Transurethral Needle Ablation of the Prostate: Report of Initial United States Clinical Trial

Purpose

We studied the efficacy and safety of transurethral needle ablation of the prostate for treatment of symptomatic benign prostatic hyperplasia (BPH).

Materials and Methods

A total of 12 patients with symptomatic BPH underwent transurethral needle ablation of the prostate. Voiding outcomes, including American Urological Association symptom scores, bother scores, quality of life scores, peak urinary flow rates, residual urine volumes and urodynamic pressure flows, were measured with time, and immediate and short-term (6 months) complications were assessed.

Results

Transurethral needle ablation of the prostate was performed with local intraurethral lidocaine anesthesia in 11 patients and general anesthesia in 1. At 6 months there was a 61.7 percent improvement in American Urological Association symptom score (25.6 to 9.8, p = 0.0001), 61.1 percent improvement in bother score (18.8 to 7.3, p = 0.0002), 70.0 percent improvement in quality of life score (13.7 to 4.1, p = 0.0001), 73.0 percent increase in peak flow rate (7.8 to 13.5 cc per second, p less than 0.0001) and 54.9 percent decrease in the post-void residual (111 to 50 cc, p = 0.0457). Prostate volumes, maximum detrusor pressures and detrusor opening pressures decreased significantly. There were no intraoperative complications. Postoperatively, all 12 patients had mild dysuria for 1 to 7 days, 5 had transient urinary retention for 1 to 4 days, 3 had hematuria for 1 to 2 days and 1 had retrograde ejaculation.

Conclusions

This initial United States trial confirms previous experience, and shows that transurethral needle ablation of the prostate appears to be a simple, safe and efficacious procedure for treatment of symptomatic BPH. In addition, it can be performed in the majority of patients using topical urethral anesthesia.     

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.     

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.     

TRANSURETHRAL RESECTION OF THE PROSTATE VERSUS TRANSURETHRAL ELECTROVAPORIZATION OF THE PROSTATE: A BLINDED, PROSPECTIVE COMPARATIVE STUDY WITH 1-YEAR FOLLOWUP

Purpose

Transurethral electrovaporization of the prostate has been increasingly used as a surgical adjunct in the management of men with lower urinary tract symptoms. In this prospective study we compare the safety and efficacy of transurethral resection of the prostate and electrovaporization.

Materials and Methods

We compared 32 consecutive men (mean age 68.9 years) with lower urinary tract symptoms treated by transurethral electrovaporization of the prostate to a cohort of 32 men (mean age 72.8 years) treated by transurethral resection of the prostate. Parameters of evaluation included American Urological Association symptom score, peak urinary flow rate, adverse events, including serial changes in serum hematocrit and sodium, operative time, postoperative catheterization time, hospitalization time and days lost from work. The data were analyzed by an investigator who was blinded to which procedure was performed.

Results

A total of 61 patients were evaluable for followup at 1 year. None required retreatment. At 1 year symptom score decreased 12.8 (66% of patients) and 12.2 (67%) and peak urinary flow increased 9.7 ml. per second (135%) and 11.3 ml. per second (136%) for electrovaporization and resection, respectively, (p <0.001). Operative time was significantly longer with electrovaporization than with resection (47.6 +/− 17.6 versus 34.6 +/− 11.2 minutes, p <0.003). Catheterization time (67.4 +/− 13.6 versus 12.9 +/− 4.6 hours), hospitalization time (2.6 +/− 0.9 versus 1.3 +/− 0.5 days) and days lost from work (18.4 +/− 7.6 versus 6.7 +/− 2.1) were significantly greater for resection than electrovaporization, respectively. There were no major complications in the electrovaporization group while in the resection group 1 patient required transfusion (5 units) and in 1 a clinical transurethral resection syndrome developed. Potency and retrograde ejaculation were normal in 18 of 18 patients (100%) and 13 of 17 (76%) after resection and 19 of 20 (95%) and 17 of 20 (85%) after electrovaporization.

Conclusions

The results indicate that transurethral resection and transurethral electrovaporization of the prostate are effective in reducing lower urinary tract symptoms with similar preservation of sexual function. Both significantly improve peak urinary flow, although resection to a greater degree. Postoperative morbidity, catheterization time, hospitalization time and days lost from work were significantly less, and operative time was significantly longer with electrovaporization. Further studies are underway to determine the long-term durability of response of transurethral electrovaporization of the prostate relative to transurethral resection.     

5-YEAR OUTCOME OF SURGICAL RESECTION AND WATCHFUL WAITING FOR MEN WITH MODERATELY SYMPTOMATIC BENIGN PROSTATIC HYPERPLASIA: A DEPARTMENT OF VETERANS AFFAIRS COOPERATIVE STUDY

Purpose

We determine outcomes after 5 years of followup for men who were randomized to receive transurethral resection or watchful waiting for moderate symptoms of benign prostatic hyperplasia.

Materials and Methods

A total of 556 patients were evaluated up to 60 months after randomization providing 966 patient-years of followup for transurethral prostatic resection and 990 for watchful waiting. Patients randomized to watchful waiting were evaluated according to whether they remained on treatment or crossed over to surgery. Outcomes included treatment failure, a genitourinary symptom score, peak flow rate, post-void residual urine volume and the degree of bother from genitourinary symptoms.

Results

All outcomes were significantly better for transurethral prostatic resection than for watchful waiting. Treatment failure rates were 10% for transurethral prostatic resection versus 21% for watchful waiting (p = 0.0004). The crossover rate at 5 years was 36% and was positively associated with the degree of bother. Men with low pretreatment peak flow rates who were randomized to transurethral prostatic resection had 85% greater improvement in peak flow rate than comparable men who were randomized to watchful waiting and eventually crossed over to resection. However, after crossover, bother from genitourinary symptoms was similar to that of the resection group.

Conclusions

For men with moderate symptoms of benign prostatic hyperplasia transurethral prostatic resection has more favorable outcomes up to 5 years of followup compared to watchful waiting. While many men do well on watchful waiting, those who undergo transurethral prostatic resection after a trial of watchful waiting have less improvement in measures of bladder function than men randomized to resection, although there is no difference in serious adverse outcomes or bother from genitourinary symptoms.     

A multicentre single-blind randomized controlled trial comparing bipolar and monopolar transurethral resection of the prostate

Introduction:

Monopolar transurethral resection of the prostate (TURP) is the gold standard surgical therapy for men with lower urinary tract symptoms due to benign prostatic hyperplasia. Although generally considered safer, TURP experience is limited in Canada.

Methods:

Forty-three patients from 5 Canadian centres were randomized to TURP with either bipolar or monopolar platforms. Patients underwent baseline determinations of American Urological Association (AUA) symptom score, peak urinary flow rate, post-void residual bladder volume and transrectal ultrasound prostate volume. Primary outcome measures were improvement in AUA symptom score, quality of life assessment and bother assessment. Secondary outcomes included procedural times, duration of catheterization, length of hospitalization, complications and the degree of thermal artifact in tissue specimens. Patients were followed for 6 months.

Results:

Twenty-two patients were treated with bipolar and 21 with monopolar TURP. Preoperative demographics were not statistically different between groups. Postoperative data collection times were equivalent in AUA symptom, quality of life, bother and sexual function assessments. No differences were observed in the procedure time (60.7 min, bipolar vs. 47.4, monopolar) or the duration of urethral catheterization (1.5 days, bipolar vs. 1.1, monopolar). More patients in the bipolar group were discharged on the same day of surgery. There were no differences in the degree of tissue thermal artifact or complication rate.

Conclusion:

This trial suggests equivalent short-term outcomes for men undergoing monopolar or bipolar TURP.     

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.     

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.     

CATHETER-FREE ENDOSCOPIC LASER ABLATION OF THE PROSTATE USING A 1-SIZE PROSTATIC STENT

Purpose

Endoscopic laser ablation of the prostate is a safe alternative to transurethral prostatic resection. Recognized disadvantages include prolonged catheterization, postoperative discomfort and delayed symptomatic improvement. We assessed the role of a 1-size temporary prostatic stent in men undergoing endoscopic laser ablation of the prostate.

Materials and Methods

A total of 55 men a mean of 73 years old with outflow obstruction, including 9 who presented in urinary retention, underwent endoscopic laser ablation of the prostate and temporary stenting. Urinary flow rate, residual urine volume, symptom score and prostate specific antigen were measured preoperatively, and 6 weeks (with the stent in situ), 3 months (after stent removal) and 12 months postoperatively. Duration of hospital stay and complications were also recorded.

Results

Of the 55 men 37 (67%) voided immediately with the stent in situ, including 7 of the 9 in retention. At 6 weeks with the stent in place mean maximum urine flow was 17.3 ml. per second (preoperatively 8.7). Dysuria was reported by 3 patients. Stent related complications were rare. One stent migrated early, resulting in urinary retention, while 2 that migrated late were asymptomatic. No patient had acute urinary retention after stent removal. Maximum urinary flow rate measured at 6 weeks with the stent in situ was similar to that 1 year after endoscopic laser ablation of the prostate.

Conclusions

The use of a 1-size, inexpensive plastic prostatic stent enabled catheter-free endoscopic laser ablation of the prostate in 67% of our patients. Early improvements in the urinary flow rate and a lower incidence of dysuria were additional benefits. The result of endoscopic laser ablation of the prostate at 1 year was comparable to that of transurethral prostatic resection.     

TRANSURETHRAL MICROWAVE THERMOTHERAPY FOR BENIGN PROSTATIC HYPERPLASIA: CLINICAL OUTCOME AFTER 4 YEARS

Purpose

We describe long-term results of transurethral microwave thermotherapy. We determined pretreatment variables favorable for the outcome.

Materials and Methods

We followed for 4 years 187 patients treated with Prostatron software 2.0.^* Preoperative evaluations consisted of score, cystoscopy, transrectal ultrasonography, urine flow and residual volume measurements. Followup examinations with score and urodynamics were performed for 4 years after transurethral microwave thermotherapy. Kaplan-Meier plots and logistic regression were used for statistical analyses.

Results

A decrease in the number of satisfied patients was noted from 62% at 1 year after transurethral microwave thermotherapy to 23% at 4 years. Initial decrease in score and increase in urine flow were followed by increase in score and decrease in flow at the 4-year followup of the 56 patients who had not received supplementary benign prostatic hyperplasia (BPH) treatment. The Kaplan-Meier analysis estimated the median time for need of supplementary BPH treatment to be 45 months. Pretreatment urine flow greater than 10 ml. per second and an irritative score less than 5 were the only factors related to a favorable outcome. Prostate volume or energy delivered to the prostate did not influence the result.

Conclusions

Four years after transurethral microwave thermotherapy 23% of the initially treated group were satisfied with the result. Two-thirds had received supplementary BPH treatment. Preoperatively less obstructed patients and those with low initial irritative scores responded more favorably to transurethral microwave thermotherapy treatment.     

HOLMIUM LASER VERSUS TRANSURETHRAL RESECTION OF THE PROSTATE: A RANDOMIZED PROSPECTIVE TRIAL WITH 1-YEAR FOLLOWUP

PURPOSE: The high-powered holmium:YAG laser can be used for incision, ablation and resection of the prostate. The technique of holmium laser resection of the prostate is compared to transurethral prostatic resection for surgical management of benign prostatic hyperplasia in this prospective randomized study. MATERIALS AND METHODS: A total of 120 urodynamically obstructed cases were randomized to holmium laser or transurethral prostatic resection. All eligible patients were assessed preoperatively and at 3 weeks, and 3, 6 and 12 months postoperatively with an American Urological Association symptom score, peak urinary flow rate, and questionnaires concerning sexual function and continence. Preoperative pressure flow study, ultrasound prostate volume assessment and post-void residual volume measurement were repeated at the 6-month visit. All complications were noted. RESULTS: Holmium laser and transurethral resections resulted in significant improvements in symptom score, quality of life score, peak urinary flow rate and post-void residual urine measurements. Operating time was significantly longer in the holmium group but nursing contact time, catheter time and hospital stay were significantly less compared to the transurethral prostatic resection group. Urodynamic results were equivalent at 6 months. There were fewer side effects in the holmium group. Effects on continence, potency and symptoms were similar with 1-year followup. CONCLUSIONS: Holmium and transurethral resections of the prostate appear to be equivalent in surgical management of bladder outflow obstruction due to benign prostate hyperplasia. Perioperative morbidity was less in the holmium group.     

LONG-TERM RESULTS OF LOWER ENERGY TRANSURETHRAL MICROWAVE THERMOTHERAPY

Purpose

We evaluate long-term results of lower energy transurethral microwave thermotherapy (Prostasoft 2.0*) and identify pretreatment characteristics that predict a favorable outcome.*Technomed Medical Systems, Lyon, France.

Materials and Methods

Between December 1990 and December 1992, 231 patients with lower urinary tract symptoms were treated with lower energy transurethral microwave thermotherapy. Subjective and objective voiding parameters were collected from medical records and a self-administered questionnaire. Kaplan-Meier plots were constructed to assess the risk of re-treatment.

Results

Of the patients 41% underwent invasive re-treatment within 5 years of followup and 17% were re-treated with medication. The re-treatment-free period was somewhat longer in patients with a peak flow rate greater than 10 ml. per second, a Madsen score 15 or less, a post-void residual volume 100 ml. or less and age greater than 65 years at baseline. Prostate volume did not modify the outcome. No incontinence was caused by transurethral microwave thermotherapy, 8% had recurrent urinary tract infection and 8% had retrograde ejaculation. Only 1 patient had a urethral stricture after transurethral microwave thermotherapy.

Conclusions

At 5 years after transurethral microwave thermotherapy 41% of the patients received instrumental treatment. Patients with a lower Madsen score and lower residual volume, and those with higher peak flow and age were somewhat better responders to lower energy transurethral microwave thermotherapy.     

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.     

INTRAPROSTATIC TEMPERATURE MONITORING DURING TRANSURETHRAL MICROWAVE THERMOTHERAPY FOR THE TREATMENT OF BENIGN PROSTATIC HYPERPLASIA

Purpose

We evaluated whether the results of transurethral microwave thermotherapy improve using high intraprostatic temperature of 55C or greater.

Materials and Methods

We accrued 30 men 58 to 85 years old (mean age 69) from the waiting list for transurethral prostatic resection in whom maximum urinary flow was less than 13 ml. per second and Madsen score was greater than 8. According to the Abrams-Griffith nomogram all but 1 patient had obstruction. Before treatment 3 thin temperature probes, each containing 5 sensors in a row, were introduced into the prostate from the perineum and positioned using transurethral ultrasound guidance. The microwave power of the transurethral microwave thermotherapy equipment was set based on the actual temperature in the prostatic tissue. A temperature of at least 55C and often more than 60C was reached at the hottest spot. Treatment duration was 1 hour. Postoperatively an indwelling catheter remained in place for 2 weeks. Patients were followed for 6 months with the first followup after 3 months.

Results

At the 3-month followup mean maximum urinary flow had increased from 7.4 to 12.5 ml. per second and the mean Madsen score had decreased from 12.6 to 2.9. At the 6-month followup mean maximum urinary flow was 12.2 ml. per second and the mean Madsen score was 3.4. Using pressure-flow data we divided the patients into responders and nonresponders. In the 18 responders maximum urinary flow had increased from 7.2 to 14.6 ml. per second (103%), the Madsen score had decreased from 12.5 to 1.4 (89%) and detrusor pressure had decreased from 9.2 to 6 kPa. (35%).

Conclusions

High energy transurethral microwave thermotherapy relieved bladder outlet obstruction in 60% of the patients and had a good effect on symptoms. Compared with a previous multicenter study with 40% responders, using the same criteria there were 60% responders in our series. Our results indicate that better control of intraprostatic temperature provides better results, approaching those after transurethral prostatic resection.     

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.     

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.     

The Safety of Transurethral Prostatectomy: A Cohort Study of Mortality in 9,416 Men

Purpose

We assessed the mortality rate from transurethral resection of the prostate.

Materials and Methods

From 1976 to 1984, 4,708 patients undergoing transurethral resection of the prostate for benign prostatic hypertrophy (BPH) were compared retrospectively to an age-matched group of 4,708 randomly selected Kaiser Permanente Medical Care Program members not undergoing surgery. The risk of mortality associated with transurethral resection of the prostate relative to no surgery was determined using proportional hazards models.

Results

The relative risk for surgery versus no surgery for the total group was 0.88 (95% confidence interval 0.82 to 0.95). Similarly, the results for each 5-year age group demonstrated a relative risk of 0.77 to 0.95.

Conclusions

This cohort study showed no excess mortality for patients undergoing transurethral resection of the prostate compared to age-matched comparison subjects randomly selected from health plan members who did not undergo surgery. Information from this study about the safety of transurethral resection of the prostate can be shared with patients when discussing treatment options.     

Prospective randomized study comparing monopolar with bipolar transurethral resection of prostate in benign prostatic obstruction: 36-month outcomes

Objectives

Monopolar transurethral resection of the prostate (TURP) is the gold standard surgical treatment for bothersome moderate to severe lower urinary tract symptoms (LUTS) secondary to benign prostate obstruction. The aim of the study is to compare monopolar versus bipolar TURP focusing on operative and functional outcomes, and evaluating complications with a long-term follow-up.

Methods

From January 2007 to July 2014, a total of 497 patients were randomized and prospectively scheduled to undergo bipolar (251) or monopolar (246) TURP. International prostate symptom score (IPSS), IPSS-Quality of life (QoL), post-void residual and maximum flow rate were assessed preoperatively and postoperatively at 3, 12, 24 and 36 months. Operative time, length of catheterization and hospitalization were all recorded. Complications were classified and reported.

Results

All patients completed the 36-month follow-up visit. Perioperative results showed no statistical significance between the two groups in terms of catheterization days, post-void residual, IPSS, IPSS-QoL score. The hospitalization length was found statistically significant in favor of the bipolar group. The 3-, 12-, 24- and 36-month follow-up showed significant and equal improvements in LUTS related to BPO in the two treatment groups. Regarding TURP complications, significant differences were observed in relation to urethral strictures, blood transfusion and TUR syndrome in favor of the bipolar group.

Conclusions

Monopolar and bipolar TURP are safe and effective techniques for BPH management. Bipolar TURP in our prospective study reported the same efficacy of monopolar prostate resection, with a significant reduction of related complications.

     

RATIO OF FREE-TO-TOTAL PROSTATE SPECIFIC ANTIGEN IN SERUM CANNOT DISTINGUISH PATIENTS WITH PROSTATE CANCER FROM THOSE WITH CHRONIC INFLAMMATION OF THE PROSTATE

Purpose

We demonstrate the effect of chronic inflammation of the prostate on the ratio of free-to-total prostate specific antigen (PSA) in serum calculated as a percentage of free PSA and, therefore, that percentage of free PSA is an unspecific means to distinguish among prostate cancer, chronic prostatitis and benign prostatic hyperplasia (BPH).

Materials and Methods

Total, free and percentage of free PSA was measured in 66 men with prostate cancer, 119 with BPH and 17 with asymptomatic chronic prostatitis. In all patients the diagnosis was histopathologically confirmed by microscopic examination of prostatic specimens after sextant biopsy, transurethral prostatic resection or prostatectomy.

Results

The median values of total, free and percentage of free PSA were 4.11 micro g./l., 0.75 micro g./l. and 20.4% in patients with BPH, 10.0 micro g./l., 0.84 micro g./l. and 8.5% in those with prostate cancer, and 7.60 micro g./l., 1.23 micro g./l. and 10.6% in those with chronic prostatitis. Patients with prostate cancer and chronic prostatitis had a significantly lower percentage of free PSA than those with BPH. Receiver operating characteristics curve analysis showed that percentage of free PSA as a discriminator between prostate cancer and BPH was not suitable for differentiating between prostate cancer and chronic prostatitis.

Conclusions

Chronic prostatitis is not characterized by elevated total PSA concentrations alone but also by a decreased percentage of free PSA, a tendency similar to that in prostate cancer. This unspecific change in percentage of free PSA must be considered to interpret the percentage of free PSA correctly.     

EVALUATION OF NEW RESECTOSCOPE LOOP FOR TRANSURETHRAL RESECTION OF BLADDER TUMORS

Purpose

We evaluate a new resectoscope loop for transurethral resection of bladder tumors.

Materials and Methods

Of 251 transurethral resections in 226 patients 111 were done with a conventional loop and 140 with the Olympus prototype model A2186 resectoscope loop. The quality of specimens provided for histological analysis was compared.

Results

Tissue orientation was preserved and cautery artifact was reduced with the new loop compared to the standard resectoscope loop.

Conclusions

Compared to a conventional resectoscope loop, the new loop resulted in a better tumor resection and helped facilitate histological evaluation of the tissue specimens.