BPH MANAGEMENT

BPH MANAGEMENT MINIMALLY INVASIVE AND ENDOSCOPIC TECHNIQUES

BPH Minimally Invasive Rx Options • Urethral stents • TUNA • Microwave thermotherapy- TUMT • Laser Therapy

• Hydrothermotherapy

Indications for Invasive Therapy for BPH • Failure of medical therapy • Urinary retention->1/3 bladder vol. • Recurrent urinary infection • Vesicolithiasis • Recurrent hematuria- gross • Azotemia

Criteria for Utilization of Alternative Minimally Invasive Therapies • Less adverse side-effects • Approaches or = surgical outcomes • No Anesthesia • Shorter Hospital stay • Less expensive • Safety profile = /> surgical therapy

Treatment Options- Minimally Invasive Therapies Advantages Less adverse effects No anesthesia No hospital stay Cheaper Approaches outcomes of surgery 

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Disadvantages Less favorable outcome, flow & sx’s Retreatment Cost $ & suffering of retreatment Complicationshematuria, dysuria, retention 

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Urethral Stents • Initially conceived to relieve BOO 2º to

BPH *, later to urethral stricture • Types1. Temporary 2. Permanent Endoscopic insertion Major role in patients unfit for surgery 

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*Fabian,1980

Urethral Stent- Temporary • Nonabsorbable

removed or changed q6-36 mos. topical with sedation success 50-90% no catheter or cysto with stent in situ complications-encrustation,migration, breakage,stress incont. UTI, hematuria

Urethral Stent-Temporary • Intraurethral Catheter(polyurethrane) – de Pezzer proximal end(like a malecot) – may used after TUMT – 16 Fr,variable to single lengths – Nissenkorn, Barnes, Trestle(two components) – Usually left for 1 month – Complications- hematuria, urinary retention, – Await large multicenter RCT

Urethral Stent- Biodegradable • Polyglycolic acid reinforced • Placed after laser prostatectomy,TUMT • Voiding difficulty at 3-4 wks, transient • Cost-effectiveness questioned,added to

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TULP or TUMT Await long term, multi-center RCT

Urethral Stent-Permanent • Attempt to permanently, definitively 

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treat BOO 2º BPH Initial enthusiasm turned to present literature silence Initially introduced to Rx USD Present use-USD,S-D dyssyner., postbrachytherapy,

Urethral Stent- Urolume • Manufactured by AMS, for BPH patients • Modified both stent and delivery device • Lengths vary from 1.5 –4.0 cm • Symptoms scores improve 8-9 pts. • Flow rates improve 4-6cc/sec(peak) • Used in nonsurgical candidates • Interest has waned with Tuna and TUMT

Urethral Stent- Urolume • Complications

epithelial hyperplasia migration of stent irritative voiding painful ejaculation

Urethral Stent- Others • Memotherm- variable results • ASI –withdrawn from production • Ultraflex-43 fr, 2-6cm, nickel-titanium

alloy, used in BPH, D-S dysyner., epithelial hypperplasia and migration low • Conclusion- temporary stents are attractive after TUNA and TUMT

Transurethral Needle Ablation of the Prostate • Heat delivery system to induce necrosis

of the prostate tissue to relieve BOO 2º BPH • Aim to prostate temp >60º C • Uses low-level radio frequency energy

delivered by needles into prostate • Use of topical anesthesia adequate

TUNA- Delivery of RF Energy • Produced by Vidamed, uses applicator

with two needles • Generator produces monopolar RF signal of 490kHz to give excellent tissue penetration • Grounding pad over sacrum large size • Size of prostate lesion f: kHz,time,depth and position of needle insertion

TUNA- Energy Characteristics • RF produces molecular agitation 

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generated heat Heat generated p: 1/radius 4 Heat lost by convection, vascularity affects lesion size as RF has no effect on vessels > 2-3mm diameter RF hotter central area and quick decline of temp as distance from needles

TUNA- Experimental Data • TUNA creates 1cm necrotic lesion with

no damage to rectum, bladder base, or distal prostatic urethra • Necrosis maximal @ 7 days, fibrosis by 15 days • Treated areas have absence of staining of PSA,smooth mus. actin, -adrenergic nerual tissue(maximal @ 1-2 weeks)

TUNA-Experimental Data • Sequential injury to different types of

nerve endings may occur NOS* most vulnerable • Central core Temp- 90-100ºC, edge of zone 50ºC • Treatment times of 5-7 min. needed to produce coagulation necrosis in Rx Site *NOS- nitric oxide synthase

TUNA-Instruments

TUNA-Instruments

RF needles deployed Note insulation and bare tips

TUNA-Treatment • Position- dorsolithotomy • Anesthesia-local, sedation, SAB, Gen • Instrument/needle placed with 0º telescope • Needle deployed/activated-20x10mm lesion • Two lesions/needle deployment-1 pair/3cm,

2 pair/4cm, additional pair/cm urethral length; Rx bilaterally • RF power delivered @2-15W for 5min., catheter is optional

TUNA-World Experience

TUNA-Summary of Data for 546 Patients*

mpkFlow increase % 6ml/sec 77

mSI decrease 13.1

Summary of world experience @12 months follow-up

% 58

TUNA- Adverse Effects • Urinary retention-13-42% • Irritative voiding-40% (1-7days)

• UTI-3% • Urethral stricture-1.5% • Hematuria-33%, mild, short-lived • Reoperation-12-14% in 2 yrs

TUNA-Indications • BPH/BOO • Lateral lobe enlargement • Prostate volume