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 <60gms
• Median lobe not ideal, but can be Rx
• Bladder neck hypertrophy not ideal
candidate
TUMT-Transurethral Microwave
Therapy
• Evaluated for past decade
• Widely used, variable urologist attitude
• Evolution from low-energy to high-energy
• Presently most commonly used devices
are Prostatron and Targis
• Current methods use either urethral
cooling catheter or non-cooling catheter
TUMT- Method of Action
• Heat induced hemorrhagic necrosis,
sympathetic nerve injury, apoptosis
• Tissue exposed to 45ºC for 60 min
suffered hemorrhagic necrosis
• Sympathetic nerve injury histologically
confirmed in 2 reports…
• Suggests thermal injury to adrenergic
fibers likely accounts for symptoms
TUMT-Method of Action
• Targis antenna(902-1928MHz) exceeds
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Prostatron(1296MHz) in efficiency of
delivery of thermal energy
1-adrenoreceptor density
after TUMT
Adrenergic nerve fibers remain in lamina
propria and epithelial layers, virtually
absent in smooth muscle layers
TUMT- Method of Action
• Apoptosis induced by moderate thermal
energy for longer period of time
• Hemorrhagic necrosis induced by higher
thermal energy over shorter time
• Brehmer and Svennson demonstrated
poptosis in 76% of cultured prostate
cells 24 hrs after heat exposure, only
14% were necrotic
Thermatrix vs High Energy,
Cooled Microwave ThermoRx
delivery
energy
effect
tolerance
TherMatrix
TUMT
Urethral Cath
High Power
Cooled Rx
Urethral Cath
Microwave:
Avg 6 watts
Tissue
Necrosis
Oral meds only
Microwave:
40-49 watts
Tissue
Necrosis
Parental
Recommended
Thermatrix vs High Energy
Microwave, Cooled ThermoRx
TherMatrix
TUMT
AUA SI @ 12m 47% decrease
PFR@12M
Side Effects
58% decrease
Minor ,Selfresolving
SAE(FDA filed None
MDRs)
High Power
Cooled Rx
44-51%
decrease
45-55%
decrease
Significant,long
er duration
Rectal fistula,
penile necrosis
5mm-62.4ºC
10mm-50.5ºC
15mm-temp
=urethral
Larson and Collins, 1995
TUMT- Clinical Results
Three months duration- TUMT vs Sham
# of Patients
110
Sham
35 pts
TUMT
75 pts
SxIndex 
14.9-10.8
13.9-6.3
pFlow 
7.4-9.4cc/sec
7.2-11.5cc/sec
Blute et al 1996,
TUMT- Clinical Results
Six Months Duration- TUMT vs Sham
# of Patients
125
Sham
44 pts
TUMT
79 pts
Sx Index 
21.3-14.3
20.8-10.5
pFlow 
7.8-9.8 cc/sec
7.8-11.8 cc/sec
Larson et al 1998
TUMT- Clinical Results
Twelve Months Duration- Prostatron 2.5 vs Turp
# of Patients
TUMT-31(26)
TURP-21(18)
Sx Index 
13.2-4.2
13.8-2.8
pFlow 
10.6-16.9 cc/sec 9.3-18.6cc/sec
Press/Flow(0Obstructed
Obstructed
6m)
62-40%
76-15%
Catheter: time 12.7 days(6-35) 4.1 days(4-5)
Irritative void
29%
19%
D’Ancona et al 1999, @ 24 mos 8/31TUMT & 1/21 needed other Rx
TUMT-Conclusion
• Symptomatic improvement after TUMT
appears to be energy related
• Objective improvement after TUMT may
be insignificant
• Symptomatic improvement may be
significant without objective improvement
Laser Therapy
• Types
Neodynium:Yttrium-Aluminum-Garnet
wavelength-1064nn
Potassium Titanyl Phosphate
wavelength-532nn
Holmium: Yttrium-Aluminum-Garnet
wavelength-2100nn
Diode- most energy efficient
Laser Therapy
• Methods of delivery
End firing, Bare tip, Sculpted tip,
Sapphire tip, Side firing, Metal or
Glass reflector, Prismatic internal
reflector, interstitial, Diffuser tip,
Diffuser tip with temperature
transducer
Laser Theraapy-Method of
Action
• 45-50ºC -tissue desiccation
• 50-100ºC - tissue coagulation,
irreversible effects
• 100ºC +- tissue boils, vaporizes,
carbonized
Laser Therapy- Summary
• There is incomplete and insufficient
quality data at present in the medical
literature to allow statement of the safety
and efficacy of Laser prostatectomy.
Hydrothermotherapy
• Recent Appliance availablilty
• Recent Application attempts
• Insufficient Outcome Evidence to
permit definitive statement of
safety or efficacy
Office-Based Transurethral Microwave
Thermotherapy for BPH Using
TheraMatrix TMx-2000
Results of Multi-Center, Prospective,
Randomized, Sham-Controlled Study