Magno_edit.qxp 25/9/08 11:05 am Page 12
Benign Prostatic Hyperplasia
Minimally Invasive Treatments for Benign Prostatic Hyperplasia
a report by
Giuseppe Mucciardi, Alessandro Gali and Carlo Magno
Department of Urology, University of Messina
Symptomatic benign prostatic hyperplasia (BPH) is a common disorder of Transurethral Microwave Thermotherapy
ageing men,
1,2
requiring treatment in 30% of cases.
3
Medical therapy is In the most recent guidelines of the American Urological Association
based on α-blockers alone or in combination with 5-α reductase (AUA) and European Urological Association (EUA), TUMT is regarded as
inhibitors; other combinations of treatment involve the use of an acceptable alternative to TURP for the treatment of symptomatic
antimuscarinics when storage symptoms are predominant. The direct BPH.
12,13
TUMT is a procedure involving the ablation of prostatic tissue
result of increasingly effective therapies is the delayed recourse to surgery through the transurethral application of microwave-generated heat and
essentially represented by transurethral resection of the prostate (TURP), the simultaneous use of a cooling system in order to protect urethral-
which even today is the ‘gold standard’ procedure for BPH.
4
adjacent tissues.
After the failure of medical therapy, patients come to surgery at an older In recent years there has been a significant evolution of the procedure
age when co-morbidities and increased anaesthetic risk make them poor through the use of increasingly innovative devices such as the high-
candidates for traditional surgical procedures, burdened by a high rate of energy devices (ProstaLund™ Feedback Thermotherapy [PLFT]), which
complications.
5–8
These are the reasons why in recent decades we have differ from previous systems for constant intraprostatic monitoring of
witnessed a remarkable spread of surgical minimally invasive treatments temperature. Customised treatments are useful because each patient
(MITs) to combine the results of TURP with a good safety profile. MITs has different characteristics in terms of prostate size and shape, tissue
offer clear advantages because they require minimal anaesthesia and most composition and, most of all, blood flow,
14
which may induce thermal
of them can be performed in an office setting, thus avoiding risks and energy dissipation, therefore making the method less effective. Guided
complications of surgery. These features result in a reduction in the length treatment is implemented because devices, according to prostatic
of hospital stay, allowing patients a quicker return to normal activities.
9
tissue heat sensitivity, calculate and display the amount of necrotic
Further benefits offered by MITs are those related to cost-effectiveness, tissue produced, otherwise known as ‘cell kill’,
15
and when the goal set
which is closely correlated to patient satisfaction with treatment, which is before treatment has been achieved, the procedure is stopped.
extremely variable and dependent on the procedure used.
10
Although the
long-term data on the effectiveness of MITs remain inadequate, it is Whatever device is used, microwaves ranging between 815 and
possible to state that they guarantee a lasting improvement of symptoms 1,296Mhz penetrate tissues in a process involving heat production
and functional outcomes, even if not to the extent of TURP.
11
(>45°C) and coagulative necrosis.
16,17
TUMT can be rapidly and easily
performed at outpatient clinics and requires only intra-urethral topical
MITs are based on the use of various constantly evolving technologies analgesia and/or intravenous sedation. The main contraindications are
and through the utilisation of specific devices it is possible to apply when prostate cancer is detected, median prostatic lobe, prostate volume
energies or substances directly on the prostate that can lead to the <30 or >100ml, acute prostatitis or urinary infection disorders, previous
glandular tissue ablation. Today, many types of MIT are available, prostate surgery, urethral stricture and neurogenic bladder.
18
Many
including transurethral microwave thermotherapy (TUMT), transurethral studies are available that demonstrate the effectiveness of TUMT based
needle ablation (TUNA), water-induced thermotherapy (WIT), on the use of different devices and with variable follow-up (see Table 1).
transurethral ethanol ablation (TEAP) and laser prostatectomy. In this
article, we will examine each MIT and report their results, advantages and One of the first large randomised studies about TUMT efficacy and
disadvantages according to the most recent literature data. safety was performed in 1998 by Roehrborn, in which the author
randomised a total of 220 patients to undergo TUMT or sham
treatment. An improvement was observed after six months of follow-
Carlo Magno is an Associate Professor of Urology and Vice
Chairman of the Department of Urology at the University up in the AUA Symptom Index (AUA-SI) from 23.6 to 12.7 in the first
Hospital ‘G Martino’, Messina. His research studies concern
group and from 23.9 to 18 in the placebo group, respectively.
19
numerous aspects of urology, including oncology, bladder
outlet obstruction, radiological imaging and basic
experimental research. His main surgical interest is In 2004, Wagrell conducted a prospective, randomised, multicentre trial
oncological surgery and minimally invasive treatment for
comparing TUMT (PLFT) with TURP. Statistically significant and
benign prostatic hyperplasia. He is a member of several
societies, including the European Association of Urology
comparable improvements in both groups were observed for
(EAU). Professor Magno received a grant from the European Council in 1987 to study in the
International Prostate Symptom Score (IPSS), quality of life (QoL) and
Urology Department of the University of Barcelona.
maximum urinary flow rate (Q
max
) at 36 months, but the safety profile
E: carlo.magno@unime.it
was better for PLFT.
30
This study follow-up was subsequently extended to
five years and similar outcomes were observed.
28
12 © TOUCH BRIEFINGS 2008