated.

Do not ignore a change in the penis

Penile cancer is uncommon, and most penile skin problems are benign.

Nevertheless, a persistent:

lump, ulcer, red patch, bleeding area, discharge, thickened foreskin or lesion that simply will not heal deserves examination.

There should be no embarrassment in asking your GP or urologist to have a look.

For early disease, treatment may be surprisingly conservative: sometimes circumcision, a cream, laser treatment or limited surgery is all that is required.

Even when invasive cancer is present, modern penile cancer surgery increasingly focuses on preserving penile tissue, urinary function and quality of life whenever this can be achieved without compromising cure.

For advanced disease, treatment becomes more complex and may involve partial or total penectomy, perineal urethrostomy, lymph-node surgery, radiotherapy and chemotherapy.

The crucial message is simple:

The earlier penile cancer is diagnosed, the greater the opportunity to cure it while preserving the penis.

Australian and international resources

Cancer Council Australia: Penile Cancer

Cancer Institute NSW: Penile Cancer

eviQ Australian Penile Cancer Chemotherapy Protocol

2026 EAU-ASCO Penile Cancer Guidelines

This information is intended for patient education and does not replace individual medical assessment. Treatment of penile cancer should be tailored to the tumour stage, pathology, lymph-node status, general health and preferences of the individual patient.

So, if you have noticed a lesion on your penis and it is growing, don’t ignore it and hope it will go away, go see your GP.

Robotic-Assisted Radical Prostatectomy: When Is a Non-Nerve-Sparing Procedure Necessary?

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Removing the prostate while putting cancer control first

Robotic-assisted radical prostatectomy is a well-established surgical treatment for localised and selected locally advanced prostate cancer. During the operation, the prostate gland and seminal vesicles are removed, and the bladder is reconnected to the urethra. In selected patients, pelvic lymph nodes may also be removed.

One of the important decisions made before and during prostate cancer surgery is whether the nerves responsible for erections can safely be preserved.

This is known as nerve-sparing prostatectomy.

Unfortunately, nerve preservation is not always appropriate. When prostate cancer is close to, involves, or is suspected of extending beyond the outer edge of the prostate near these nerves, attempting to preserve them may compromise the completeness of cancer removal.

In this situation, a partial or complete non-nerve-sparing robotic prostatectomy may be recommended.

The guiding principle is simple:

Preserve the nerves when it is oncologically safe to do so, but do not preserve them at the expense of adequately treating the prostate cancer.

What are the nerves that are being “spared”?

Running immediately alongside the prostate are delicate bundles of nerves and blood vessels known collectively as the neurovascular bundles.

These structures contain nerves that play an important role in producing erections.

They sit extremely close to the outer surface, or capsule, of the prostate. This anatomical relationship creates a challenge during prostate cancer surgery.

If the cancer is safely contained within the prostate and sufficiently distant from the neurovascular bundle, the surgeon may be able to carefully dissect the prostate away while preserving the nerves.

This is a nerve-sparing radical prostatectomy.

If cancer is suspected to extend towards or through the prostate capsule in this area, the surgeon may need to remove some or all of the neurovascular tissue together with the prostate.

This is a non-nerve-sparing prostatectomy.

Why would a surgeon deliberately remove the erectile nerves?

It may initially seem counterintuitive to remove structures that are so important for sexual function.

The reason is cancer control.

The primary purpose of radical prostatectomy is to completely remove the prostate cancer.

If a tumour is growing very close to the edge of the prostate, particularly next to a neurovascular bundle, dissecting too close to the prostate in an attempt to preserve the nerves could potentially leave cancer cells behind.

This is called a positive surgical margin.

In appropriately selected patients, taking a wider margin around the prostate may therefore provide a safer cancer operation.

The decision represents a balance between:

Cancer control

and

preservation of erectile function.

When these two goals conflict, cancer control generally takes priority.

When may a non-nerve-sparing prostatectomy be recommended?

Non-nerve-sparing surgery may be considered when there is a significant risk that prostate cancer has extended towards or into the tissues surrounding the prostate.

Examples include:

Locally advanced prostate cancer

A tumour suspected of extending through the prostate capsule, particularly clinical T3 disease, may require a wider surgical excision.

Cancer close to the neurovascular bundle on MRI

Modern multiparametric prostate MRI can provide valuable information about the location of the tumour and its relationship to the prostate capsule and neurovascular bundles.

Features suggesting extraprostatic extension may influence the decision not to preserve the nerve bundle on that side.

High-grade prostate cancer

Higher-grade cancers, including cancers with an unfavourable Gleason score or ISUP Grade Group, may have a greater likelihood of extending outside the prostate.

The biopsy result alone does not automatically determine whether the nerves can be preserved, but it forms part of the overall assessment.

Extensive cancer on prostate biopsy

Large-volume disease, particularly when concentrated along the outer portion of the prostate near a neurovascular bundle, may make nerve preservation less appropriate.

Very high PSA or other high-risk features

PSA level, PSA density, biopsy findings, MRI appearance and clinical examination are considered together when estimating the likelihood of disease extending beyond the prostate.

Cancer involving one particular side of the prostate

Importantly, nerve sparing does not necessarily have to be “all or nothing.”

If the cancer is predominantly on one side, it may sometimes be possible to preserve the neurovascular bundle on the opposite side.

This is known as unilateral nerve sparing.

Nerve sparing is not simply YES or NO

Modern robotic prostate surgery is more nuanced than dividing operations into completely nerve-sparing and completely non-nerve-sparing procedures.

Depending on the location and extent of the cancer, surgery may involve:

  • Bilateral nerve sparing
  • Unilateral nerve sparing
  • Partial nerve sparing
  • Wider excision on one side and nerve preservation on the other
  • Complete bilateral non-nerve-sparing surgery

The surgical plan can therefore be tailored to the individual patient and, importantly, to the cancer on each side of the prostate.

How does nerve-sparing surgery differ from non-nerve-sparing surgery?

During nerve-sparing surgery, the surgeon carefully separates the neurovascular bundle from the surface of the prostate while attempting to minimise traction, heat and other potential injury to these delicate nerves.

During non-nerve-sparing surgery, the dissection is deliberately performed further away from the prostate.

The neurovascular tissue is removed together with the prostate where necessary to obtain a wider cancer margin.

The robotic platform provides magnified three-dimensional vision and highly controlled instrument movement. This allows the surgeon to identify tissue planes with considerable precision.

However, robotic technology cannot make an unsafe nerve-sparing operation safe.

The biology and location of the cancer ultimately determine how close to the prostate the surgeon can safely operate.

What happens to erections after non-nerve-sparing prostatectomy?

This is one of the most important issues to discuss before surgery.

The nerves surrounding the prostate are responsible for signalling increased blood flow into the penis to produce a natural erection.

If both neurovascular bundles are completely removed, the likelihood of recovering spontaneous erections adequate for sexual intercourse is very low.

This is different from nerve-sparing surgery, where the nerves remain anatomically intact but may temporarily function poorly following surgery.

After nerve-sparing prostatectomy, erectile recovery can occur gradually over many months and sometimes over 18–24 months or longer.

After complete bilateral non-nerve-sparing surgery, however, the nerves themselves have been removed rather than temporarily stunned.

The expectations for recovery are therefore very different.

Does non-nerve-sparing surgery affect sensation or orgasm?

This is an important distinction.

The nerves responsible for penile sensation are different from the neurovascular nerves primarily responsible for erections.

Many men can therefore continue to experience penile sensation and sexual pleasure following radical prostatectomy.

Orgasm may also remain possible.

However, radical prostatectomy removes the prostate and seminal vesicles and disconnects the reproductive pathway. Consequently, there is no ejaculation of semen after surgery.

This is sometimes described as a dry orgasm.

The sensation of orgasm can also feel different after prostate surgery.

Does non-nerve-sparing prostatectomy cause infertility?

Yes.

Radical prostatectomy results in permanent infertility because the prostate and seminal vesicles are removed and sperm can no longer enter the ejaculate.

Men who may wish to father children in the future should discuss sperm banking before surgery.

This applies whether the operation is nerve sparing or non-nerve sparing.

Is a non-nerve-sparing procedure reversible?

No.

Once a neurovascular bundle has been surgically removed, it cannot simply be reattached at a later date.

This is an important difference between temporary nerve dysfunction and actual nerve removal.

After nerve-sparing surgery, the nerves may be anatomically preserved but temporarily injured or “stunned”. Recovery may therefore occur with time.

After complete non-nerve-sparing surgery, the erectile nerves have been physically removed as part of the cancer operation.

The procedure itself is therefore not reversible.

However, this does not mean that erections or sexual activity are impossible.

There are several effective treatments available for erectile dysfunction following prostatectomy.

Can erections still be achieved after non-nerve-sparing surgery?

Rarely yes, but they will usually require assistance.

Treatment options include:

PDE5 inhibitor tablets

Medications such as sildenafil or tadalafil are commonly used after prostate surgery.

They rely substantially on functioning nerve pathways and are therefore generally more effective following nerve-sparing surgery.

Their effectiveness following complete bilateral non-nerve-sparing surgery is considerably more limited.

Vacuum erection device

A vacuum erection device creates negative pressure around the penis, drawing blood into the erectile tissues.

A constriction ring can then be placed around the base of the penis to maintain the erection.

Because this technique does not depend on intact erectile nerves, it can be useful after non-nerve-sparing surgery.

Penile injection therapy

Medication can be injected directly into the erectile tissue of the penis.

These medications act directly on penile blood vessels and therefore do not require normal prostate-associated nerve signalling.

For this reason, penile injections can be highly effective even after bilateral non-nerve-sparing prostatectomy.

Penile prosthesis

For men with persistent erectile dysfunction who wish to restore reliable erections, a penile prosthesis can provide an effective long-term solution.

An inflatable penile prosthesis allows an erection to be mechanically produced when desired.

For appropriately selected men, satisfaction rates following penile prosthesis surgery are generally high.

What about penile rehabilitation?

Penile rehabilitation may be discussed following radical prostatectomy.

The objectives can include maintaining penile tissue health, encouraging regular oxygenation of the erectile tissues, minimising shortening and fibrosis, and assisting the return to sexual activity.

A rehabilitation program may involve:

  • PDE5 inhibitor medication where appropriate
  • Vacuum erection therapy
  • Penile injection therapy
  • Regular sexual stimulation
  • Early assessment and management of erectile dysfunction

The appropriate program depends heavily on whether surgery was bilateral nerve sparing, unilateral nerve sparing or completely non-nerve sparing.

It is therefore important that expectations are realistic.

After complete bilateral nerve removal, rehabilitation cannot make the removed nerves grow back. Instead, treatment focuses on maintaining penile health and providing alternative ways of achieving an erection.

Can the surgeon decide during the operation whether to spare the nerves?

Sometimes.

The intended degree of nerve sparing is usually planned before surgery using information from:

  • Prostate MRI
  • Prostate biopsy
  • PSA
  • Clinical examination
  • Location and volume of cancer
  • Gleason score and ISUP Grade Group
  • Estimated risk of extraprostatic extension
  • The patient’s existing erectile function
  • The patient’s priorities regarding cancer control and sexual function

However, the final surgical approach may occasionally need to be modified according to findings encountered during the operation.

The most important objective remains adequate removal of the cancer.

Does non-nerve-sparing surgery improve cancer cure rates?

Not every patient benefits from wider surgery.

For men with cancer safely confined within the prostate, unnecessary removal of the neurovascular bundles may produce significant functional consequences without providing additional cancer benefit.

Conversely, when cancer is suspected of extending close to or beyond the prostate capsule adjacent to a neurovascular bundle, wider excision may reduce the risk of leaving tumour at the surgical margin.

This is why the decision must be individualised.

The best operation is not automatically the operation that preserves the most nerves. It is the operation that provides appropriate cancer clearance while preserving as much normal function as can safely be preserved.

What about urinary continence?

Nerve sparing primarily relates to erectile function, rather than the urinary sphincter responsible for continence.

Urinary control after radical prostatectomy depends on several factors including:

  • Age
  • Pre-operative urinary function
  • Pelvic floor strength
  • Urethral length
  • Bladder function
  • Surgical anatomy and technique
  • Previous prostate treatments
  • Individual healing

Pelvic floor rehabilitation before and after surgery can be an important part of recovery.

Non-nerve-sparing surgery does not automatically mean that a patient will remain incontinent.

Questions worth asking before surgery

If a non-nerve-sparing robotic prostatectomy has been recommended, useful questions to discuss with your urologist include:

Why is nerve preservation considered unsafe in my particular cancer?

Is the concern on one side or both sides of the prostate?

Could unilateral or partial nerve sparing be considered?

What does my MRI show about the relationship between the cancer and neurovascular bundles?

What is my estimated chance of erectile recovery with the proposed operation?

What erectile rehabilitation options will be available after surgery?

Should I consider sperm banking before treatment?

These conversations are particularly important because the decision to remove a neurovascular bundle is generally irreversible.

The important message

A non-nerve-sparing robotic-assisted radical prostatectomy is not an inferior version of nerve-sparing surgery.

In the right patient, it is a deliberate cancer-control strategy.

When prostate cancer is close to or suspected of involving the tissues surrounding the prostate, preserving the erectile nerves too aggressively may risk leaving cancer behind.

Modern robotic surgery allows the operation to be tailored to the individual patient. Some men can undergo bilateral nerve preservation, others may benefit from preservation on only one side, while patients with more extensive disease may require a wider non-nerve-sparing excision.

The consequences for erectile function are important and should be understood before surgery.

Once the neurovascular nerves have been removed, the procedure cannot be reversed.

However, loss of spontaneous erections does not mean the end of sexual intimacy. Vacuum devices, penile injection therapy and penile prostheses can provide effective options when natural erections are no longer possible.

Ultimately, the aim is to achieve the best possible balance between two important goals:

Effective treatment of the prostate cancer and preservation of quality of life.

A note for patients

Every prostate cancer is different. MRI findings, biopsy results, PSA, cancer grade, age, general health, pre-existing erectile function and personal priorities all influence the appropriate surgical approach.

A detailed discussion with your urologist before robotic prostatectomy is essential so that you understand whether nerve sparing is appropriate, what degree of nerve preservation may be possible and what this means for cancer control, continence and sexual function.

This information is intended for general patient education and does not replace individual medical advice. Treatment recommendations should be based on your individual prostate cancer characteristics, imaging, pathology, general health and discussion with your treating urologist.