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1 Laser therapy Several different coagulation necrosis techniques have been utilized Transurethral laser-induced prostatectomy (TULIP) is performed under transrectal ultrasound guidance The instrument is placed in the urethra and transrectal ultrasound is used to direct the device as it is slowly pulled from the bladder neck to the apex The depth of treatment is monitored with ultrasound Most urologists prefer to use visually directed laser techniques Visual coagulative necrosis is performed under cystoscopic control, and the laser fiber is pulled through the prostate at several designated areas depending upon the size and configuration of the gland Four-quadrant and sextant
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1 Transurethral resection of the prostate (TURP) Ninety-five percent of simple prostatectomies can be performed endoscopically Most of these procedures are performed under a spinal anesthetic and require a 1- to 2-day hospital stay Symptom scores and flow rate improvement are superior following TURP relative to any minimally invasive therapy; however, the length of the hospital stay is greater Much controversy revolves around possible higher rates of morbidity and mortality associated with TURP in comparison with open surgery, but the higher rates observed
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dard loop, this procedure usually takes longer than a standard TURP Long-term comparative data are needed 4 Hyperthermia Microwave hyperthermia is most commonly delivered with a transurethral catheter Some devices cool the urethral mucosa to decrease the risk of injury However, if temperatures do not go above 45 C, cooling is unnecessary Symptom score and flow rate improvement are obtained, but (as with laser surgery) large randomized studies with long-term follow-up are needed to assess durability and cost-effectiveness
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Andriole GL et al Safety and tolerability of the dual 5-alphareductase inhibitor dutasteride in the treatment of benign prostatic hyperplasia Eur Urol 2003 Jul;44(1):82 8 [PMID: 12814679] AUA Practice Guidelines Committee AUA guideline on management of benign prostatic hyperplasia (2003) 1: Diagnosis and treatment recommendations J Urol 2003 Aug;170(2 Pt 1):530 47 [PMID: 12853821] Bent S et al Saw palmetto for benign prostatic hyperplasia N Engl J Med 2006 Feb 9;354(6):557 66 [PMID: 16467543] Djavan B et al Benign prostatic hyperplasia progression and its impact on treatment Curr Opin Urol 2004 Jan;14(1):45 50 [PMID: 15091050] Kaplan SA Use of alpha-adrenergic inhibitors in treatment of benign prostatic hyperplasia and implications on sexual function Urology 2004 Mar;63(3):428 34 [PMID: 15028431] Kortmann BB et al Urodynamic effects of alpha-adrenoceptor blockers: a review of clinical trials Urology 2003 Jul;62(1):1 9 [PMID: 12837408] McConnell JD et al; Medical Therapy of Prostatic Symptoms (MTOPS) Research Group The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia N Engl J Med 2003 Dec 18;349(25):2387 98 [PMID: 14681504] O Leary MP Lower urinary tract symptoms/benign prostatic hyperplasia: maintaining symptom control and reducing complications Urology 2003 Sep;62(3 Suppl 1):15 23 [PMID: 12957196] Schulman CC Lower urinary tract symptoms/benign prostatic hyperplasia: minimizing morbidity caused by treatment Urology 2003 Sep;62(3 Suppl 1):24 33 [PMID: 12957197] Thorpe A et al Benign prostatic hyperplasia Lancet 2003 Apr 19;361(9366):1359 67 [PMID: 12711484] Wilt TJ et al Tamsulosin for benign prostatic hyperplasia Cochrane Database Syst Rev 2003;(1):CD002081 [PMID: 12535426]
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approaches have been described for lateral lobes, with additional treatments directed at enlarged median lobes Coagulative techniques do not create an immediate visual defect in the prostatic urethra tissue is sloughed over the course of several weeks up to 3 months following the procedure Visual contact ablative techniques take longer in the operating room because the fiber is placed in direct contact with the prostate tissue, which is vaporized A new laser technique that is gaining popularity is photovaporization of the prostate (PVP) using a high-power KTP laser An immediate defect is obtained in the prostatic urethra, similar to that seen during TURP Interstitial laser therapy places fibers directly into the prostate, usually under cystoscopic control Irritative voiding symptoms may be less in these patients as the urethral mucosa is spared and prostate tissue is resorbed by the body rather than sloughed Advantages to laser surgery include minimal blood loss, rare occurrence of transurethral resection syndrome, the ability to treat patients while on anticoagulation therapy, and outpatient surgery Disadvantages are the lack of tissue for pathologic examination, the longer postoperative catheterization time, the more frequent irritative voiding complaints, and the expense of laser fibers and generators Large multicenter, randomized studies with long-term follow-up are needed in comparing laser prostate surgery with TURP and other forms of minimally invasive surgery 2 Transurethral needle ablation of the prostate (TUNA) This procedure uses a specially designed urethral catheter that is passed into the urethra Interstitial radiofrequency needles are then deployed from the tip of the catheter, piercing the mucosa of the prostatic urethra Radiofrequencies are then used to heat the tissue, resulting in coagulative necrosis Bladder neck and median lobe enlargement are not well treated by TUNA Subjective and objective improvement in voiding occurs In randomized trials comparing TUNA to TURP, similar improvement was seen when comparing life scores, peak urinary flow rates, and postvoid residual urine 3 Transurethral electrovaporization of the prostate This technique uses the standard resectoscope High current densities result in heat vaporization of tissue, creating a cavity in the prostatic urethra Because the device requires slower sweeping speeds over the prostatic urethra and the depth of vaporization is approximately one-third of a stan-
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