Prostatic Urethral Lift: A Minimally Invasive BPH Solution

Benign prostatic hyperplasia (BPH) is a common condition in aging men, leading to troublesome urinary symptoms due to prostate enlargement. Traditional treatments range from medications to invasive surgeries, but not all patients tolerate or prefer these options. A prostatic urethral lift offers a minimally invasive alternative that relieves symptoms while preserving sexual function and reducing recovery time.

Prostate Gland Configuration

The prostate gland, a walnut-sized organ below the bladder, encircles the urethra as it exits the bladder neck. Its structure directly affects urinary function, as enlargement can obstruct urine flow. The transition zone, surrounding the prostatic urethra, is the primary site of hyperplastic growth in BPH, leading to urethral compression and lower urinary tract symptoms (LUTS).

The prostate’s fibromuscular stroma and glandular tissue allow it to contract and relax in response to autonomic nervous system signals. In BPH, excessive tissue proliferation within the transition zone causes mechanical obstruction. The degree of obstruction depends on the size and orientation of the enlarged tissue. Some cases involve lateral lobe hypertrophy, while others feature median lobe overgrowth extending into the bladder outlet, further complicating urinary flow.

The prostate receives blood supply primarily from the inferior vesical artery, a branch of the internal iliac artery. Increased vascularization in BPH can contribute to tissue congestion and exacerbate symptoms. Smooth muscle fibers interwoven with glandular elements allow pharmacologic treatments, such as alpha-blockers, to provide temporary relief by relaxing these fibers, though they do not resolve the underlying obstruction.

How the Lift Mechanism Works

The prostatic urethral lift (PUL) mechanically separates the lateral lobes to widen the urethral lumen, improving urinary flow without tissue removal. Small, permanent implants exert lateral tension on the obstructing tissue, preserving the gland’s integrity while alleviating compression.

A cystoscopic delivery system ensures precise implant placement under direct visualization. Each implant consists of a nitinol capsular tab connected by a polyethylene suture to a stainless steel urethral end piece. The implant anchors the lateral lobe to the prostatic capsule, retracting obstructive tissue. Most patients receive four to six implants for optimal relief.

Clinical trials, such as the L.I.F.T. study published in Urology, show significant improvements in urinary flow and symptom scores while maintaining erectile and ejaculatory function. Peak urinary flow rate (Qmax) improves by an average of 3–4 mL/s, with symptom severity decreasing by 40–50% based on the International Prostate Symptom Score (IPSS).

Median Lobe Considerations

Prostatic urethral lift procedures primarily target lateral lobe hypertrophy, but an enlarged median lobe presents a distinct challenge. Unlike lateral lobe overgrowth, which compresses the urethra from the sides, median lobe enlargement extends into the bladder outlet, potentially creating a ball-valve effect that obstructs urinary flow. This can lead to pronounced LUTS, including urgency, incomplete emptying, and nocturia.

The effectiveness of the lift mechanism in median lobe cases depends on tissue pliability. In some patients, the median lobe can be retracted laterally by the implants, but in cases of rigid or extensive protrusion, the lift alone may be insufficient. Studies indicate that while the lift effectively addresses lateral lobe hypertrophy, median lobe involvement often requires alternative treatments such as transurethral resection or laser enucleation.

Tissue Responses to the Implant

Once the implants are placed, the prostate undergoes structural and cellular adaptations. The immediate effect is lateral lobe separation, alleviating urethral compression. Over time, fibroelastic remodeling stabilizes the expanded configuration, maintaining urethral patency without significant fibrotic overgrowth.

Histological examinations show minimal foreign body reaction, indicating that the materials—nitinol, stainless steel, and polyethylene—are well tolerated. Unlike thermal ablation techniques, which cause coagulative necrosis and tissue sloughing, the lift preserves glandular and stromal integrity. This reduces postoperative scarring and minimizes edema, promoting faster recovery and lowering the risk of transient urinary retention.

Postprocedure Anatomical Adjustments

Following implant placement, the prostate adapts structurally, maintaining its architecture while redistributing pressure away from the urethra. The adjustment begins with immediate urethral expansion, followed by longer-term stabilization as the tissue conforms to the implants.

The lateral lobes remain retracted due to sustained outward tension, preventing gradual urethral reocclusion. Imaging studies, including MRI and ultrasound, confirm that the widened urethral lumen persists for years, with minimal implant migration or displacement. The absence of thermal or excisional trauma reduces postoperative scarring, ensuring sustained symptom relief. Clinical follow-ups show consistent LUTS improvement, with benefits maintained for over five years.