Minimally invasive treatment for BPH

• Minimally invasive treatment for BPH

• Urologists have been trying to develop other therapies to decrease the amount of obstructing prostate tissue while avoiding the above-mentioned adverse effects associated with TURP. These therapies are collectively called minimally invasive therapies.

• Most minimally invasive therapies rely on heat to cause destruction of prostatic tissue; however, this heat is delivered in a limited and controlled fashion with the hope that the complications associated with TURP may be avoided. They also allow for the use of milder forms of anesthesia, which translates into less anesthetic risk for the patient.

• Heat may be delivered in the form of laser energy, microwaves, radiofrequency energy, high-intensity ultrasound waves, and high-voltage electrical energy. Delivery devices are usually similarly passed through a working sheath placed in the urethra, although they are usually of a smaller size than that needed for TURP. Devices may also simply be attached or incorporated into a urinary catheter or passed through the rectum, from which the prostate may also be accessed.

• Keep in mind that many of these minimally invasive therapies are undergoing constant improvements and refinements resulting in increased efficacy and safety. Ask urologists about the specifics of the minimally invasive therapies that they use and what results they have experienced.

• Transurethral incision of the prostate (TUIP) has actually been in use for many years and, for a long time, was the only alternative to TURP. It may be performed with local anesthesia and sedation.
  • TUIP is suitable for patients with small prostates and for patients unlikely to tolerate TURP well because of other medical conditions.
  • TUIP is associated with less bleeding and fluid absorption compared to TURP. It is also associated with a lower incidence of retrograde ejaculation and impotence compared to TURP.
• Lasers deliver heat to the prostate in a variety of ways.
  • They may be used to directly evaporate, ie, melt away prostate tissue. They may also be used in a manner in which the laser is not actually in direct contact with the prostate but delivers heat energy into the prostate, resulting in cell death of the prostate tissue. Laser fibers may first be placed directly into the prostate tissue and then turned on, releasing energy into the tissue. All these laser treatments essentially cause thermal destruction of prostate tissue (coagulation necrosis). Over time, this destroyed tissue then contracts, with resultant decreased prostatic volume.
  • Lasers may be used in a knifelike fashion to directly cut away prostate tissue, similar to a TURP procedure.
  • Laser treatment usually results in decreased bleeding, fluid absorption, length of hospital stay, and incidence of impotence and retrograde ejaculation when compared to standard TURP; however, in patients in whom lasers are used for thermal destruction (coagulation necrosis), they may cause significant swelling of the prostate, resulting in prolonged catheterization after the procedure. Additionally, because treating tissue with a laser involves a time interval during which dead cells slough and healing follows, patients may experience urinary urgency or an irritation, resulting in frequent or uncomfortable urination for some weeks.
  • The results of laser therapy are variable in that many lasers are being used in many different ways. They usually bring about more relief of urinary symptoms than treatment with medicines, but not quite as much as provided by a TURP procedure.
  • A laser treatment in which the laser is used to excise prostate tissue like a knife (in a fashion similar to TURP) has recently been shown to be as effective as TURP.
• The use of microwave energy, termed transurethral microwave therapy (TUMT), delivers heat to the prostate via a urethral catheter or a transrectal route.
  • The surface closest to the probe (the rectal or urethral surface) is cooled to prevent injury. The heat causes cell death, with subsequent tissue contraction, thereby decreasing prostatic volume.
  • TUMT can be performed in the outpatient setting with local anesthesia.
  • Microwave treatment appears to be associated with significant prostatic swelling; a considerable number of patients require replacement of a urinary catheter until the swelling somewhat subsides. In terms of efficacy, TUMT places between medical therapy and TURP.
• Transurethral needle ablation of the prostate (TUNA) involves using high-frequency radio waves to produce heat, resulting in a similar process of thermal injury to the prostate as previously described. A specially designed transurethral device with needles is used to deliver the energy.
  • TUNA can be performed under local anesthesia, allowing the patient to go home the same day.
  • Similar to microwave treatment, radiofrequency treatment is quite popular, and a number of urologists have experience with its use.
  • Radiofrequency treatment appears to reliably result in significant relief of symptoms and better urine flow, although not quite to the extent achieved with TURP.
• High-intensity ultrasound energy therapy delivers heat to prostate tissue, with the subsequent process of thermal injury.
  • High-intensity ultrasound waves may be delivered rectally or extracorporeally and can be used with the patient on intravenous sedation.
  • Urinary retention appears to be common with its use.
  • High-intensity ultrasound energy also produces moderate results in terms of improvement of the urinary flow rate and urinary symptoms, although its use is now relatively limited compared to the more popular TUNA and TUMT.
• Water-induced thermotherapy is a relatively new procedure in which heated water is circulated through a balloon in the prostatic urethra, thus initiating a process of thermal destruction of prostate tissue.
  • Only local anesthesia is needed.
  • Further analysis of outcomes of patients treated with this procedure is needed before an assessment of its efficacy and its place in the treatment of BPH can be determined. Optimal results may not be apparent for 3-4 months after the procedure.
• Mechanical approaches are used less commonly and are usually reserved for patients who cannot have a formal surgical procedure. Mechanical approaches do not involve the use of energy to treat the prostate.
  • Prostatic stents are flexible devices that can expand when put in place to improve the flow of urine past the prostate. Their use has been associated with encrustation, pain, incontinence, and overgrowth of tissue through the stent, possibly making their removal quite difficult. To date, their full role and long-term effects are not fully known.
  • Balloon dilation involves transurethral placement of a balloon, which is then inflated with the intent of expanding the prostatic urethra. Balloon dilation has largely been abandoned. Efficacy has not been demonstrated with this procedure.