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.     

Injectables in the prostate

PURPOSE OF REVIEW: Benign prostatic hyperplasia with associated symptoms and morbidity is increasingly common among aging men. Medical treatment of lower urinary tract symptoms is the mainstay of therapy with progressive disease requiring more invasive intervention. Transurethral resection of the prostate remains a widely applied gold standard therapy. Numerous minimally invasive surgical therapy options have arisen and subsequently faded over recent years. Those remaining in use are largely positioned between pharmacological treatment and transurethral resection of the prostate. Intraprostatic injection therapy, the oldest minimally invasive surgical therapy, has been investigated for over 100 years with renewed interest recently. This review will provide some history of intraprostatic injection for benign prostatic hyperplasia including the most recent reports using transperineal, transrectal and transurethral routes with different injectables. RECENT FINDINGS: For benign prostatic hyperplasia, transperineal and transurethral injection routes have received the most systematic evaluation. Intraprostatic injection of botulinum toxin type A has received much recent attention with regards to mechanism of action and efficacy. Anhydrous ethanol remains the most extensively studied injectable to date. SUMMARY: Injection therapy remains a very promising minimally invasive surgical therapy for benign prostatic hyperplasia with increased attention from the urologic community in recent years. Further experience both with systematic laboratory and clinical trials investigation will be necessary before widespread clinical adoption.     

Is the minimally invasive treatment as good as transurethral resection for benign prostatic hyperplasia?

Despite the development of new technologies, transurethral resection of the prostate (TURP) is still considered the gold standard for surgical treatment of the benign prostate hyperplasia (BPH). In general, new minimally invasive treatments have not demonstrated better outcomes than TURP in evidence based medicine trials published to date, and should be reserved for patients who prefer to avoid surgery, who are unsuitable candidates for surgery or who no longer respond favorably to medication. TUMT and TUNA appears to be more effective than medical therapy but less effective than TURP. Both treatments can be given under topical anesthesia or local prostatic or perineal block. Efficacy of transurethral vaporization appears similar to TURP, but the studies are short-term and the glands operated on are relatively small. In patients with small prostates, the transurethral incision of the prostate can also be a good option, associated with less morbidity than TURP. Bipolar resection of the prostate is similar to TURP in effectiveness, but the data are inconclusive regarding blood loss, length of catheterization and hospital stay. Long-term comparative trials are needed to determine if the minimally invasive therapies are superior to standard TURP.     

Nonablative minimally invasive thermal therapies in the treatment of symptomatic benign prostatic hyperplasia

PURPOSE OF REVIEW: As all new treatment modalities nonablative thermal therapy for minimal invasive treatment of benign prostatic hyperplasia should be critically analyzed. This review discusses the literature to identify the merits of these so-called minimally invasive treatments and the place they should take in the armamentarium of benign prostatic hyperplasia therapy options. RECENT FINDINGS: In this review we analyze the different techniques and clinical studies of hot water induced thermotherapy, transurethral microwave thermotherapy, transurethral needle ablation and high intensity focused ultrasound. The high intensity focused ultrasound treatment is noninvasive, but due to the poor clinical results in benign prostatic hyperplasia and its need for anesthesia, this therapeutic option shifted towards the selective ablation of prostate cancer. The transurethral needle ablation treatment can be performed in an outpatient setting although most centers do not. The treatment is not suitable for the bigger prostates and therefore narrows its indication. Water induced thermotherapy is a very promising therapy, although without comparative studies a justified positioning remains difficult. SUMMARY: Of all nonablative thermal therapies, transurethral microwave thermotherapy is the best documented and with several randomized studies comparing transurethral microwave thermotherapy to surgical treatments of the prostate, this therapy definitively found its place as a serious alternative to the ablative surgical treatment options.     

Office based transurethral needle ablation of the prostate with analgesia and local anesthesia

PURPOSE: We evaluated the efficacy and feasibility of performing office based transurethral needle ablation of the prostate with analgesia and local anesthesia. MATERIALS AND METHODS: A total of 56 consecutive patients underwent transurethral needle ablation of the prostate for symptomatic benign prostatic hyperplasia. Oral rofecoxib (50 mg) and ciprofloxacin (250 mg) were administered before the procedure with 25 mg hydroxyzine and 50 to 100 mg meperidine intramuscularly. A combination of 2% lidocaine solution and jelly was used for anesthesia. Patients rated discomfort during anesthesia administration and the procedure using a 10-point scale of 0--no discomfort to 10--the worst pain/discomfort ever experienced in the patient life. Overall satisfaction with the procedure was assessed with a 4-point scale of 1--very satisfactory to 4--very unsatisfactory. Followup was 12 months for uroflow and 36 months for International Prostate Symptom Score. RESULTS: The mean age of 47 patients was 65.4 years. Mean discomfort ratings were 3.6 and 4.9 for anesthesia administration and the procedure, respectively. Average operative time was 34.4 minutes, excluding anesthesia administration. The mean overall satisfaction score was 1.5. The mean preoperative International Prostate Symptom Score was 23.1, which improved to 10.9, 11.2, 12.3, 13.8 and 11.3 at 3, 6, 12, 24 and 36 months, respectively. Mean maximum uroflow improved from 8.2 ml/sec at baseline to 12.8, 13.9 and 13.3 ml/sec at 3, 6 and 12 months, respectively. CONCLUSIONS: Administration of an intramuscular narcotic combined with oral analgesic and topical lidocaine provided adequate pain control for transurethral needle ablation of the prostate, making it a feasible office procedure.     

Real-time optical coherence tomography for minimally invasive imaging of prostate ablation.

OBJECTIVE: Numerous ablation techniques have been developed to alleviate urethral obstruction and improve urodynamics in benign prostatic hyperplasia. Most techniques, however, rely on visual observation of surface changes for ablation end points. The feasibility of using real-time optical coherence tomography (OCT) for minimally invasive imaging to guide and monitor prostate resection is demonstrated with representative techniques of laser and radiofrequency ablation. Empiric comparisons of ablation dynamics are made, and the use of OCT as a high-resolution, subsurface modality for image guidance is evaluated. MATERIALS AND METHODS: Optical coherence tomography is a high-resolution, high-speed near-infrared imaging technique analogous to ultrasound imaging, except that reflections of light are detected rather than sound. High-speed OCT is used to image the dynamic process of laser and radiofrequency ablation of in vitro human prostate tissue. OCT images of ablation sites are compared with corresponding histology. RESULTS: Based on comparisons between OCT images and corresponding histology, OCT imaged transurethral prostate tissue morphology, including urethral sinuses and submucosal glands. Real-time OCT imaging provided rapid feedback and control of ablation dynamics. The compact and portable OCT technology is amenable to minimally invasive beam-delivery devices. CONCLUSIONS: Optical coherence tomography offers a minimally invasive means of assessing transurethral prostate morphology. Real-time OCT has the potential to provide image guidance of prostate resection for many of the existing surgical treatments directed at alleviating urethral obstruction associated with benign prostatic hyperplasia.     

高龄前列腺增生患者经尿道电切汽化术的麻醉

目的：探讨高龄高危前列腺增生患者经尿道前列腺电切汽化切割术麻醉的方法及其安全性。方法：将80例75～94岁的患者随机分为腰-硬联合麻醉（combined spinal-epidural anesthesia,CSEA）组和硬膜外麻醉（epidural anesthesia,EA）组,各40例,观察各组麻醉起效时间,阻滞平面,镇痛和肌松效果,局麻药和静脉辅助药的用量及术中SAP,DAP,HR,RR,SpO2的变化,术后随访有无头痛、恶心、呕吐等副作用。结果：CSEA组比EA组麻醉起效快,镇痛及肌松效果好。局麻药和辅助药用量少（P〈0.01）,术中血流动力学变化及术后随访两组无显著差异。结论：CSEA用于高龄高危前列腺增生患者经尿道电切汽化术的麻醉安全有效,围手术期个体化处理及麻醉操作和用药是关键。     

膀胱癌合并良性前列腺增生的同期微创治疗

目的探讨膀胱癌合并良性前列腺增生的同期经尿道微创治疗。方法合并良性前列腺增生可经尿道电切治疗的膀胱癌患者56例同期行经尿道前列腺切除、部分切除或切开。结果随访6～84个月,5例复发,无尿道及前列腺窝转移。结论合并良性前列腺增生可予经尿道膀胱肿瘤切除术(transurethral resection of bladder tumor,TURBT)的非浸润性膀胱肿瘤或膀胱尿路上皮癌患者适应行同期微创治疗。     

Practical value of prostatography]

From September 1988 to September 1989 perineal puncture prostatography with 60% urografin was performed in 21 patients with the prostate enlargement. Prostatographic findings suggested that 15 patients had benign prostatic hyperplasia and 6 had prostatic cancer. The diagnosis had been histologically proved after prostatectomy in 19 cases. The procedure was easily and safely conducted at outpatient clinic without complications. We believe that prostatography is useful in differential diagnosis of prostatic diseases and in selecting operative methods.     

Ethanol injection therapy of the prostate for benign prostatic hyperplasia: preliminary report on application of a new technique.

PURPOSE: We evaluate the efficacy of a new technique of minimally invasive treatment for benign prostatic hyperplasia involving direct injection of dehydrated ethanol. MATERIALS AND METHODS: Dehydrated ethanol was injected transurethrally with lumbar or sacral and urethral anesthesia in 10 patients with prostatic hyperplasia. Endoscopic injection was performed at 4 to 8 sites in the prostate and 3.5 to 12.0 ml. ethanol were used. RESULTS: There were no intraoperative complications but postoperative urinary retention occurred transiently in all patients which required catheterization for a mean of 8.8 days. Mean symptom score plus or minus standard deviation was 12.2+/-5.8 at 3 months postoperatively, which was significantly improved from 23.1+/-7.0 preoperatively (p<0.01). Mean quality of life score also improved significantly from 5.1+/-0.6 preoperatively to 3.2+/-1.5 at 3 months postoperatively (p<0.01), mean peak urinary flow rate increased from 8.0+/-2.2 (9 patients) to 13.1+/-3.6 ml. per second (p<0.05) and mean residual urine volume decreased from 129.1+/-55.3 (9 patients) to 49.3+/-34.7 ml. (p<0.05). There was no significant change in prostate volume. Acute epididymitis and chronic prostatitis occurred in 1 patient each. CONCLUSIONS: This technique can be performed as an outpatient procedure and appears to be safe and cost-effective. Retrograde ejaculation can be avoided.     

前列腺增生并膀胱结石的微创治疗（附34例报告）

目的：探讨前列腺增生症（BPH）并膀胱结石的微创治疗方法和疗效.方法：采用分期治疗办法,先在局麻下经尿道采用EMS系统作气压弹道碎石,3天后再行经尿道前列腺电切（TURP）.结果：34例经尿道气压弹道碎石手术时间20～60 min,平均45 min;无膀胱黏膜损伤、膀胱穿孔、泌尿系感染.患者感轻微疼痛但可忍受.其中4例患者术后排尿恢复通畅,予以出院,其余30例行TURP,手术时间20～75 min,平均50 min,术中、术后均未输血,无TUR综合征（TURS）发生.术后持续膀胱冲洗1～2天,术后5天拔除尿管,患者排尿通畅.30例患者随访3个月～2年,术后IPSS评分为（7.5±0.5）分,最大尿流率（MFR）平均〈15 ml/s.结论：TURP结合EMS系统气压弹道碎石术是BPH并膀胱结石的一种安全、有效的治疗方法.     

Saturation prostate biopsy with periprostatic block can be performed in office

PURPOSE: Recent reports of saturation prostate biopsy performed in the operating room with the patient under anesthesia have shown increased cancer detection rates over repeat office based prostate biopsy. We report equivalent success and tolerability of saturation biopsy in the office using local anesthesia. MATERIALS AND METHODS: We performed 24 core saturation prostate biopsies in 15 patients using periprostatic local anesthesia. Before biopsy 20 cc 2% lidocaine (10 cc per side) were injected under ultrasound guidance into the periprostatic nerve entry into the prostate bilaterally. After measurements were made a random 24 core prostate biopsy was performed using a spring loaded biopsy gun. Pain was determined using a visual analog scale to assess tolerability. RESULTS: Complete 24 core biopsies were successful and well tolerated in all 15 patients. Cancer detected in 5 patients (33%) was clinical stage T1C. Mean prostate specific antigen before biopsy was 11.2 ng./dl. (range 5 to 24.1). The indication for biopsy was elevated prostate specific antigen after a previous normal biopsy in 12 patients. In 2 patients prostatic intraepithelial neoplasia was noted on a previous biopsy and in 1 previous atypia was identified on biopsy. The mean visual analog scale pain score was 0.7 (range 0 to 3). Prolonged minor hematuria greater than 5 days in duration occurred in 3 cases requiring no intervention. No other complications occurred. Nerve sparing was not more difficult in the single patient who underwent radical prostatectomy. CONCLUSIONS: Saturation prostate biopsy is well tolerated in the office setting with the patient under local anesthesia. The additional risk, time and cost of performing these procedures in the operating room using anesthesia may be safely avoided.     

Holmium laser enucleation of the prostate: Problem-based evolution of the technique

Holmium laser enucleation of the prostate (HoLEP) is a minimally invasive and size-independent treatment for benign prostatic hyperplasia with excellent long-term surgical outcome. Considered difficult to learn, different modifications of the technique have been proposed in the last 21 years to overcome the most common problems encountered during this procedure. We present a step-by-step technique including the reasons and advantages of each modification we have progressively adopted until we evolved into our totally en-bloc no-touch low-power HoLEP.     

经尿道绿激光汽化术联合汽化电切术治疗重度前列腺增生的临床研究

目的:评估经尿道前列腺选择性绿激光汽化术联合汽化电切术(PVP+TUVP)与经尿道前列腺汽化电切术(TUVP)治疗体积大于80ml重度BPH的安全性和临床疗效。方法:选取符合入选标准的重度BPH患者95例,按手术方式随机分为PVP+TUVP治疗组48例和TUVP对照组47例,比较两种术式的手术时间、术中出血量、术后血尿时间、症状评分、尿流动力学及并发症等指标。结果:PVP+TUVP组手术时间略长于TUVP组,但差异无统计学意义(P>0.10)。PVP+TUVP组术中出血量、术后血尿时间、并发症均少于TUVP组,差异有统计学意义(P<0.05)。术后随访12个月,PVP+TUVP组IPSS评分、QOL评分、Qmax、RUV均比术前明显改善(P<0.002),但组间比较差异无统计学意义(P>0.05)。结论:对于体积大于80ml重度BPH患者,PVP+TUVP比TUVP具有术中风险低、术后恢复快和并发症少等优点,临床疗效相似,是一种更加安全有效的微创手术方式。     

Transurethral prostatic resections under local anesthesia.

Standard transurethral prostatic resections were done on 18 patients with benign prostatic hyperplasia. Local anesthesia was used with standard 1 per cent lidocaine local infiltration of the prostate and topical instillation into the urethra. This anesthesia was supplemented in a few instances by modest doses of intravenous tranquilizers, which has proved to be a safe, simple and effective procedure.     

Relationship between prostate specific antigen density, microvessel density and prostatic volume in benign prostatic hyperplasia and advanced prostatic carcinoma

The aim of this study was to investigate the relationship between prostate specific antigen density and prostate volume with microvessel density in patients with benign prostatic hyperplasia and advanced prostatic carcinoma. Sixty-eight patients with benign prostatic hyperplasia and 11 patients with advanced prostatic carcinoma participated in the study. The paraffin blocks of all patients were stained with CD34 by the standard immunohistochemical technique and microvessel density, prostate specific antigen density and prostatic volume were determined. In patients with benign prostatic hyperplasia the mean microvessel density, mean prostate specific antigen density and mean prostatic volume were 74±89±22.73, 0.12±0.10 and 59.97±27.0 ml, respectively. There was no correlation between prostate specific antigen density and mean prostatic volume or microvessel density (r=0.079 and −0.095, respectively). In patients with advanced prostatic carcinoma the mean microvessel density, mean prostate specific antigen density and mean prostatic volume were 147.90±47.55, 0.63±0.41 and 54.00±22.42 ml, respectively. In this group, while there was a good correlation between prostate specific antigen density and microvessel density (r=0.785), no significant correlation was found between prostatic volume and microvessel density (r=−0.07). There was significant statistical difference in patients with advanced prostatic carcinoma compared to patients with benign prostatic hyperplasia in terms of mean microvessel density (p<0.0001). The findings that there was no correlation between prostatic volume and MVD either in benign prostatic hyperplasia or in prostatic carcinoma suggest that microvessel development is not correlated with prostatic volume but may be correlated with morphology.     

How do I treat and follow my TUNA patients

Transurethral needle ablation (TUNA) of the prostate is an alternative treatment for benign prostatic hyperplasia (BPH) generating temperatures around 100°C leading to necrotic lesions inside the prostate. TUNA is a minimally invasive, low morbidity associated, approach that uses radiofrequency energy. The needles are covered by teflon shields that protect the urethra from thermal injury. Since the introduction of TUNA, there has been a constant upgrading of the device to improve treatment quality. The main advantage of this therapy is the possibility of an outpatient care due to its anaesthesia-free option with a prostatic block. Catheterisation after the procedure is required in 10–40% of cases. Long-term data (5 years) on TUNA demonstrate a sustained improvement of both IPSS score and urinary flow. About a quarter of patients require further intervention at 5 years’ follow-up. The safety profile, along with the significant improvement in both objective and subjective parameters observed after TUNA, makes it an attractive approach for symptomatic BPH.     

Retrograde transurethral balloon dilation of prostate: Innovative management of abacterial chronic prostatitis and prostatodynia

Retrograde transurethral balloon dilatation (RTBD) of the prostate recently has been suggested as alternative therapy for patients with benign prostatic hyperplasia (BPH). Seven patients with documented functional urinary outlet obstruction at the level of the bladder neck or prostatic urethra underwent RTBD of prostate. Each patient had a classic diagnosis of abacterial chronic prostatitis or prostatodynia based on history, physical examination, and localization cultures. Prior to RTBD of prostate, patients underwent cystoscopy, voiding cystourethrogram, urodynamic and uroflow studies. RTBD of prostate was done as an outpatient procedure requiring intravenous sedation or general anesthesia. Dilation was performed with a 25-mm urethroplasty balloon catheter inflated at 3.5 atm of pressure for twenty minutes. Improvement in voiding symptomatology was noted in all patients and graded numerically (0-10 scale), with ten indicating normal voiding. Follow-up to date ranges from one to five months. This technique may have promise as a treatment option in patients with abacterial chronic prostatitis and prostatodynia.     

良性前列腺增生微创治疗进展

BPH治疗方法有药物治疗、外科治疗及微创治疗等,其中微创治疗因其损伤小、疗效好、恢复快、患者易于接受等优点,越来越多地被泌尿外科医生接受,如经尿道针刺射频消融术(TUNA)、经尿道微波治疗(TUMT)、选择性绿激光前列腺汽化术(PVP)、经尿道钬激光前列腺剜除术(HOLEP)等,本文对此进展进行了综述。     

Local anesthesia for ultrasound guided prostate biopsy: a prospective randomized trial comparing 2 methods

PURPOSE: Since the introduction of prostate specific antigen (PSA) screening, asymptomatic men often undergo transrectal ultrasound guided prostate biopsy. This procedure may cause significant discomfort, which may limit the number of biopsies. We performed a randomized prospective study to compare periprostatic infiltration with 1% lidocaine with intrarectal instillation of 2% lidocaine gel before prostate biopsy. MATERIALS AND METHODS: From October 1999 to July 2000, 150 men underwent prostate biopsy at the Miami Veterans Administration and Jackson Memorial Hospital. Experienced senior residents performed all biopsies. Patients were randomized into 2 groups depending on the method of anesthetic delivery. A visual analog scale was used to assess the pain score. Statistical analysis of pain scores was performed using the Student t test. RESULTS: Ultrasound guided prostate biopsy was done in 150 cases. There was a statistical difference in the mean pain score after periprostatic infiltration and intrarectal instillation (2.4 versus 3.7, p = 0.00002) with patients receiving periprostatic infiltration reporting significantly less pain. CONCLUSIONS: Men should have the opportunity to receive local anesthesia before ultrasound guided prostate biopsy with the goal of decreasing the discomfort associated with this procedure. Our prospective randomized study indicates that ultrasound guided periprostatic nerve block with 1% lidocaine provides anesthesia superior to the intrarectal placement of lidocaine gel.