BPH

• Balloon Dilation
  • Variable balloon lengths and diameters are available
  • Dilatation was carried out over 5 to 20 min with a pressure of 2 to 5 atmospheres.
  • Treatment was performed under local or short general anesthesia
  • Improvement rates of 84 to 14.3 percent were reported.
  • This treatment has fallen out of favor.
• Prostatic Urethral Stents
  • Many types available and many have been withdrawn from use
  • Best implanted by endoscopic control
  • Stents may be biodegradable, temporary, or permanent.
    • The optimal result would be a stent completely covered by urothelium, making encrustation impossible.
  • Alleviation of voiding symptoms has periodically been reported in up to 85 percent of patients in the short term, with corresponding improvement in objective parameters as well.
  • Currently, stents are thought to provide an alternative for patients for short-term management or for long-term management in patients unfit for surgical relief and who would otherwise have an indwelling Foley catheter.
  • Removal of the stent can be difficult, and there is concern regarding potential long-term results and interference with subsequent procedures, if required..
• Resection and Modalities Producing Vaporization or/and Coagulation Necrosis
  • Traditional electrocautery, laser, microwave, and radiofrequency energy can be utilized to resect, vaporize, or cause coagulation necrosis of prostatic tissue.
    • At temperatures lower than 45°C, coagulation necrosis of normal tissue does not occur.
    • Irreversible cellular damage begins to occur above 45°C.
      • Coagulation can take up to an hour to occur at temperatures minimally above this level.
    • At 60°C to 100°C, coagulation is rapid and at 100°C is virtually instantaneous.
    • At temperatures higher than 100°C, tissue vaporization is produced.
• Microwave Thermotherapy
  • Transurethral modality
  • Uses microwave energy to produce temperatures of 45°C to 60°C in the transitional zone of the prostate
    • Results in coagulation necrosis occurring over an hour or so, the usual duration of treatment.
    • The urethral urothelium is cooled via a "jacket" around the catheter
    • Rectal temperature is continuously monitored
    • Variables include the microwave frequency and intensity and the shape and size of the microwave antenna.
    • Minimal erectile dysfunction, stricture, and incontinence have been reported. Mild ejaculation problems have been reported in 0 to 44 percent of treated patients.
• Laser Prostatectomy
  • The tissue effects of laser energy are produced by:
    • The virtually instantaneous attainment of temperatures higher than 60°C creating coagulation necrosis
    • Temperatures above 100°C to create vaporization.
    • There seems to be little difference in the results of coagulation versus vaporization, except for a slight advantage in Qmax improvement at 12 months following vaporization.
• Potential advantages of Laser over TURP:
  • A shorter surgery
  • Fewer complications including sexual dysfunction and stricture
  • A quicker recovery
  • Equivalent results
  • Less bleeding
    • This is definitely an advantage in anticoagulated patients.
• Potential disadvantages as compared to TURP:
  • Lack of tissue for pathologic analysis (except for the Ho:YAG laser),
  • A delayed time to voiding
  • Postoperative filling and storage symptoms for up to 2 to 3 months
  • Lower QMAx improvement.
• The types of laser utilized for clinical BPH treatment include:
  • Neodynium yytrium garnet (Nd:YAG).
    • This is generally applied transurethrally through contact or noncontact fibers.
    • At low power density, this laser penetrates deeply and produces coagulation necrosis.
    • At higher energy levels, vaporization and coagulation occur.
    • Interstitial fibers can also be placed to produce coagulation necrosis with interstitial application;
      • Post procedure, the lesions result in secondary atrophy and regression of the prostatic "lobes."
      • Internal scarring with retraction of the periurethral tissue also probably occurs.
  • Semiconductor diode.
    • This can be used with either a free beam low energy technique or an interstitial technique
  • Potassium titanyl phosphate laser (KTP).
    • This uses a free beam treatment with high energy density to create vaporization without concurrent deep coagulation.
  • Pulsed holmium:YAG.
    • This causes thermomechanical vaporization and can be used as a cutting tool.
• Needle Electrode Delivered Radiofrequency
  • Mechanism:
    • Interstitial placement of a radiofrequency delivery electrode creates tissue heating due to the resistance to the current as it flows from an active electrode through the tissue to an indifferent electrode.
    • Transurethral needle ablation (TUNA) creates temperatures of 60°C to 100°C during treatment times of 5 to 7 min to produce zones of coagulation necrosis.
    • Potential advantages:
      • No catheter requirement afterward as an advantage
      • But up to 20 to 40 percent of patients experience urinary retention lasting 2 to 3 days.
      • Minimal complications:
  • Hematuria is reported as minor.
  • Sexual dysfunction and stricture are rare.
• Electrosurgical Resection and Vaporization
  • Mechanism:
    • This technique uses a resection loop and electrosurgical generator capable of delivering cutting and coagulating current.
    • The lower voltage continuous cutting wave form instantaneously vaporizes a path through the tissue and does not result in significant coagulation.
      • The coagulation current consists of short segments of higher voltage lower current energy, resulting in deeper penetrative heating and hemostasis.
      • New resection loops have been developed that can be used at higher cutting wattages to create increased hemostasis.
      • For electrovaporization, a higher monopolar cutting wattage is used to vaporize surface tissue and cause simultaneous coagulation beneath.
        • The dessicated base, however, is less susceptible to further vaporization.
  • TURP
    • Remains the standard for comparison for treatment.
    • Literature controversies over past 10 years:
      • Mortality rate of 2.5 percent within 90 days after surgery
      • Requirement for reresection of about 2 percent per year or 16 percent at 8 years when compared with open prostatectomy.
      • The relative risk of death was 1.45 at up to 5 years after TURP
      • The risk of reoperation was approximately double.
      • Nevertheless, these criticisms have not been confirmed and significant methodological issues have been raised regarding the initial data analysis.
  • Transurethral Vaporization (TUVP) of the Prostate
    • This technique uses familiar electrosurgical technology and TURP-like maneuvers-
      • The learning curve is short.
      • The ease and results of therapy are highly dependent on the generator utilized.
      • Potential advantages compared to TURP:
        • Decreased blood loss
        • Decreased catheter time
        • Decreased hospital stay.
      • Potential disadvantages compared to TURP
        • The operative time is longer
        • The technique is most applicable to prostates weighing less than 50 g.
      • Sexual side effects and incontinence rates are similar to those following TURP
  • Electrosurgical Incision of the Bladder Neck and Prostate (TUIBN-P)
    • This transurethral technique is most useful in those patients with a smaller prostate (weighing 30 g or less)
      • Based on historical statistics, nearly 80 percent of patients undergoing TURP in the United States have less than 30 g of tissue resected
    • It is probably an underutilized technique
    • Potential advantages compared to TURP
      • Quicker
      • Technically easier
      • Results similar as with TURP (global improvement rates slightly less).
      • The incidence of reported complications is lower:
        • Incontinence 0 to 1 percent
        • Impotence 0 to 4 percent
        • Retrograde ejaculation 15 to 40 percent
        • Bladder neck contracture 1 percent.
• High Intensity Focused Ultrasound (HIFU)
  • Mechanism:
    • This is a form of interstitial thermal ablation achieved by heating tissue to temperatures above 70°C.
    • Achieved by directing ultrasonic energy with a transrectal probe.
      • Creates an area of coagulation necrosis resulting from many overlapping focal lesions.
  • Complications:
    • Urinary retention
    • Infection
    • Epididymitis
  • Clinical trials are ongoing.
• Water-Induced Thermotherapy
  • Mechanism:
    • This involves circulating 60°C water through a transurethral intraprostatic balloon
  • Reportedly requires no anesthesia
  • Initial trials report significant improvements in Qmax and reduction in AUA symptom scores
  • Clinical trials are ongoing.
• Ethanol Interstitial Injection
  • This involves the transurethral injection of ethanol into the prostate to create an ovoid space of necrosis.
  • Clinical trials are planned.

References

• Abrams P: In support of pressure-flow studies for evaluating men with lower urinary tract symptoms. Urology 44:153-155, 1994.
• Ball AJ, Fenely RCL, Abrams PH: The natural history of untreated "prostatism " Br J Urol 53:613-616, 1981.
• Barry MJ: Epidemiology of benign prostatic hyperplasia. AUA Update Series 16:274-279, 1997.
• Barry MJ, Fowler FJ, Bin L, et al: The natural history of patients with benign prostatic hyperplasia as diagnosed by North American urologists. J Urol 157:10-15, 1997.
• Barry MJ, Fowler FJ, Jr., O'Leary MP, and the Measurement Committee of the AUA: The American Urological Association symptom index for benign prostatic hyperplasia. J Urol 148:1549-1557, 1992.
• Barry MJ, Williford WO, Chang Y, et al: Benign prostatic hyperplasia specific health status measures in clinical research: How much change in the AUA symptom index and the BPH impact index is perceptible to patients? J Urol 154:1770-1774, 1995.
• Blaivas J: The bladder is an unreliable witness. Neurourol Urodyn 15:443-445, 1996.
• Denis L, Griffiths K, Khoury S, et al, eds. 4th International Consultation on Benign Prostatic Hyperplasia (BPH). Plymouth, United Kingdom, Plymbridge Distributors, Ltd., 1998.

  Chapter 3: Regulation of prostatic growth. Cockett ATK, Coffey D, DiSant Agnese A, et al.
  Chapter 5: Initial evaluation of LUTS. Artibani W, Correa R, Desgranchamps F, et al.
  Chapter 6: Quantification of symptoms, quality of life and sexuality. Adolfsson J, Barry M, Batista JE, et al.
  Chapter 7: The urodynamics of LUTS. Abrams P, Buzelin JM, Griffiths D, et al.
  Chapter 10: Interventional therapy. Altwein J, Baba S, Blute M, et al. Chapter 11: Endocrine treatment. Akaza H, Bartsch G, Calais daSilva F, et al. Chapter 12: Alpha-blocker therapy. AldoBono V, Andersson KE, Chapple C, et al.
  Chapter 15: BPH 1997-New treatment strategy. ElHilali M, Kirby R, McConnell J.
  Lepor H, Williford WO, Barry MJ, et al: The efficacy of terazosin, finasteride, or both in BPH. N Engl J Med 335:533-539, 1996.

• McConnell J: Why pressure flow studies should be optional and not mandatory for evaluating men with benign prostatic hyperplasia. Urology 44:156-158, 1994.
• McConnell JD, Barry MJ, Bruskewitz R, et al: Benign prostatic hyperplasia: Diagnosis and treatment. Clinical Practice Guideline, no. 8, AHCPR publication No. 94-0582, Rockville, Md., Agency for Health Care Policy Research, Public Health Service, US Dept. Of Health and Human Services, 1994.
• Walsh PC, Retik AB, Vaughan ED Jr., Wein AJ, eds: Campbell's Urology, 7th ed. Philadelphia, Saunders Company, 1998. Chapter 45: The molecular biology, endocrinology, and physiology of the prostate and seminal vesicles. Partin AW, Coffey DS.

  Chapter 46: Epidemiology, etiology, pathophysiology, and diagnosis of benign prostatic hyperplasia. McConnell JD.
  Chapter 47: Natural history, evaluation, and nonsurgical management of benign prostatic hyperplasia. Lepor H.
  Chapter 48: Minimally invasive treatment of benign prostatic hyperplasia. McCullough DL.
  Chapter 49: Transurethral surgery. Mebust WK.

• Wasson JH, Reda DJ, Bruskewitz RC, et al: A comparison of transurethral surgery with watchful waiting for moderate symptoms of BPH. N Engl J Med 332:75-79,1995.
• Wein AJ: Criteria for assessing outcome following intervention for benign prostatic hyperplasia. In: Lepor H, ed. Prostatic Diseases. Philadelpha, Saunders, 1999, pp 210-231.

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