Long-term results of treatment of benign prostatic hypertrophy by trans-rectal prostatic hyperthermia]

From November 1987, 250 patients with symptomatic benign prostatic hyperplasia underwent transrectal prostatic hyperthermia. Forty-six patients had an indwelling catheter while 204 patients were obstructed but could still void spontaneously. Hyperthermia was administered in 5 or 10 sixty-minute sessions, with a calculated intraprostatic temperature of 42.5 or 43 degrees C. At the two-year follow-up, residual urine volume was significantly decreased while peak flow rate, maximum flow nomogram and subjective symptoms were only slightly improved, i.e. patients were still obstructed postoperatively. Transrectal prostatic hyperthermia cannot be considered as a first choice therapy for symptomatic benign hyperplasia but it can be offered only to carefully selected patients who cannot undergo any alternative therapeutic procedure.     

Local microwave hyperthermia of benign prostatic hyperplasia.

Recently, hyperthermia has been used for treatment of benign prostatic hyperplasia. The preliminary results reported were promising. However, apart from patients with total urinary retention, objective voiding parameters have not been reported in detail for patients with prostatism. In a phase II study we treated 30 patients with benign prostatic hyperplasia by local microwave hyperthermia (915 MHz.). The prostate was heated transrectally to 42 to 43C, with the treatment consisting of 8 sessions of 60 minutes each given twice a week. To assess the results of treatment several parameters were determined before and 4 weeks after hyperthermia therapy, including transrectal ultrasound of the prostate with volumetry, urinary flow rate and residual volume. Of the patients 28 could be evaluated and only 2 showed a relevant improvement. Neither the voiding parameters nor the size of the prostate could be changed significantly by hyperthermia. The success rate of 7.1% is even lower than the spontaneous temporary regression rate of benign prostatic hyperplasia. Thus, we believe that hyperthermia cannot be regarded as an effective treatment for benign prostatic hyperplasia comparable to transurethral resection.     

Clinical experience of local hyperthermia for benign prostatic hyperplasia]

A total of 20 patients with benign prostatic hyperplasia underwent transrectal local hyperthermia. For heating of the prostate gland, the PROSTATHERMER (Biodan-Medical System, Israel) was used. Patients were treated twice weekly, for 1 hour, with 6 sessions on an outpatient basis. Four of the 20 patients who had acute toxicity such as urethral irritability due to urethral thermoprobe could not tolerate the treatment. In the majority of the patients who were completely treated, a significant decrease in frequency of nocturia, decrease in post-void residual urine capacity and increase in urine flow rate were observed. No significant change in prostate volume was noted. With a mean follow-up of 6 months, only 1 patient required subsequent prostatic resection. These findings indicate that local hyperthermia applied by this method is effective in the treatment of benign prostatic hyperplasia and that improvement of the thermometry system is needed.     

Significance of transrectal hyperthermia in the treatment of benign prostatic hyperplasia]

Though the local hyperthermia for the management of benign prostatic hyperplasia has drawn much attention as one non-surgical treatment, no definite conclusion could yet be obtained in terms of the efficacy. In this study local hyperthermia was induced in evaluable 33 cases with benign prostatic hyperplasia using Primus, and the effectiveness of this modality of treatment was investigated by analysing the subjective and objective response following hyperthermia. The prostate was heated trans-rectally up to 43 degrees C with 915 MHz microwave for one hour. Hyperthermia was carried out twice a week for ten times for the sake of thermotolerance. Urinary obstructive symptoms were divided into diurnal and nocturnal frequency, urinary urgency, the degree of urinary stream, hesitancy and dribbling. Each symptom was described before and after the treatment according to the scoring system. Moreover, objective changes of urinary flow and prostatic size were estimated by the residual urine volume, uro-flowmetry, rectal palpation of the prostate and echography. Hyperthermic treatment improved urinary flow markedly, but no appreciable alteration could be observed as to the size of the prostate. The overall efficacy, including subjective and objective response, could be summarized as 37% of effectiveness, and 33% of slight effectiveness, that is, 70% of effective ratio. As to the side effect, anal pain was noted in few cases of the present series. Therefore, transrectal hyperthermia may be a suitable modality for non-surgical treatment of benign prostatic hyperplasia.     

Effects of mepartricin (S-160) on spontaneous canine benign prostatic hyperplasia

OBJECTIVE: The effects of mepartricin (S-160) on spontaneous canine benign prostatic hyperplasia (BPH) were investigated by histological, histochemical and biochemical analysis. METHODS: Aged beagle dogs (5-9 years old) with spontaneously developed BPH were treated orally with a placebo or S-160 (5, 10 or 20 mg/kg/day) for 8 weeks. The methodology included measurement of prostatic volume by transrectal ultrasonography, qualitative evaluation of prostatic morphology, determination of plasma and intraprostatic estradiol level by radioimmunoassay and immunohistochemical detection of estrogen receptors and androgen receptors in the prostate. RESULTS: S-160 significantly reduced the prostatic volume and regressed histologically the hyperplastic grade of prostate, and also fairly decreased the plasma and intraprostatic estradiol concentration and the estrogen and androgen receptors in the prostate. CONCLUSIONS: These results suggest that the reduction of estradiol and estrogen receptors in the prostate may play a crucial role in the regression of BPH by S-160.     

Increased intraprostatic pressure in patients with chronic prostatitis

The purpose of this prospective study was to develop a method for measuring intraprostatic pressure. Intraprostatic, extraprostatic and perineal subcutaneous pressures were measured in 43 patients. Twenty-four patients had chronic nonbacterial prostatitis (CNP) and prostatic hyperplasia (group A), 10 patients had benign prostatic hyperplasia (BPH) (group B) and 9 patients served as controls (group C). The pressure measurements were performed with a Stryker pressure monitor under transrectal ultrasonographic control at three different points: perineal subcutaneous tissue, paraprostatic tissue and the apex of the prostate beneath the capsule. Significantly higher intraprostatic pressure values (P < 0.001) were recorded in the patients with CNP compared with the BPH patients or the controls. We conclude that this novel method of measuring intraprostatic pressure, which has not been reported earlier, could be a new tool in the diagnosis of CNP and in the evaluation of the therapeutic effects of the different treatment modalities used in CNP. Received: 8 May 1998 / Accepted: 28 October 1998     

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.     

Interstitial temperature measurements during transurethral microwave hyperthermia.

Microwave hyperthermia is presently being investigated as a treatment for alleviating the symptoms of urinary outlet obstruction associated with benign prostatic hyperplasia. Two clinical techniques using intracavitary microwave applicators are being evaluated for safety and efficacy at various institutions. The transrectal technique uses a directional microwave radiator that is inserted into the rectum adjacent to the prostate. The transurethral approach uses a symmetrically radiating applicator located within the prostatic urethra. Transrectal prostatic heating techniques require surface cooling to prevent hazardous temperatures in the intervening rectal mucosa. Since transurethral applicators radiate from within the prostatic urethra, heating is confined to the obstructive tissue immediately surrounding the applicator. Concern has been expressed regarding the possibility of thermal injury to the prostate and adjacent rectum during transurethral hyperthermia treatment. In this report we present interstitial temperature measurements of prostatic and rectal temperatures in 5 patients. Temperature was observed to decrease at a rate of about 6C/cm. outward from the applicator. No clinically significant temperature increase was observed beyond 1 cm, outside the prostatic capsule or in the rectal mucosa.     

Rectal invasion by benign prostatic hyperplasia.

Rectal invasion by benign prostatic hyperplasia occurred subsequent to an open transrectal biopsy of the prostate gland. Frequent transrectal resections of the prostate controlled this unusual lesion initially. However, massive intrarectal regrowth of this clinically malignant but histologically proved benign prostatic enlargement required eventual pelvic exenteration.     

Local microwave hyperthermia as a treatment alternative for benign prostatic hyperplasia.

It appears that the technology for local microwave application of heat to the prostate for the management of benign prostatic hyperplasia has arrived. There are a number of issues to be resolved in the coming years that will determine the role this modality will play in the overall management of men with benign prostatic hyperplasia. These issues include: transurethral versus transrectal route, hyperthermia (42 degrees C to 44 degrees C) versus thermotherapy (greater than 45 degrees C), and a proper assessment as to whether the technique is really efficacious, given the known placebo response in all studies currently available. The results with the transrectal route appear to improve patients' symptoms objectively and subjectively, without causing irreversible tissue effects. Thus, its action has been likened to alpha blockade. But, it appears that the transrectal approach is relatively inefficient because of a significant loss in microwave power with rectal cooling. A probe placed transurethrally can accurately and easily deliver the intended power to the center of the prostate, where theoretically it has its greatest effect on both the dynamic and static components of outlet obstruction. Currently, the transurethral devices described by Sapozink and Devonec will produce histologic necrosis. The theoretical value of combining urethral heating with cooling is that it will allow treatments of greater power deeper in the prostate adenoma, but the greatest advantage over transurethral heating without cooling may be in the ability to effect a response in a single session. Finally, the placebo response is a well known phenomenon seen in all drug trials conducted for the management of benign prostatic hyperplasia.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intraprostatic testosterone and dihydrotestosterone. Part I: concentrations and methods of determination in men with benign prostatic hyperplasia and prostate cancer

Owing to inconsistencies and methodological differences, the present peer-reviewed literature lacks conclusive data on the intraprostatic levels of androgens, in particular dihydrotestosterone (DHT), in untreated benign prostatic hyperplasia (BPH) and prostate cancer. To date, no difference has been shown between DHT concentrations in normal prostatic tissue and BPH, and nor has a difference been shown in DHT concentrations between the histologically distinct regions of the prostate. Recent literature has also failed to show a consistent difference in androgen level between BPH and prostate cancer. The role of intraprostatic DHT in the pathogenesis of BPH and in the initiation and progression of prostate cancer thus remains to be established. Increased knowledge of the mechanisms of the androgenic steroid pathways in prostatic diseases, with a special focus on intraprostatic androgen levels may lead to more optimized and more personalized forms of treatment, and probably new therapeutic targets as well.     

Ultrasound in urodynamics

Recent developments of ultrasound imaging have contributed much to the understanding of urodynamics in patients with lower urinary tract symptoms (LUTS). These include ultrasound estimated bladder weight (UEBW), transrectal power Doppler imaging of the prostate and transrectal ultrasonography during voiding (voiding TRUS). UEBW, which is obtained by measuring the thickness of the anterior bladder wall using a 7.5 MHz probe, represents well the degree of bladder hypertrophy caused by obstruction. This parameter is, accordingly, of clinical use in the evaluation of obstruction. The UEBW predicted the presence of obstruction as determined by pressure-flow study with a diagnostic accuracy of 73%. Transrectal power Doppler imaging of the prostate has made it easy to detect prostatic vessels and furthermore to obtain their resistive index (RI). Accumulating data suggest strongly that RI reflects the intraprostatic pressure. More interestingly, RI decreases significantly during voiding in normal subjects but not in patients with benign prostatic hyperplasia. Thus, this method is of particular use in monitoring noninvasively the dynamic change in intraprostatic pressure during voiding. Voiding TRUS makes it possible to monitor the movement of not only the posterior urethra but also the prostate during voiding. Based on our recent study, the anterior fibromuscular stroma (AFMS) seems to contract to open the urethra. Although the physiological function of the AFMS in the prostate remains unknown, AFMS may play a significant role in normal micturition. Due to its noninvasiveness and ease of application, ultrasound imaging would play a vital role in the diagnostic process for patients with LUTS in future.     

Comparison of histological compositions and apoptosis in canine spontaneous benign prostatic hyperplasia treated with androgen suppressive agents chlormadinone acetate and finasteride

PURPOSE: Chlormadinone acetate and finasteride are androgen suppressive agents clinically used for benign prostatic hyperplasia but their mechanism for inducing prostatic atrophy differs. We investigated the effect of these androgen suppressive agents on prostatic histology and apoptosis using the spontaneous canine benign prostatic hyperplasia model. MATERIALS AND METHODS: Animals were treated with oral chlormadinone acetate or finasteride for 25 weeks. The prostatic volumes were analyzed every 5 weeks. Prostatic androgen and estrogen concentrations, histological composition and apoptosis were determined at the end of treatment. Apoptosis was measured by in situ labeling of 3' hydroxy ends of the DNA breaks using the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling method. RESULTS: There was a similar volume reduction effect with 0.3 mg./kg. chlormadinone acetate daily and 1 mg./kg. finasteride daily. Chlormadinone acetate decreased testosterone and dihydrotestosterone but finasteride decreased only dihydrotestosterone in the prostate gland. The concentration ratio of estradiol-to-total androgen in the prostate was significantly increased in finasteride treated canines. Chlormadinone acetate and finasteride decreased the epithelial and stromal components. The extent of apoptosis observed in the prostate was significantly higher in the chlormadinone acetate group compared to that of the control and finasteride groups. CONCLUSIONS: Although a similar effect of chlormadinone acetate and finasteride was observed in the induction of prostatic regression and composition of the histological components, the sustained increase in apoptosis was observed only in chlormadinone acetate treated canines. We suggest that different intraprostatic endocrine environments created by chlormadinone acetate or finasteride, which have different intraprostatic testosterone levels and estradiol-to-androgen ratios, may be responsible for the different outcomes in the extent of apoptosis.     

Local hyperthermia in benign prostatic hyperplasia]

In recent years, hyperthermia has been used for the treatment of benign prostatic hyperplasia (BPH). The preliminary results reported were promising. Except for patients with total urinary retention, however, objective voiding parameters have not been reported in detail for patients with "prostatism". In a phase II study we treated 30 patients with BPH by local microwave hyperthermia (915 MHz). The prostate was heated transrectally to 42-43 degrees C in eight sessions of 60 min each. The sessions were given twice a week. To assess the results of the treatment the following parameters were determined before and 4 weeks after hyperthermia therapy: transrectal ultrasound of the prostate with volumetry, urinary flow rate, and residual volume. In all, 28 patients were evaluatable. Only 2/28 showed clinical improvement. Neither the voiding parameters nor the size of the prostate were significantly changed by hyperthermia. The success rate of 7.1% is even lower than the spontaneous temporary regression rate of BPH. Thus, to our mind, hyperthermia cannot be regarded an effective treatment comparable to TUR for BPH.     

The long-term influence of vasectomy on prostatic volume and morphology in man

During the past two decades several papers have described the changes in prostatic secretory capacity following vasectomy. Based upon results indicating a reduction of secretory function, it was suggested that even prostatic size and the incidence of benign prostatic hyperplasia (BPH) might be altered after the operation. In this study, which included 56 males who had been vasectomized 8 years previously and 56 age-matched control persons, transrectal ultrasonic scanning of the prostate was used for exact measurements of the prostatic volume and for the investigation of intraprostatic echo pattern. The total prostatic volume, the volume of the periurethral gland, and the volume of the peripheral zone were not influenced by the vasectomy; nor was the growth rate of these zones affected. In the vasectomy group, the frequency of adenomatous prostates was 19.6%, whereas 30.3% of prostates in the control group had ultrasonic signs of BPH. However, this is not a statistically significant difference. Subdividing the material according to age did not reveal altered BPH frequency in any age group when vasectomized and controls were compared.     

Transurethral prostatic tissue ablation via a single needle delivery system: initial experience with radio-frequency energy and ethanol

We report an initial clinical experience to evaluate the safety and efficacy of outpatient prostatic ablation for the treatment of symptomatic benign prostatic hyperplasia (BPH) using local anesthesia (OPAL) with radio-frequency energy and intraprostatic absolute ethanol injection (EI). Twenty-three patients were treated with OPAL and five patients were treated with EI. Pre-operative data for all patients included international prostate symptom score (IPSS), quality of life score (QL), maximum flow rate (Q(max)), and post void residual determination. Prostate specific antigen (PSA) and transrectal ultrasound prostate volume determination were also done for EI patients. Needle deployment into the prostate was carried out at the 2, 4, 8 and 10 o'clock positions for lateral lobe hyperplasia and the 6 o'clock position for middle lobe hyperplasia. IPSS, QL, Q(max) and post void residual data were collected at 1, 3, 6 and 12 months post procedure. Both procedures resulted in statistically significant reductions of IPSS and QL. Trends towards improvement were seen both for Q(max) and post void residual, with Q(max) significantly improved after OPAL. Among EI patients, the prostate volume was reduced at 6 months post treatment to 37.2+/-17.9 g from 53.0+/-19.0 g (P=0.03) preoperatively. OPAL was safe but suffered from a high re-treatment rate. EI demonstrated encouraging results with regards to safety, symptom improvement and prostate volume reduction.     

巨大膀胱后异位前列腺1例报告并文献复习

目的探讨膀胱后异位前列腺的临床特征和治疗。方法回顾性分析1例膀胱后巨大实性异位前列腺的临床资料,并对既往文献进行复习。结果患者体检发现正常前列腺上方有一实性肿物,盆腔CT、盆腔MRI提示肿物直径约7cm,与膀胱后壁相邻。PSA为20ng/ml。术前行B超引导下经直肠肿物穿刺活检,病理结果为前列腺增生组织。手术切除肿物及前列腺。组织学和免疫组化检查结果证实肿物为前列腺组织。患者术后恢复顺利,PSA降为0。结论膀胱后异位前列腺极为罕见,手术切除是可靠的治疗方法。     

Doppler resistive index in benign prostatic hyperplasia: correlation with ultrasonic appearance of the prostate and infravesical obstruction

OBJECTIVE: This study was designed to characterize the resistive index (RI) of prostatic blood flows obtained by transrectal power Doppler sonography (TRPDS) in benign prostatic hyperplasia (BPH). METHOD: In 140 patients with lower urinary tract symptoms, the RI was measured using TRPDS and compared with age and planimetric parameters of the prostate obtained by conventional transrectal sonography. In addition, the RI was related with pressure flow studies. RESULTS: The RI was significantly higher in patients with BPH (0.72+/-0.06, p<0.0001) than those with a normal prostate (0. 64+/-0.04). Although the RI correlated significantly with age and all prostatic planimetric parameters, multiple regression analysis revealed that age and presumed circle area ratio were independent predictors for RI. The RI was also higher in patients with infravesical obstruction than those without (0.74+/-0.06 vs. 0. 70+/-0.05, p<0.005). There was a significant correlation between RI and urodynamic parameters obtained in pressure flow studies. Out of 33 patients with obstruction, 28 (85%) had an RI of 0.7 or more, while 11 out of 24 patients (46%) without obstruction had an RI less than 0.7. CONCLUSION: The RI is promising as a new parameter to estimate the intraprostatic pressure to investigate BPH. Its value to represent urodynamic information during voiding remains to be studied.     

良性前列腺增生相关性血尿的彩色多普勒表现

目的：探讨前列腺增生相关性血尿的经直肠彩色多普勒超声特征。方法：对53例诊断为前列腺增生患者经直肠超声观察其前列腺动脉尿道支,测量其最大血流速度（Vmax）、最小血流速度（Vmax）、阻力指数（RI）。进行统计学处理。结果：良性前列腺增生相关性血尿组及非血尿组前列腺动脉Vmax均值分别为（23．07±3．71）cm／s、（17．12±4．25）cm／s（P=0．00）,Vmax均值分别为（4．75±3．26）cm／S、（5．07±2．54）cm／s（P=0．35）,RI均值分别为（0．79±0．035）、（0．67±0．041）（P=0．00）。结论：经直肠彩色多普勒超声可显示前列腺动脉尿道支,出现前列腺增生相关性血尿的患者,前列腺腺体血流信号增加,前列腺动脉最大血流速度增快,血供增加,血管阻力指数增大。Vmax及RI可作为良性前列腺增生相关性血尿的预测指标。     

超声引导的经直肠前列腺穿刺活检术（附121例报告）

为提高前列腺癌的诊断水平，应用端扫式双平面高频（７．５ＭＨｚ）探头的腔内Ｂ超为指引，配以自动弹射式组织芯活检装置，对１２１例可疑前列腺癌患者行经直肠前列腺穿刺活检术。结果：前列腺增生７８例，前列腺癌３３例，前列腺炎１０例。该技术简单、准确、取材满意、并发症少，但必须掌握其适应证，避免不必要的活检，提高对前列腺癌的活检阳性率。