A PROSPECTIVE, RANDOMIZED 1-YEAR CLINICAL TRIAL COMPARING TRANSURETHRAL NEEDLE ABLATION TO TRANSURETHRAL RESECTION OF THE PROSTATE FOR THE TREATMENT OF SYMPTOMATIC BENIGN PROSTATIC HYPERPLASIA

Purpose

We assess the 1-year efficacy and safety of transurethral needle ablation of the prostate compared to transurethral resection of the prostate for the treatment of symptomatic benign prostatic hyperplasia (BPH).

Materials and Methods

A prospective, randomized clinical trial of 121 men 50 years old or older with symptomatic BPH was performed at 7 medical centers across the United States. Of the men 65 (54%) were treated with transurethral needle ablation of the prostate and 56 (46%) underwent transurethral resection of the prostate. Mean and percentage changes from baseline and between cohorts for American Urological Association (AUA) symptom score, AUA bother score, quality of life score, peak urinary flow rate and post-void residual urine volume were measured at 1, 3, 6 and 12 months following treatment. Length of procedure, hospitalization, type of anesthesia, post-procedure catheterization, side effects and sexual function were compared.

Results

Transurethral needle ablation and resection resulted in a statistically significant improvement in AUA symptom, bother and quality of life scores, peak urinary flow rate and post-void residual. At 1-year followup, needle ablation and resection were equally effective in enhancing quality of life. Needle ablation had less effect on sexual function, with resection being associated with a greater incidence of retrograde ejaculation. Needle ablation could be performed as an outpatient procedure with local anesthesia while resection required anesthesia and hospitalization. Needle ablation was associated with markedly fewer side effects than resection.

Conclusions

Compared to transurethral resection of the prostate, transurethral needle ablation of the prostate is an efficacious, minimally invasive treatment for symptomatic BPH that is associated with few side effects.     

Transurethral Evaporation of the Prostate for Treatment of Benign Prostatic Hyperplasia: Results in 168 Patients With up to 12 Months of Followup

Purpose

We assessed the safety and efficacy of transurethral evaporation of the prostate for the treatment of symptomatic benign prostatic hyperplasia (BPH).

Materials and Methods

A total of 168 patients with symptomatic BPH underwent transurethral evaporation of the prostate. Peak flow rate, American Urological Association symptom index and post-void residual were assessed at baseline, and at 3, 6 and 12 months of followup.

Results

We found a statistically significant decrease in mean American Urological Association symptom index from 20.6 at baseline to 7.2 at 12 months (mean difference 13.4, 65% reduction, p <0.0001). We also found a statistically significant improvement in mean peak flow rate from 8.2 to 18.2 cc per second, respectively (mean difference 10, 122% increase, p <0.0001). The most frequent complications were irritative voiding symptoms in 22.6% of patients and urinary tract infections in 4.8%. There were no additional major complications.

Conclusions

From these results transurethral evaporation of the prostate appears to be safe and effective for treatment of BPH at 12 months of followup.     

THE EFFECTS OF TRANSURETHRAL NEEDLE ABLATION AND RESECTION OF THE PROSTATE ON PRESSURE FLOW URODYNAMIC PARAMETERS: ANALYSIS OF THE UNITED STATES RANDOMIZED STUDY

PURPOSE: We evaluated the effects of transurethral needle ablation and prostate resection on pressure flow urodynamic parameters in men with benign prostatic hyperplasia (BPH), compared symptomatic and objective parameters of efficacy 6 months after initial treatment, and determined whether urodynamic assessment may predict symptomatic improvement. MATERIALS AND METHODS: We enrolled 121 patients with clinical BPH, American Urological Association symptom index of 13 or greater and maximum urinary flow of 12 ml. per second or less in a randomized study comparing transurethral needle ablation to prostate resection at 7 institutions in the United States. Patients underwent baseline and followup assessments at 6 months, including pressure flow studies. RESULTS: Patients who underwent each procedure had statistically and clinically significant improvement in symptom index, BPH impact index and quality of life score. After needle ablation and prostate resection maximum flow improved from 8.8 to 13.5 (p<0.0001) and 8.8 to 20.8 ml. per second (p<0.0001), detrusor pressure at maximum flow decreased from 78.7 to 64.5 (p = 0.036) and 75.8 to 54.9 cm. water (p<0.001), and the Abrams-Griffiths number decreased from 61.2 to 37.2 (p<0.001) and 58.3 to 10.9 (p<0.001), respectively. At 6 months the differences in transurethral needle ablation and prostate resection were significant in terms of maximum flow (p<0.001) and the Abrams-Griffiths number (p<0.001) but not detrusor pressure at maximum flow or symptom assessment tools. The presence or absence of urinary obstruction at baseline did not predict the degree of symptomatic improvement in either treatment group. CONCLUSIONS: Transurethral needle ablation and prostate resection induce statistically and clinically significant improvement in various quantitative symptom assessment questionnaires at 6 months. The parameters of free flow rates and invasive pressure flow studies also significantly improve after each treatment. However, transurethral prostate resection induces a significantly greater decrease in the parameters of obstruction. Baseline urodynamic parameters do not predict the degree of symptomatic improvement and they may not be helpful in patient selection for transurethral needle ablation.     

A prospective study of transperineal prostatic block for transurethral needle ablation for benign prostatic hyperplasia: the Emory University Experience.

PURPOSE: We evaluate the feasibility, effectiveness and role of transperineal prostate block in providing anesthesia during minimally invasive radio frequency thermal therapy of the prostate. MATERIALS AND METHODS: A total of 38 consecutive patients undergoing transurethral needle ablation for symptomatic benign prostatic hyperplasia were entered in this prospective study. All patients received transperineal prostatic block as the main method of anesthesia. A mixture of equal volumes of 1% lidocaine and 0.25% bupivacaine, each with epinephrine (1:100,000 concentration ratio) was used. Pain control during the instillation of transperineal prostatic block and transurethral needle ablation was assessed using a 10-point linear analog pain scale and questionnaire. RESULTS: Median patient age was 65.5 years (range 47 to 79), with 21% of men in the eighth decade of life. Median American Urological Association symptom score was 25.0 (range 14 to 35), bother score was 20.0 (11 to 28), quality of life score was 4.0 (3 to 6) and peak urinary flow rate was 8.9 cc per second (3.5 to 15.7). Median sonographic prostate volume was 35.0 cc (range 17 to 129). Median volume of anesthetic agent used was 40.0 cc (range 30 to 60) per case (1.1 cc solution per 1 cc prostate tissue). No adverse events were encountered. Median pain score was 3.3 (range 1 to 6) during instillation of transperineal prostatic block and 1.0 (0 to 6) during transurethral needle ablation. Transperineal prostatic block proved highly effective and was a satisfactory method of anesthesia during transurethral needle ablation as judged by postoperative questionnaire. No sedation, narcotic or analgesia was required. All procedures were performed in the outpatient cystoscopy suite or office setting without support of an anesthesia team or conscious sedation monitoring. CONCLUSIONS: Transperineal prostatic block is a safe, convenient, effective and satisfactory method of minimally invasive anesthesia for transurethral needle ablation of the prostate in an outpatient office setting. Elderly patients and those at high surgical risk can be treated safely using this approach. Considerable cost saving is seen secondary to omission of charges related to anesthesia team support, recovery room facility and conscious sedation monitoring.     

A Statistical Study of the American Urological Association Symptom Index for Benign Prostatic Hyperplasia in Participants of Mass Screening Program for Prostatic Diseases using Transrectal Sonography

Purpose

A study was done on the prevalence of urinary symptoms in community based populations in Japan regarding the influences of aging and benign prostatic hyperplasia (BPH) as evaluated by transrectal sonography.

Materials and Methods

In 961 Japanese men 55 to 87 years old who underwent mass screening for prostatic diseases the American Urological Association symptom index scores were compared with age and ultrasonic diagnosis of the prostate.

Results

Moderate to severe symptoms (symptom score 8 or more) were found in 265 of our 961 samples (27.6 percent), while BPH was also recognized ultrasonically in 197 (20.5 percent). Frequencies of urinary symptoms and BPH increased significantly with age. BPH related increase in total symptom scores occurred only in select men when adjusted by age.

Conclusions

The ability of the American Urological Association symptom index to characterize BPH in an individual was limited because of the lack of specificity to the disease along with the considerable influence of aging on the symptom score. Currently, transrectal sonography is the most reliable method for the definitive diagnosis of BPH.     

Age Related Urodynamic Changes in Patients with Benign Prostatic Hyperplasia

Purpose

We determined age related urodynamic changes in patients with untreated symptomatic benign prostatic hyperplasia (BPH).

Materials and Methods

A total of 222 patients (mean age 67.3 years, range 45 to 90) with the clinical diagnosis of symptomatic BPH was entered into a prospective protocol evaluating the international prostate symptom score (I-PSS), prostate volume, noninvasive uroflowmetry, residual volume and a pressure-flow study. To obtain a homogeneous study population only patients with a noninvasive maximum flow rate of 15 ml. per second or less and an I-PSS of 7 or more were eligible.

Results

There was no correlation between age and I-PSS (p greater than 0.05) but there was a statistically significant decrease in maximum flow rate (p = 0.045) and voided volume (p = 0.0013) with age. Prostate volume increased constantly from 31.3 to 64.4 ml. in patients 45 to 50 and older than 80 years, respectively (p less than 0.0001). Pressure-flow studies revealed an age related decrease in cystometric bladder capacity (p = 0.0003) and invasive maximum flow rate (p = 0.0057) but no changes in detrusor pressure at maximum flow rate (p greater than 0.05), maximum detrusor pressure (p greater than 0.05) and linear passive urethral resistance relation (p greater than 0.05). The incidence of urodynamically proved bladder instability increased from 20 to 47 percent in men 45 to 50 and older than 80 years, respectively.

Conclusions

The well established age related decrease in maximum flow rate and voided volume in patients with prostatism cannot be attributed to an increase in bladder outflow obstruction or impaired detrusor function. Because 60 percent of all men older than 80 years did not have urodynamic obstruction despite a decreased maximum flow rate of 10 to 15 ml. per second, all patients meeting these criteria and having symptoms bothersome enough to justify surgery should undergo pressure-flow studies before surgical intervention.     

A Novel Transurethral Microwave Thermal Ablation System to Treat Benign Prostatic Hyperplasia: Results of a Prospective Multicenter Clinical Trial

Purpose

We evaluated the efficacy, safety and impact on quality of life of a newly designed microwave thermal ablation system in patients with benign prostatic hyperplasia (BPH).

Materials and Methods

Microwave thermal ablation was administered to 154 BPH patients at 3 centers in Canada and the United Kingdom during a single 1 to 2-hour office or clinic procedure without general or regional anesthesia and without need for potent medications necessitating intensive patient monitoring. Various measures of symptoms, voiding function and patient quality of life were assessed at baseline, 6 weeks, and 3, 6, 9 and 12 months after treatment.

Results

Mean American Urological Association symptom score 12 months after treatment (8.8, 95% confidence interval 7.7 to 10.0) was significantly lower (p <0.05) by 56% than that at baseline (20.1, 95% confidence interval 19.1 to 21.0). The incidence of mild symptoms increased from 0 to 57%, while that of severe symptoms decreased from 49 to 8%. There was a significant increase (p <0.05) in peak flow rate of 45% from 9.3 ml. per second (95% confidence interval 8.8 to 9.7) at baseline to 13.4 ml. per second (95% confidence interval 12.5 to 14.4) at 12 months. Similar symptomatic and urodynamic improvements occurred in all prostate volume categories. Convalescence was rapid after treatment with little or no need for home bed rest or restriction of usual activities. Patients expressed a high level of satisfaction with treatment and found the prostate symptoms to be significantly more tolerable. Adverse events were infrequent, transient and readily managed.

Conclusions

Microwave thermal ablation proved to be safe and effective for treatment of BPH with a significant positive impact on patient quality of life.     

Reversible Change of Bladder Hypertrophy Due to Benign Prostatic Hyperplasia After Surgical Relief of Obstruction

Purpose

Ultrasound estimated bladder weight was compared before and after surgery for benign prostatic hyperplasia (BPH) to reveal a possible reversible change in bladder hypertrophy.

Materials and Methods

Ultrasound estimated bladder weight was measured before and after subcapsular (17) or transurethral (16) prostatectomy in 33 male patients with BPH. Sequential changes in the American Urological Association symptom score and urinary flow rate were also examined.

Results

Along with a significant improvement in the American Urological Association symptom scores and maximum flow rate, ultrasound estimated bladder weight decreased from 52.9 +/− 22.6 to 31.6 +/− 15.8 gm. in 12 weeks after treatment. In all but 4 patients (29 of 33, or 87.9%) ultrasound estimated bladder weight decreased to less than 35.0 gm. in 12 weeks after treatment. Interestingly, in all patients with an initial ultrasound estimated bladder weight of greater than 80 gm. the bladder weight still remained at an abnormally high level 12 weeks after treatment.

Conclusion

Bladder hypertrophy was completely reversible after the surgical treatment of the obstruction in the majority of patients with BPH. The measurement of ultrasound estimated bladder weight was of value in monitoring therapeutic effects in BPH patients. An extraordinarily high ultrasound estimated bladder weight of 80 gm. or more might suggest degenerative and irreversible pathological changes in the bladder detrusor.     

The American Urological Association Symptom Index for Benign Prostatic Hyperplasia as a Function of Age, Volume and Ultrasonic Appearance of the Prostate

Purpose

Our study was conducted to reveal quantitatively the relative effects of age and ultrasonic appearance of benign prostatic hyperplasia (BPH) on urinary symptoms as evaluated by the American Urological Association (AUA) symptom index score.

Materials and Methods

In 929 examinees (732 with a normal prostate and 197 with BPH) on a mass screening program for prostatic diseases using transrectal ultrasonography in Japan, the AUA symptom score was compared to age, prostatic volume and presumed circle area ratio using simple and multiple regression analyses.

Results

Simple regression analysis demonstrated the symptom score to correlate significantly with age (R = 0.162, p <0.0001), prostatic volume (R = 0.072, p = 0.0281) and presumed circle area ratio (R = 0.150, p <0.0001). However, multiple regression analysis demonstrated that age and presumed circle area ratio were significant independent determinants of the total symptom score. Among 7 symptoms included in the AUA symptom index weak stream and hesitancy scores were not influenced by age, prostatic volume or presumed circle area ratio.

Conclusions

As a parameter representing the degree of BPH in terms of the severity of urinary symptoms, presumed circle area ratio was preferable to prostatic volume. Regression analyses confirmed again that the AUA symptom index was influenced considerably by age and was not specific to BPH.     

Nerve Block in Prostate Surgery

Purpose

We describe a novel technique for anesthetizing the prostate, which should be used for patients at risk undergoing prostate surgery with general, spinal or epidural anesthesia.

Materials and Methods

Local anesthesia to the prostatic plexus supplemented by monitored anesthesia care was performed on 40 patients with outflow obstruction secondary to an enlarged prostate. Of the patients 34 underwent transurethral resection of the prostate, 5 underwent visual laser ablation and 1 underwent transurethral electrovaporization.A 20 gauge spinal needle was inserted via a suprapubic approach toward the base and apex of the prostate, and guided by the left index finger inserted into the rectum. Lidocaine was injected into the prerectal space. Bulging of the rectal wall caused by the amount of lidocaine injected was appreciated. Insertion into the proper area was essential for a good anesthetic result.

Results

Adequate anesthesia levels could be obtained without major complications. All but 1 patient with poor bladder compliance were rendered free of a Foley catheter. There were no deaths.

Conclusions

This technique has definite advantages for patients who are at risk for prostate surgery with general or spinal anesthesia.     

Prostate Tissue Composition and Response to Finasteride in Men With Symptomatic Benign Prostatic Hyperplasia

Purpose

We sought to quantify prostate tissue changes induced by finasteride and to identify a predictor of finasteride response in men with symptomatic benign prostatic hyperplasia (BPH) via a randomized, placebo controlled, double-blind clinical trial.

Materials and Methods

Men with symptomatic BPH (52 to 78 years old) were randomly assigned to 6 months of treatment with finasteride (26) or placebo (15). Outcome measures were clinical (urinary symptom score and flow rate), chemical (serum prostate specific antigen and dihydrotestosterone levels), volumetric (transrectal ultrasound, and magnetic resonance imaging for whole and zonal prostate volumes) and histological (morphometry of prostate sextant biopsies, separated into inner and outer gland segments, to measure the percent epithelium, stroma and glandular lumen).

Results

In the finasteride group we found a suggestion of decreasing symptom scores and increasing flow rates (not significant) with significant decreases (p <0.01) in prostate specific antigen (48%), dihydrotestosterone (74%) and prostate volume (21%). Finasteride treatment induced a 55% decrease in inner gland epithelium (p <0.01) with little effect on stroma or lumina. We also found a linear correlation between pretreatment inner gland epithelial content and prostate volume decrease induced by the drug (tau = 0.58, p = 0.01).

Conclusions

Finasteride treatment results in a major suppression of prostate epithelium, which is most pronounced in the inner gland. Moreover, a finasteride induced prostate volume decrease was predictable by quantification of epithelial tissues of the inner gland. These data lend additional support to the emerging concept of transition zone primacy in symptomatic BPH.     

Primary results of transurethral prostate ethanol injection

Introduction

Minimally invasive methods, especially the novel techniques, gain more and more popularity in benign prostate hyperplasia (BPH) treatment. Transurethral ethanol injection is one of these novel methods as it is easy to apply for BPH treatment and quite successful. The present study evaluates the results of a single-year transurethral ethanol injection prostate (TUEP) follow-up employed for the first time in our country.

Materials and methods

Fifty-two patients with lower urinary tract symptoms underwent TUEP. It was performed in ten patients under local anesthesia and in 42 patients under sedation. Dehydrated ethanol with a concentration of 95–98 % was injected using transurethral approach with a rigid cystoscope. Forty-two patients were followed for 1 year.

Results

At the end of the first year, the average patients’ IPSS scores decreased from 22.6 to 12.8 and prostate volume from 49.5 to 38.8 cc. Q-average increased from 3.3 to 7.1 ml/s and Qmax from 6.4 to 9.7 ml/s. Residual urine decreased from 160.1 ml to 68 cc. There were not any dire postoperative complications. In 77.8 % of the patients, TUEP succeeded. In 13.8 % of the patients, alternative treatment methods were to be employed.

Conclusion

TUEP, an effective minimally invasive treatment option, can be performed with medically high-risk BPH patients under regional anesthesia. The procedure is easy, inexpensive, safe, and rapid to us. Yet, long-term and multi-centered studies with larger patient series are needed to define further benefits.     

The Early Postoperative Morbidity of Transurethral Resection of the Prostate and oF 4 Minimally Invasive Treatment Alternatives

Purpose

We compared the early postoperative morbidity of transurethral resection of the prostate to minimally invasive treatment alternatives with respect to the objective rate of complications and subjective morbidity assessed by a patients addressed diary-type questionnaire.

Materials and Methods

Parameters evaluated preoperatively were the International Prostate Symptom Score (I-PSS), free flow study, post-void residual, transrectal ultrasonography and a pressure-flow study. The patients underwent transurethral resection reference 28, transrectal high intensity focused ultrasound reference 20, visual laser ablation reference 15, transurethral needle ablation reference 15 and transurethral electrosurgical vaporization reference 17 of the prostate. One the day of hospital discharge the patients received the questionnaire and were asked to answer daily 7 questions concerning micturition status. After 6 weeks the questionnaire was returned and an I-PSS, uroflowmetry and post-void residual were obtained.

Results

Preoperatively, there was no statistically significant difference regarding the I-PSS, peak flow rate, prostate volume and degree of bladder outlet obstruction. After 6 weeks the peak flow rate improved most prominently after transurethral electrosurgical vaporization (+13.2 ml. per second), transurethral resection of the prostate (+12.3 ml. per second) and visual laser ablation (+11.1 ml. per second). The I-PSS decreased most significantly after transurethral resection (−14.1) and transurethral electrosurgical vaporization (−8.4). There was no difference regarding the rate of adverse events within the first 6 weeks postoperatively in the 5 treatment arms. Mean duration of catheter drainage plus or minus standard deviation was 3.7 +/− 1.2 days after transurethral resection of the prostate, 6.8 +/− 1.7 days after high intensity focused ultrasound, 7.8 +/− 1.5 days after visual laser ablation, 2.0 +/− 0.4 days after transurethral needle ablation and 3.3 +/− 0.8 days after transurethral electrosurgical vaporization. Analysis of the questionnaire revealed that the daytime frequency, degree of hematuria and incontinence were comparable for all 5 procedures within the first 6 weeks postoperatively. Postoperative dysuria was greatest after visual laser ablation and transurethral electrosurgical vaporization. Regarding the degree of nocturia, there was no improvement after visual laser ablation, while the remaining 4 procedures yielded a significant and comparable decrease. The most significant subjective improvement in uroflowmetry was reported after transurethral resection of the prostate and transurethral electrosurgical vaporization. Regarding the global quality of life question, the patients were generally more worried after visual laser ablation and transurethral needle ablation compared to the other 3 procedures.

Conclusions

The overall morbidity of transurethral resection of the prostate within the first 6 weeks postoperatively is equivalent to that of the 4 minimally invasive treatment alternatives evaluated in our study. When comparing the 4 minimally invasive procedures, no dramatic differences were notable, although visual laser ablation seems to be associated with a greater degree of morbidity as assessed by this questionnaire.     

The American Urological Association Symptom Score in the Evaluation of Men With Lower Urinary Tract Symptoms: at 2 years of followup, does it work?

Purpose

The American Urological Association (AUA) benign prostatic hyperplasia (BPH) guidelines committee established criteria for the diagnosis and treatment of patients BPH. In a prospective study we determined the usefulness of these guidelines in 145 previously untreated patients with BPH symptoms.

Materials and Methods

Patients were evaluated initially by AUA symptom score, digital rectal examination, urinalysis, serum creatinine and prostate specific antigen. Based on symptom score, patients with mild symptoms were treated with watchful waiting, while those with moderate and severe symptoms were offered watchful waiting, finasteride alpha-blockers, or laser or transurethral prostatectomy. Minimum followup was 2 years. Patients were offered a change in therapy if they had an intolerable adverse event or no improvement. Analysis included maintenance of therapy at 1 and 2 years, number of office visits and diagnostic tests performed. In addition, all patients were queried regarding which factors influenced their therapeutic choice.

Results

Of 37 patients with mild symptoms 31 (81 percent) remained on watchful waiting at 2 years and 6 advanced to medical therapy. Among 71 patients with moderate symptoms 9 of 15 (60 percent) remained on watchful waiting, 27 of 36 (75 percent) remained on alpha-blockers and 12 of 20 (60 percent) remained on finasteride at 2 years. Of the 37 patients with severe symptoms 1 of 5 (20 percent) remained on watchful waiting, 1 of 6 (17 percent) remained on finasteride and 9 of 15 (60 percent) remained on alpha-blockers, while 3 of 5 (60 percent) who underwent laser prostatectomy and all 6 (100 percent) who underwent transurethral prostatectomy received no further treatment. At 2 years 83 percent of the men who selected either finasteride or alpha-blockers as either the primary or secondary therapeutic choice were still on medications. Most patients with mild (61 percent) or moderate (51 percent) symptoms cited adverse events as the predominant concern when selecting therapeutic options. In contrast, efficacy was the overriding concern (70 percent) in patients with more severe symptoms.

Conclusions

Overall, with these guidelines and the AUA symptom score 110 men (76 percent) were still on original therapy at 1 year and 99 (68 percent) at 2 years. Additionally, 31 patients (21 percent) changed to an alternative, nonoperative therapy. These results suggest that the AUA BPH guidelines provide a rational and balanced approach for evaluation and management of patients with symptomatic BPH. Patients can reasonably expect to remain on the initial therapeutic option for at least 2 years.     

Neodymium: YAG Laser Coagulation Prostatectomy: 3 Years of Experience with 227 Patients

Purpose

For 3 years we prospectively followed a cumulative cohort of men who underwent neodymium:YAG laser coagulation prostatectomy to relieve bladder outlet obstruction to determine the safety, efficacy and durability of this procedure.

Materials and Methods

A total of 227 men with symptomatic bladder outlet obstruction was treated with the Urolase* side-firing laser fiber between October 15, 1991 and October 15, 1994. Voiding outcomes, including peak urinary flow rates, residual urine volumes and American Urological Association symptom scores, were measured with time, and immediate and long-term complications were assessed.*C. R. Bard, Inc., Covington, Georgia.

Results

Median patient followup was 26 months (maximum 42). Significant improvement occurred in all measured voiding parameters, including 133 percent in peak flow rates and 61 percent in symptom scores 1 year postoperatively. Overall 87 percent of patients noticed improved quality of life as a result of surgery. Minimum postoperative followup was 6 months in all cases. Complications included prostatitis in 2.6 percent of patients, urethral stricture in 1.8 percent, bladder neck contracture in 4.4 percent and reoperation for residual prostate tissue in 5.3 percent.

Conclusions

Neodymium:YAG laser coagulation of the prostate represents an efficacious surgical intervention for symptomatic bladder outlet obstruction with minimal associated morbidity. Voiding outcomes are durable through 3 years.     

Efficacy of transurethral needle ablation of the prostate for the treatment of benign prostatic hyperplasia

BACKGROUND: We evaluated the efficacy and safety of transurethral needle ablation (TUNA) of the prostate for treatment of symptomatic benign prostatic hyperplasia (BPH) as one institute participating in a Japanese clinical trial. METHODS: Thirty-three patients with symptomatic BPH were treated with the TUNA procedure in our institute. The international prostate symptom score (IPSS), quality of life (QOL) score, residual urine volume (RV), prostate volume (PV) and peak urinary flow rates (Qmax) were measured and complications were assessed. RESULTS: We followed and evaluated 30 of the 33 cases. At 12 months there were significant improvements in the IPSS (20.7 to 11.2, P < 0.0001), QOL score (4.9 to 2.1, P < 0.0001), RV (46.6 to 22.6 mL, P < 0.01), PV (37.8 to 30.0 mL3, P < 0.002) and Qmax (8.00 to 11.0 mL/s, P < 0.002). There were no serious complications. CONCLUSION: This trial shows that the TUNA procedure is a safe and efficacious treatment for symptomatic BPH.     

Total Prostate and Transition Zone Volumes, and Transition Zone Index are Poorly Correlated With Objective Measures of Clinical Benign Prostatic Hyperplasia

Purpose

We determined if total prostate volume, transition zone volume or transition zone index is correlated with the severity of clinical benign prostatic hyperplasia (BPH).

Materials and Methods

A total of 93 men 52 to 85 years old, who were referred to a urology outpatient facility for treatment of clinical BPH, elevated serum prostate specific antigen or abnormal digital rectal examination, underwent measurement of total prostate and transition zone volume at transrectal ultrasonography. All men were requested to undergo uroflowmetry and complete the American Urological Association (AUA) symptom score.

Results

The pairwise correlations between AUA symptom score, versus total prostate and transition zone volumes and transition zone index were not statistically or clinically significant. A weak pairwise relationship was observed between peak flow rate versus total prostate volume (r² = 0.160), transition zone volume (r² = 0.156) and transition zone index (r (²) = 0.147). The pairwise relationships between AUA symptom scores versus all prostate volumes were not statistically significant for subjects with mild (score 8 or less) or moderate to severe (score more than 8) symptoms.

Conclusions

Total prostate and transition zone volumes, and transition zone index are not directly related to AUA symptom score and only weakly related to peak flow rate. These findings provide further evidence that the total prostate, total BPH and relative BPH volumes are not useful determinants of the severity of clinical BPH.     

Transurethral plasma vaporization of the prostate: 3-month functional outcome and complications

Study Type – Therapy (multi‐centre cohort) Level of Evidence 2b

OBJECTIVE

To evaluate the early functional outcomes of transurethral plasma vaporization of the prostate (TUVis) in a multicentre study.

PATIENTS AND METHODS

A prospective multicentre observational study was conducted in eight urology departments. The inclusion criterion was benign prostatic hyperplasia (BPH) requiring surgical treatment. Patients on anti‐coagulant therapy were not excluded. The TUVis procedure was performed according to a classic transurethral resection of the prostate (TURP) scheme following the manufacturer’s recommendations. We evaluated subjective functional outcome using self‐questionnaires (International Prostate Symptom Score [IPSS] and five‐item International Index of Erectile Function [IIEF‐5]) and objective criteria (prostate volume, prostate‐specific antigen [PSA], uroflowmetry, post residual volume) at baseline and at 1‐ and 3‐month follow‐ups. All types of complications were systematically recorded.

RESULTS

Despite 52% of patients receiving anticoagulant therapy before surgery, we reported only 3% with haemorrhagic complications, no blood transfusion, a mean catheterization time of 44 h and a mean postoperative stay of 2.9 nights. No significant change in irrigation time, catheter time or hospital stay was observed in patients with or without anticoagulant therapy. The IPSS and bother scores significantly decreased after the 3‐month follow‐up (57% and 59%, respectively), but the average remaining prostate volume was 29 cc and the tissue ablation rate was only 0.5 cc/min. Three major complications occurred, consisting of two urinary fistulas and one partial bladder coagulation.

CONCLUSIONS

The TUVis procedure has a proven fast postoperative recovery time, good short‐term functional outcome and good haemostatic efficiency. However, the tissue ablation rate was lower than expected and we encountered three major complications, the mechanisms of which remain unclear. Considering the high energy level required to create the plasma effect, the generator, cable and resectoscope must be carefully checked before each procedure.     

THE IMPACT OF MEDICAL THERAPY ON BOTHER DUE TO SYMPTOMS, QUALITY OF LIFE AND GLOBAL OUTCOME, AND FACTORS PREDICTING RESPONSE

Purpose

We determine the effect of placebo, finasteride, terazosin and a combination of drugs on bother due to symptoms, quality of life and patient perception of improvement, and identify baseline clinical factors that predict clinical response to medical therapy.

Materials and Methods

A total of 1,229 subjects with clinical benign prostatic hyperplasia (BPH) were randomized to 1 year of placebo, finasteride, terazosin or drug combination. The primary outcome measures were American Urological Association (AUA) symptom score and peak flow rate. Relevant secondary outcome measures were symptom problem score, BPH impact score and global rating of improvement.

Results

Group mean differences in symptom problem and BPH impact scores between the finasteride versus placebo, and terazosin versus combination groups were not statistically or clinically significant. Group mean differences in all outcome measures were highly statistically significant between the terazosin and finasteride, and combination and finasteride groups. The percentage of subjects who rated improvement as marked or moderate with placebo, finasteride, terazosin and combination was 39, 44, 61 and 65%, respectively. In the subsets of men in the placebo, finasteride, terazosin and combination groups with prostates greater than 50 cm.³ group mean decrease from baseline in AUA symptom score was -2.5, -3.6, -6 and -7, group mean increase in peak flow rate was 0.6, 2.7, 3.6 and 3.7 ml. per second, group mean decrease in symptom problem score was -2.2, -1.9, -3.1 and -4.5, and group mean decrease in BPH impact score was -0.6, -0.3, -1.1 and -1.5, respectively. A correlational analysis failed to show a significant relationship between baseline prostate volume and treatment response to finasteride. There was a significant but weak relationship between change in AUA symptom score and peak flow rate in the finasteride and combination groups. The symptom responses with terazosin were independent of baseline peak flow rate.

Conclusions

In men with clinical BPH finasteride and placebo are equally effective, while terazosin and combination are significantly more effective. In men with clinical BPH and large prostates the advantage of finasteride over placebo in terms of symptom reduction, impact on bother due to symptoms and quality of life is small at best, while the advantage of terazosin and combination over finasteride and placebo is highly significant. Baseline prostate volume was not a predictor of response to finasteride in the overall study population. On the basis of our results alpha 1 blockers, such as terazosin, should be first line medical treatment for BPH.     

Interstitial Radiofrequency Therapy of the Prostate: Results of a Pilot Study

Purpose

We assessed the feasibility of using interstitial radiofrequency therapy for benign prostatic hyperplasia (BPH) in 50 patients.

Materials and Methods

Therapy was given using a standard diathermy unit as the radiofrequency generator and a disposable needle electrode. The main outcome measure was improvement in symptoms assessed by symptom scores.

Results

Patients with bothersome symptoms or acute retention showed clinically significant improvements in symptom score, while those with chronic retention did not. There were no serious complications.

Conclusions

Interstitial radiofrequency therapy may be effective for symptomatic BPH. Further studies with long-term objective data are under way to assess its role in the management of BPH.