Minimally Invasive Prostatic Urethral Lift: Surgical Technique and Multinational Experience

Background

Many men with benign prostatic hyperplasia (BPH) are dissatisfied with current treatment options. Although transurethral resection of the prostate (TURP) remains the gold standard, many patients seek a less invasive alternative.

Objective

We describe the surgical technique and results of a novel minimally invasive implant procedure that offers symptom relief and improved voiding flow in an international series of patients.

Design, setting, and participants

A total of 102 men with symptomatic BPH were consecutively treated at seven centers across five countries. Patients were evaluated up to a median follow-up of 1 yr postprocedure. Average age, prostate size, and International Prostate Symptom Score (IPSS) were 68 yr, 48 cm³, and 23, respectively.

Surgical procedure

The prostatic urethral lift mechanically opens the prostatic urethra with UroLift implants that are placed transurethrally under cystoscopic visualization, thereby separating the encroaching prostatic lobes.

Outcome measurements and statistical analysis

Patients were evaluated pre- and postoperatively by the IPSS, Quality-of-Life (QOL) scale, Benign Prostatic Hyperplasia Impact Index, maximum flow rate (Q_max), and adverse event reports including sexual function.

Results and limitations

All procedures were completed successfully with a mean of 4.5 implants without serious adverse effects. Patients experienced symptom relief by 2 wk that was sustained to 12 mo. Mean IPSS, QOL, and Q_max improved 36%, 39%, and 38% by 2 wk, and 52%, 53%, and 51% at 12 mo (p < 0.001), respectively. Adverse events were mild and transient. There were no reports of loss of antegrade ejaculation. A total of 6.5% of patients progressed to TURP without complication. Study limitations include the retrospective single-arm nature and the modest patient number.

Conclusions

Prostatic urethral lift has promise for BPH. It is minimally invasive, can be done under local anesthesia, does not appear to cause retrograde ejaculation, and improves symptoms and voiding flow. This study corroborates prior published results. Larger series with randomisation, comparator treatments, and longer follow-up are underway.     

Urethral Lift for Benign Prostatic Hyperplasia: A Comprehensive Review of the Literature

Current treatments for benign prostatic hyperplasia (BPH) include watchful waiting, medical therapy, and interventional procedures. The post-surgical complication profile and the early discontinuation of medical therapy are significant drawbacks of the established approach and stimulate the search for less-invasive approaches. Our aim is to provide a comprehensive review all available literature on prostatic urethral lift (PUL), presenting an overview of safety, indications, surgical technique and results of the procedure, and to evaluate the potential role it could play in the treatment of BPH. A comprehensive search was conduct on PubMed and Scopus database to identify original articles in English dealing with PUL without any limit to publication date. Keywords used were prostatic urethral lift, urethral lifting, Urolift, benign prostatic hyperplasia and minimally invasive therapy. The PUL seems to offer a better IPSS improvement when compared to medical therapy, but the result is inferior when compared to surgical therapy. Published studies report an absence of degradation of erectile or ejaculatory function after treatment, which appears a noteworthy benefit of PUL. Additional advantages of the PUL are a better complication profile in comparison to other surgical therapies and the use of a local anesthesia, sometimes without postoperative catheterization. The PUL, a novel, minimally invasive treatment option for men affected by BPH, presents a promising potential although it is clear that PUL is not a substitute for traditional ablative surgical approach, as this procedure requires a scrupulous selection of the patient.     

Urethral sphincter innervation and clitoral blood flow after the transobturator (TOT) approach

Introduction and hypothesis

The aim of the study was to exclude neurovascular damage due to prosthetic mini-invasive surgery using transobturator tape (TOT) by pre- and postoperative electromyography (EMG) of the striated urethral sphincter and a color Doppler ultrasonography evaluation of clitoral blood flow.

Methods

A total of 25 women affected by clinical stress urinary incontinence (SUI) were enrolled. After undergoing urodynamic assessment, pelvic organ prolapse quantification, urine culture, Q-tip test, and stress test, each subject underwent color Doppler ultrasonography to record clitoral blood flow and EMG of the urethral sphincter with a needle electrode inserted through the mucosa into the muscle tissue before surgery. A single urogynecologist performed the TOT surgical technique for the treatment of all patients. Urogynecologic examination, EMG, and color Doppler ultrasound follow-up were performed at 1 and 6 months after surgery.

Results

At the urogynecologic examination performed 1 and 6 months after the TOT approach the stress test was negative, urethral hypermobility was reduced, and sling exposure was not observed for each patient. There was no statistically significant difference in electromyographic values (p?>?0.05) in both the follow-ups with regard to baseline values. Pulsatility index (PI), resistance index (RI), and peak systolic velocity (PSV) values increased during the first follow-up (p?<?0.01); PI and RI values increased during the second follow-up with respect to baseline values (p?<?0.01)

Conclusions

TOT prosthesis surgery, avoiding denervation and devascularization of pelvic structures, does not damage the urethral sphincter.     

尿道血管瘤5例报告

目的：探讨尿道血管瘤的病因、诊断、治疗、预后等相关问题。方法：对2例尿道血管瘤患者进行传统手术切除，对3例尿道血管瘤患者进行等离子双极汽化电切系统（TUPKVP）治疗并就其诊断、治疗、预后等相关临床问题进行分析。结果：1例经3次TUPKVP治疗后控制出血，其余4例均1次治愈。病理检查报告均为尿道血管瘤。随访1～4年无复发，无相关并发症发生，结论：尿道外口血管瘤也可选择手术切除，经尿道电切为治疗尿道血管瘤的首选方法，二者均预后较好。     

Prostatic tissue levels of cefpiramide (CPM)

The concentration of CPM in prostatic tissue and serum in 12 patients with benign prostatic hypertrophy was measured. One gram of CPM was injected intravenously prior to prostatectomy. One, 2, 3 and 5 hours following the administration of CPM, the mean serum level of CPM was 142, 88.2, 87.4 and 61.2 micrograms/ml, respectively, while the mean level in the prostatic tissue was 48.3, 15.1, 15.6 and 8.3 micrograms/g, respectively. The prostatic tissue level of CPM was thought to be enough to eradicate gram-negative and gram-positive bacteria in the prostate. It is presumed from our study that clinical effectiveness of CPM might be expected in the case of acute or chronic bacterial prostatitis.     

Prostatic Transrectal Ultrasound (TRUS) Guided Biopsy Schemes and TRUS Prostatic Lesion-Guided Biopsies

Objectives: Recent data support the sextant TRUS guided biopsy scheme of the prostate and TRUS prostatic lesion-guided biopsies are inadequate to detect all clinically important cancers. Consequently, different types of schemes with more than six biopsies have recently been proposed. The type of scheme and the number of biopsies needed to optimize the detection rate of prostate cancer is still a somewhat controversial issue. In order to draw attention to the most interesting issues and controversies involving needle biopsies, we describe not only the most common methods used but also some of the new schemes proposed in literature.Methods: Literature on prostate biopsy was reviewed and a selection of articles made. Keywords used for the Medline search included: prostate cancer, biopsy, transrectal ultrasound and diagnosis.Results: Over the last few years, an increasing number of investigators have modified the standard sextant biopsy scheme, increasing the number and areas of the prostate sampled, especially biopsies taken more laterally or in the anterior horn or medially towards the apex of the prostate. Cancer yield does not appear to be related solely to the number of biopsies but also to the regions of the prostate sampled.Conclusions: In the current PSA era, prostatic biopsies only performed at lesions detected by TRUS are obsolete. Sextant and lesion-directed biopsies maximizes detection rate using the lowest possible number of biopsy cores if hypoechoic lesions are clearly visible. In the case of a negative TRUS and/or digital rectal examination, the ideal number of cores and prostate areas requiring sampling is still not defined, but the use of 10 or 12 multiple biopsies is becoming routine in many centers. In the future, biopsy techniques will probably be individualized for each patient according to TRUS findings, prostatic volume and PSA levels.     

Prostatic tumor (R3327) skeletal metastasis

Male Copenhagen rats were inoculated with monodispersed R3327-MatLyLu prostate tumor cells via the tail vein under concomitant temporal occlusion of the inferior vena cava to develop an animal model for skeletal metastasis of prostate cancer. This procedure reproducibly resulted in metastatic tumor growth in the lumbar region of the vertebral column. Microscopically, tumor growth became visible in the fifth and sixth lumbar vertebrae within 4 days after inoculation. Clinical signs of nerve function disablement (hind leg paresis and paralysis) followed within 14 days of such a procedure. Cell culture technique confirmed the presence of a viable, proliferating tumor cell population within the spinal canal of the fifth and sixth lumbar vertebrae. Histologically, a clear response of osteoclastic and concomitant osteoblastic activities was observed in the lumbar spinal column. In the serum, a transient phase of hypercalcemia could be demonstrated. The development of skeletal metastases in these animals was not reflected by significant alteration in serum levels of acid phosphatase, prostatic-specific antigen, or osteocalcin. These observations support the concept of the vertebral venous plexus being involved in the dissemination of prostate tumor cells. The surgical procedures described permit experimental investigations of bone metastasis of prostatic cancer.     

前列腺腔内术后尿道狭窄原因及处理

目的探讨前列腺患者腔内手术后尿道狭窄的原因及处理方法。方法经尿道前列腺汽化电切术后尿道狭窄32例，术前均行膀胱镜检未见尿道狭窄，术后出现排尿困难，经尿道探杆检查、膀胱镜检及尿道造影明确诊断为尿道狭窄。其中14例为尿道外口狭窄，9例为尿道球膜部狭窄，4例为阴茎部尿道狭窄缘于尿道扩张造成，5例为前列腺尿道部疤痕狭窄。18例行尿道扩张治愈，7例行尿道内切开加尿道扩张治愈，4例前列腺部尿道狭窄再次电切治愈，3例行尿道成形术。结果32例治疗后能维持通畅的排尿，其中4例患者须定期尿扩随访。结论经尿道前列腺汽化电切术后尿道狭窄主要发生于尿道外口及前尿道，与器械、留置尿管、感染及尿道扩张等因素相关。治疗方法主要为尿道扩张及尿道内切开，尤应重视术后的尿扩随访。     

尿道会师术325例

报告４４年间因新鲜尿道损伤行尿道会师术并有随访结果者３２５例，总治愈率为５８．７％。认为尿道会师术应作为膜部尿道损伤的首选治疗方法；其操作强调动作轻巧，不宜反复勉强会师；严格掌握尿道会师术指征；后期坚持尿道扩张十分重要，须由专科医师实施