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Treatment of Benign Prostatic Hyperplasia in the Geriatric Patient
for patients who are at high surgical and anaesthetic risk, or for those levels.
41
In conclusion, TUMT is a safe and effective therapy for BPO
who are being treated with anticoagulant drugs. Bipolar and is still considered a good alternative treatment for patients who
electrosurgery has proved to be safe and effective, with a reduction are at high surgical and anaesthetic risk or who refuse the standard
of TUR syndrome events and, most likely, a shorter catheter stay. surgical therapy, and in older patients with chronic urinary retention.
Elderly people, especially those with a larger prostate or a cardiac
pacemaker, could benefit from the use of a bipolar device in order to Transurethral Needle Ablation
minimise complications. Cost analysis evaluation and further multi- TUNA of the prostate utilises low-level radiofrequency energy
institutional randomised and comparative studies with longer follow- delivered via needle to the hyperplasic tissue, producing coagulation
up times are needed in order to consider bipolar TURP as a surgical necrosis. It can be performed under regional or local anaesthesia with
option that is as effective as standard TURP, but with fewer side sedation. As few randomised studies are available on the efficacy and
effects. Otherwise, minimally invasive therapy should be proposed to safety of TUNA, definite conclusions cannot yet be made. Hill et al.
42
frail elderly patients. conducted a randomised multicentre study comparing TUNA and
TURP; although the overall improvement rate was superior in the
Minimally Invasive Therapies TURP group, the risk of adverse effects was lower in the TUNA group
Over the last 20 years, several minimally invasive surgical techniques at five-year follow-up. These results were confirmed by a meta-
have been developed for treating benign prostatic obstruction (BPO), analysis conducted by Boyle et al.
43
Preliminary results from the Real
including transurethral microwave thermotherapy (TUMT), Life Data Registry on Transurethral Needle Ablation (TUNA
®
) of the
transurethral needle ablation (TUNA) and laser prostatectomy Prostate confirm the feasibility of this technique.
44
Follow-up at six
(holmium laser enucleation, potassium–titanyl–phosphate [KTP] laser). months in 230 patients treated at 20 European centres showed a
significant improvement of mean total IPSS (from 20.1 to 7.4), IPSS–
Transurethral Microwave Thermotherapy QoL (from 4.3 to 1.7) and maximum flow rate (from 9 to 15.5ml/s), with
Raising the temperature of cells in the prostate above 45°C causes a a post-operative complication rate of 31% and a failure rate of 12%.
thermal injury that produces a coagulation necrosis of the tissue. The
procedure has seen an evolution in the last 20 years from the early, Laser Prostatectomy
low-energy devices to the high-energy software and the current Since its introduction two decades ago, laser technology has been
transurethral application (ProstaLund Feedback Thermotherapy [PLFT]), investigated for the treatment of BPH as an alternative to TURP. Laser
which, by monitoring the intraprostatic temperatures and calculating energy has been used to produce coagulation necrosis and
the cell-kill assessment, allows for personalised treatment. vaporisation or enucleation of prostatic tissue. Today, two laser
procedures can challenge the position of TURP: holmium laser
TUMT is advised for patients with symptomatic BPO or with chronic enucleation of the prostate (HoLEP) and, more recently, high-powered
urinary retention. Contraindications include the presence of prostate KTP photoselective prostatic vaporisation (PVP).
45,46
HoLEP consists of
cancer, a median prostatic lobe, prostate volume <30 and >100ml, the enucleation of the prostatic adenoma using a holmium laser fibre
prostate length <30mm, prostate height <20mm and neurogenic and a dedicated resectoscope. At the end of the procedure, the
bladder voiding dysfunction. TUMT requires sedo-analgesia and prostatic tissue is removed using a mechanical morcellator, applied
topical anaesthesia, and proper selection of the patients is very either transurethrally or suprapubically, with subsequent aspiration of
important to ensure a positive outcome. the tissue cores from the bladder.
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Several studies have demonstrated the efficacy of TUMT in terms of Several studies have shown that HoLEP is an effective alternative to
symptomatic and functional results, especially since higher-energy TURP in improving LUTS due to BPH, with fewer side effects.
protocols are available.
33–36
The improvement of symptoms score and Randomised comparative trials have demonstrated that HoLEP is as
maximum flow rate are durable in long-term follow-up studies.
37
effective as TURP in terms of relieving symptoms and improving
Wagrell et al.
38
reported the three-year results of the first prospective, urinary flow rates up to three-year follow-up in patients with a prostate
randomised, multicentre trial comparing PLFT and TURP; at 36 size between 40 and 200g. Morbidity in terms of length of hospital stay
months, considerable improvements in International Prostate and time for catheter removal was lower in the HoLEP group. It is also
Symptom Score (IPSS), QoL and Q
max
were found in both groups a relatively bloodless procedure, with no side effects related to
compared with baseline, with no statistically significant differences systemic fluid absorption and a similar overall re-intervention rate
between the Q
max
and QoL groups. The safety profile seemed to be to TURP.
47–50
However, one of the most debated issues is its long
more beneficial for PLFT three years after treatment. Recently, a five- learning curve. HoLEP requires significant endoscopic skills,
year follow-up of the same study seemed to confirm these results.
39
particularly for larger prostates, with the medium learning curve
Patients with indwelling catheters due to BPO could benefit from evaluated at between 20 and 50 procedures.
47–50
However, adequate
TUMT, as reported by Schelin et al. In this study, 80% of the group had mentoring can potentially shorten this learning curve.
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the catheter removed after treatment.
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PVP is a new attempt to vaporise prostatic tissue using laser energy.
The most frequent complication of TUMT is acute urinary retention The KTP laser is a high-wattage laser (80W) that emits a green light
that needs routine catheterisation after the procedure. Morbidity after at a wavelength of 532nm that is preferentially absorbed by
TUMT consists of symptoms such as urgency and frequency, which haemoglobin but not by the irrigation fluid (see Figure 1). Thus, any
usually disappear in about 30–45 days. blood-rich tissues, such as the prostate, are a good target. KTP laser
energy allows efficient tissue vaporisation with a small depth
Small sample sizes and differences in study design limit the penetration of 1–2mm and little dissipation of heat from the
comparison between devices with different designs and energy prostatic tissue.
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EUROPEAN UROLOGICAL REVIEW 17
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